Gastro-oesophageal reflux disease occurs when gastric acid. It occurs in about 1/4th of the Western population.
Pathophysiology
As we know, the lower oesophageal sphincter (LOS) allows food into the stomach from the oesophagus. In order to this it needs to relax episodically. In GORD, the LOS relaxes more frequently, thus allowing gastric acid into the oesophagus causing pain and damage to the oesophageal mucosa.
⚠️ Risk factors
Age
Obesity
Male gender (2:1)
Smoking
Caffeinated drinks
Fatty/spicy foods
😷 Presentation
Other symptoms include:
Belching
Odynophagia (pain in oesophagus when swallowing)
Chronic cough
Nocturnal cough
Examination may be unremarkable.
- Weight loss
- Dysphagia
- Early satiety
- Malaise
- Loss of appetite
🔢 Classification
Classification is done using the Los Angeles Classification for GORD:
Grade | Description |
A | One or more breaks in the mucosal fold <5mm (not continuous between the breaks). |
B | One or more breaks in the mucosal fold >5mm (not continuous between the breaks). |
C | Breaks are continuous between 2+ mucosal folds but <75% of circumference. |
D | Breaks cover >75% of circumference. |
🔍 Investigations
- Clinical diagnosis based on history and resolution after administering a PPI.
- 24hr pH monitoring is the gold standard. It is only required in patients who do not respond to medical treatment and who may require surgery. It may be combined with oesophageal manometry to assess oesophageal motility and exclude dysmotility.
Not usually required without red flag symptoms. Endoscopy’s main role would be to exclude malignancy and any other complications of reflux (Barrett’s, oesophagitis, stricturing).
If symptoms are refractory to PPI or are new onset in elderly patients, endoscopy may be indicated.
💡 PPIs need to be stopped 2 weeks prior to OGD.
🧰 Management
🏃🏽 Lifestyle Conservative treatments such as lifestyle modifications should be advised. This includes:
- Weight loss
- Smoking cessation
- Diet changes (no alcohol, caffeine, fatty foods)
- Refractive to medical therapies
- Patient does not want lifelong medication
- Complicated GORD (particularly recurrent pneumonia).
Fundoplication This is the main surgery done. This is when the fundus of the stomach is wrapped around the GOJ. It increases the resting LOS pressure.
Stretta
This uses radio-frequency waves to thicken the LOS.
Linx This is a string of magnetic beads inserted around the LOS to tighten the LOS, yet are able to open with passage of food.
⛔️ Complications
- Aspiration pneumonia
- Barrett’s oesophagus
- Oesophageal strictures
- Oesophageal cancer
- Anaemia
💊 Medication 🥇 PPIs are first-line treatment (omeprazole, lansoprazole). PPIs need to be stopped 2 weeks prior to OGD, however. Antacids such as magnesium trisilicate or alginates such as Gaviscon can also be tried. Ranitidine (+ other -tidines)- an H2 antagonist (antihistamine).
