Gastro oesophageo reflux disease (GORD)
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Causes, Diagnosis and Investigations, Management, Hiatus Hernia
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Gastro oesophageo reflux disease (GORD)
- 1. Gastro Oesophageo Reflux Disease (GORD) JMJ 1
- 2. Contents • Pathophysiology • Oesophageo mucosal defense mechanisms • Clinical features • Diagnosis and investigations • Treatment • Complications JMJ 2
- 3. Pathophysiology • Between swallows, • Muscles of oesophagus are relaxed, • Except for those of sphincters. • LOS remains closed usually • Muscles of LOS get relaxed when swallowing is initiated • Transient lower oesophageal sphincter relaxations (TLESRs) • Part of normal physiology • But occurs more frequently in GORD patients • Little amount of reflux is normal • Sphincter pressure also increases in response to • Rises in intra abdominal and intragastric pressures. JMJ 3
- 4. The main anti reflux mechanisms JMJ 4
- 5. Other anti reflux mechanisms • Intra abdominal segment of oesophagus • Acts as a flap valve • Mucosal rosette formed by folds of gastric mucosa & • the contraction of the crural diaphragm at the LOS • Acting like a pinchcock, • Prevents acid reflux • Large hiatus hernia can impair this mechanism • Oesophagus is rapidly cleared normally or refluxate • By secondary peristalsis • By gravity • By salivary bicarbonate JMJ 5
- 6. Factors associated with gastro oesophageal reflux • Pregnancy and obesity • Fat, chocolate, coffee or alcohol ingestion • Large meals • Cigarette smoking • Drugs • Antimuscuranics • Calcium- channel blokers • Nitrates • Systemic sclerosis • After treatment of achalasia • Hiatus hernia JMJ 6
- 7. Factors associated with gastro oesophageal reflux • Pregnancy and obesity • Fat, chocolate, coffee or alcohol ingestion • Large meals • Cigarette smoking • Drugs • Antimuscuranics • Calcium- channel blokers • Nitrates • Systemic sclerosis • After treatment of achalasia • Hiatus hernia JMJ 7
- 8. Osophageal mucosal defense mechanisms • Surface • Mucus and the unstirred water layer trap bicarbonate • This is a weak buffering mechanism, compared to that in the stomach and duodenum • Epithelium • Apical cell membrane and junctional complexes between cells act to limit diffusion of H+ into the cells. • In oesophagitis – junctional complexes are damaged. JMJ 8
- 9. Osophageal mucosal defense mechanisms • Postepithelium • Bicarbonate normally buffers acid, in the cells and intracellular spaces • Hydrogen ions impair the growth and replication of damaged cells • Sensory Mechanisms • Acid stimulates primary sensory neurons in the oesophagus by activating the VANILOID RECEPTOR 1 (VR1) • This can initiate inflammation and release pro-inflammatory substances from the tissue to produce pain • Pain can also be due to - contraction of longitudinal oesophageal muscle JMJ 9
- 11. Heartburn • Is the major feature • Aggravated by • Bending • Stooping • Lying down • Relieved by • Oral antacids • Patient complains pain on drinking • Hot liquids • Alcohol JMJ 11 Which promotes acid exposure
- 12. Heartburn • Correlation between heartburn and esophagitis is poor • Differentiation of cardiac and oesophageal pain can be difficult • In addition to the clinical features, • a trial of PPI is always worthwhile and • if symptoms persist, • ambulatory pH and impedance monitoring should be performed JMJ 12
- 13. Regurgitation of food and acid • Particularly on bending or lying flat • Aspiration pneumonia is unusual without an accompanying stricture • But cough and asthma can occur & respond slowly (1-4 months to a PPI JMJ 13
- 14. JMJ 14
- 15. Hiatus Hernia Hiatus Hernia Sliding Hiatus Hernia Rolling or para- oesophageal hernia JMJ 15
- 16. Sliding hiatus hernia JMJ 16 • Oesophageal-gastro junction and part of stomach • ‘slides’ through the hiatus • That it lies above the diaphragm • Present in 30% of people over 50 years • Produces no symptoms • Any symptoms are due to reflux
- 17. Rolling or para-oesophageal hernia JMJ 17 • Part of the fundus of the stomach, • Prolapses through the hiatus, • Alongside the oesophagus • LOS remains below the diaphragm & remains competent • Occasionally severe pain occurs due to volvulus or strangulation
- 18. Rolling or para-oesophageal hernia JMJ 18
- 19. Features of pain in GORD and Cardiac ischemia GORD • Burning, worse on bending, stooping or lying down • Seldom radiates to the arms • Worse with hot drinks or alcohol • Relieved by antacids Cardiac ischemia • Gripping or crushing • Radiates to neck or left arm • Worse with exercise • Accompanied by dyspnea JMJ 19
- 20. Diagnosis and Investigations JMJ 20 • Clinical diagnosis can be made • Unless there are alarm signs, (esp.dysphagia), • Patients under 45 years, • Can safely be treated initially without investigations Investigations Assess oesophagitis & hiatus hernia by endoscopy Document reflux by intraluminal monitoring
- 21. Intraluminal Monitoring JMJ 21 • 24 hour luminal Ph monitoring or, • Impedance combined with manometry is helpful • if there is no response to PPI & • should always be performed to confirm reflux before surgery • Excessive reflux • pH <4 for >4% of the time
- 22. Treatment JMJ 22 • Loss of weight • Raising head end of the bed at night • Precipitating factors should be avoided, • With dietary measures • Reduction in alcohol and caffeine consumption & • Cessation of smoking
- 25. Alginate-containing antacids JMJ 25 • 10 ml tds • ‘over the counter’ agents for GORD • They form a gel or ‘foam raft’ with gastric contents to reduce reflux • Magnesium containing antacids • Tends to cause diarrhea • Aluminum containing compounds • Cause constipation
- 26. Dopamine antagonist prokinetic agents JMJ 26 • Metoclopramide and domepridone • Enhances peristalsis & • Speed gastric emptying
- 27. H2- receptor antagonists JMJ 27 • Cimetidine • Ranitidine • Famotidine • Nizatidine • Acid suppressors • If antacids fail • They can be often obtained over the counter
- 28. Proton Pump Inhibitors JMJ 28 • Omeprazole • Rabeprazole • Lansoprazole • Pantoprazole • Esomeprazole • Inhibit gastric hydrogen/potassium- APTase • Reduce gastric acid secretion by 90% • DOC for all mild cases • Most respond well • 20-30% will persist with heartburns • Severe symptoms – bd dosing & prolonged Tx
- 29. Endo luminal gastroplication JMJ 29 • In this endoscopic procedure, • multiple plications or pleates are • made below the gastro-oesophageal junction.
- 30. Surgery JMJ 30 • Never be performed to hiatus hernia alone • Best predictor • Typical reflux symptoms with documented acid reflux • Current surgical techniques – • Return the oesophageal junction to the abdominal cavity • Mobilize the gastric fundus • Close the diaphragmatic crura snugly • Involve a short tension-free fundoplication
- 31. Surgery JMJ 31 • Indications for operation • Not clear • Intolerance to medication • Desire for freedom from medications • Expense of therapy • Concern of long-term side effects • Patients with oesophageal dysmotility unrelated to acid reflux, • patients with no response to PPIs and • those with undelying functional bowel disease • should NOT have surgery
- 32. JMJ 32
- 33. JMJ 33 Complications • Peptic stricture • Barrett’s oesophagus
- 34. JMJ 34 Peptic Stricture • Due to usage of PPI – strictures are uncommon in this era • Usually occurs in – patients over the age of 60 • Present with intermittent dysphagia for solids • which worsens gradually over a long period • Mild cases • May respond to PPI alone • Severe cases • Need endoscopic dilatation • Long term PPI therapy
- 35. JMJ 35 Barrett’s Oesophagus • Part of normal oesophageal squamous epithelium is • replaced by metaplastic coloumnar mucosa • to form a segment of ‘columnar-lined oesophagus’ (CLO) • There is almost always a hiatus hernia • Diagnosis is made by • Endocopy showing proximal displacement of squamo coloumnar mucosal junction • Biopsies demonstrating coloumnar lining above the proximal gastric folds • Interstinal metaplasia is no longer a requirement – (British Society of Gastroenterology guidelines)
- 39. JMJ 39 Barrett’s Oesophagus • Barret’s oesophagus may be seen as • Continual circumferential sheet • Finger like projections extending upwards from the squamo- coloumnar junction • Islands of coloumnar mucosa interspersed in areas of residual squamous mucosa • Central obesity increases risk of Barrett’s by 4.3 times • Commonest in middle aged obese men • 0.12-0.5% - develop oesophageal adenocarcinoma
- 40. JMJ 40