1. Alimentary LailaHasan
Gastro-oesophageal Reflux Disease (GORD)
Definitions:
Hiatus hernia: anatomical abnormality with part of
stomach in the chest – usually asymptomatic. The
stomach normally herniates through the diaphragm into
the chest.
Gastro-oesophageal reflux- reflux of gastric contents up into the
oesophagus which can occur normally with no symptoms
Gastro-oesophageal reflux disease (GORD) – damage and/or
symptoms due to reflux of gastric fluid. It is important to note that
presentation of symptoms may not occur!
Also important to note is that A normal endoscopy does not
exclude GORD:
– 50-60% of patients with GORD will have no
oesophagitis ie a normal endosocpy =‘endoscopy negative refluxers’
This mmeans you may get very bad symptoms but not any results on the endoscopy, so the test and
presentation of symptoms and underlying pathology do not correlate well.
Reflux oesophagitis – inflammation of the lower oesophagus produced by persistent episodes
of reflux – may be asymptomatic
Normal
Superficial
Ulceration
Stomach join has krept up the
oesophagusby aprox 7cm. So 2/3
of oesophagus is covered by
stomach. This shows Barrett’s
Oesophagus
slightlynarrowed
oesophagus
indictiviteof reflux
disease
Reflux oesophagitis

2. Alimentary LailaHasan
Barrett’s oesophagus – presence of intestinal metaplastic columnar epithelium which has
replaced squamous epithelium due to acid reflux (or repetitive acid contact). This is a
premetaplasmic state.
Epidemiology
GORD = 5-8% in the British Public
Heartburn = 30-60%
The findings when dyspepsia(bad digestion with complex symptoms such as bloating, epigastric
pain, chest pain and nausea) is diagnosed by Rapid access endoscopy are:
20% oesophagitis, 7-10% duodenal ulcer, 5% gastric ulcer.
PATHOPHYSIOLOGY:
Reflux of small amounts of gastric contents is normal BUT in GORD =there are frequent,
prolonged, large amounts and / or damage because anti-reflux mechanisms fail
In the normal physiology there are a number of different mechanisms to prevent reflux. These are:
1. Lower oesophageal sphincter (LOS) –intra-abdominal and thoracic portion which is 4cm
segment of smooth muscle (there is one in the upper oesophagus but this is less utilised). It
is a high pressure zone of muscle contraction which normally relaxes on swallowing to
allow food through and regains tone to prevent reflux. It can increase in tone in response to
rises in gastric and abdominal pressure.
2. Intra-abdominal segment acts as flap valve
3. Mucosal rosette formed by gastric folds occlude gastro-oesophageal junction
4. Contraction of crural diaphragm has a pinchcock-like action at LOS
5. Rapid clearance of content from oesophagus by peristalsis that makes acid go distally to the
stomach.
The ProposedmechanismsthatleadtoGORD are:
1. Transient LOS relaxation episodes (This can be spontaneous and more susceptible at
daytime)
2. Low resting tone in LOS which fails to increase when patient lies flat which it would
normally (Patients often sleep with many pillows to relieve the reflux as the intra abdo
pressure increases)
3. LOS tone fails to increase when gastric or abdo pressure increases
4. Increased oesophageal mucosal sensitivity to acid
5. Delayed gastric emptying eg. in diabetes
6. Prolonged episodes of GOR which occur at night and postprandially
7. Reduced oesophageal clearance of acid due to poor peristalsis or ‘trapping’ acid in hiatus
hernia
8. A large hiatus hernia can impair crural diaphragm pinchcock effect as it prevents the
diaphragm from pinching LOS.
Exacerbating factors
 Smoking

3. Alimentary LailaHasan
 Alcohol
 Pregnancy
 Obesity
 Exertion
 Posture – stooping or lying flat
 Drugs : NSAIDS (directly irritate the oesophagus mucosa), nitrates (relax the smooth
muscle of oesophagus so reflux is no longer inhibited) and muscle relaxants
 Large meals, fat, chocolate, coffee
 Hiatus hernia
 Systemic sclerosis
Most diagnostics are based on gaining a good history and not by clinical tests:
as abdo pressure increases
Thiscan occur as
acid can cause
trouble higher
up the oesoph,
causing
irritation.

4. Alimentary LailaHasan
Achalasia: Lower chest discomfort and chest pain. The oesophagus does
not relax, which is different from GORD
The complications of GORD are:
 Reflux oesophagitis = 60%
 Of those with oesophagitis:
 Barrett’s = 10% (adenocancer risk 40-
100x)
 Stricture = 4-20%
 Ulceration = 5%
 Bleeding = <2%
What is Barrett’s oesophagus?
• Columnar epithelium with intestinal metaplasia transformation of squamous lining of
lower oesophagus due to reflux. It is important to
note that the reflux could be bile or pancreatic in
nature and not just acid reflux.
• Premalignant
• Most people with it will die of other diseases
• Surveillance endoscopy to detect dysplasia?
There are squamousislands still
residingasthe normal oesophagus
liningbutthe masshas beenreplaced
by columnarepithelium.
Barrett’s complicated by
adenocarcinoma

5. Alimentary LailaHasan
A Peptic stricture is a benign obstruction within the alimentary tract that could
cause GORD
TREATMENTS:
The Aims of treatment are to:
– Alleviate symptoms
– Heal oesophagitis
– Preventcomplications
– Prevent recurrent disease
–
Treatment can be divided by three ports of action: Lifestyle, medical and Surgery
1. Lifestyle – useful in mild cases
a. Decrease weight
b. Stopsmoking, alcohol,certainfoods
c. Avoidtightclothing
d. Raise headof bed*
e. Avoidstooping
f. Avoidlarge mealslate inthe evening
Shownto increase healingof oesophagitisincombinationwithhistaminereceptorantagonists*
2. Medical
a. Antacidsandalginates :good forrelief of reflux symptoms:magnesiumtrisilicateand
aluminiumhydroxide orgaviscon
i. Little evidence thattheyare betterthanplacebo
ii. No evidenceof oesophagitishealing
b. H2RA: reflux symptomsare controlledin80% after 6-8 weeks.(cimetidine,ranitidine)
c. Healingdependsondose,frequencyandgrade (I-V)
i. Overall 50% healedafter6-8weeks
ii. Grade I = 80%, Grade III = 20% at 8 weeks
iii. Control of symptomsdoesn’t=healing
d. Prokinetics: helpemptyingandclearingof oesophagus
i. eg. metoclopramide,
ii. domperidone
iii. cisapride)
Theyhave beenfoundtobe betterthan placeboincontrollingsymptoms,BUTthere islittle evidence that
theyheal oesophagitis

6. Alimentary LailaHasan
e. Protein Pump Inhibitos (PPIs) – omeprazole, esomeprazole, lansoprazole,
pantoprazole, rabeprazole – all inhibit gastric hydrogen pump which stops gastric
acid production.
i. Most effective medical treatment(healingrates>80% over8weeks)
ii. Excellentsymptomrelief
iii. Relief of symptomsgoodpredictorof endoscopichealing
iv. Effective forall grade of oesophagitis
v. Effective forresistantoesophagitis
vi. Preventscomplications
vii. Safe,fewadverse side effects
3. Surgical
a. Endoscopic (induce a ‘controlled’ stricture)
i. Stitch (sewing maching device)
ii. Radiofrequency damage of LOS
iii. Injection of compounds into LOS
1. All to be evaluated longterm
b. Surgical
i. Laproscopic or open WRAP (Nissen fundoplication) This is the tightening of
the lower valve and are for those people who have low oesophagus sphincter
tone and don’t want to be on PPIs.
1. As good as longterm PPI and prevent complications?
2. Cheaper than longterm PPI?
Initial Managment
Typical symptoms – no sinister symptoms and patient <45years old
Trial of treatmentwithoutinitial investigation –stepupor stepdownapproach
Stepup : lifestyle,antacids/alginates,H2RA,prokinetics,PPIs
Stepdown : lifestyle +PPIsanddecrease accordingto response
Patientassessedat6-8 weeks- successof Rx basedonsymptomrelief.If still symptomaticconsider
investigation
Who to Investigate?
• Sinister symptoms
• Diagnosis unclear
• Fails to respond to treatment after 6-8wks
• Relapses quickly
• >45 years of age with recent onset symptoms?
Post endoscopy management
If the Endoscopy shows:
• Oesophagitis + grade – commence medical treatment
• Complications :
• stricture – dilate (medical Rx increase or surgical)

7. Alimentary LailaHasan
• Barrett’s – medical, endoscopic, surgical treatment – consider surveillance until
75 years of age
• Consider surgery in certain circumstances for long term problems or failure to improve on
medical treatment but always need pH and manometry before proceeding. (Manometry is
when a tube with pressure sensors goes through the nose down to the stomach. The patient is
asked to swallow causing peristalsis occurs and a reading is obtained of the pressure on the
valves which is then projected into a graph).
If the Endoscopy shows:
• Normal – no oesophagitis but story good for reflux (endoscopy negative refluxer?)
• then undergo a Manometry and 24 pH studies. (A pH study involves the same sort of tubing
down the oesophagus into the stomach but instead of pressure sensors the acid content is
measured over a 24 hour period. At the same time the patient is asked to note down any
symptoms they feel and note the date and time of those symptoms. Once the study is complete
you can correlate whether the symptoms correspond to increased gastric pH at that time or the
symptoms were not due to increased pH. You can therefore define whether a patient needs to
be treated just for the symptoms and not the cause of increased gastric secretion.)