Editing GORD (section)

== '''Management:''' ==

=== '''Lifestyle''' (not proven very much) ===

** Weight loss (if overweight)
** Elevation of bed head
** Eliminate fatty foods,      caffeine, chocolate, spicy foods, etc
** Don't eat right before bed
** Smaller, more frequent meals
** Quit smoking and drinking
** Elimination of constipation

=== '''Medical''' ===

** PPI
*** Irreversibly binds the H+,       K+-ATPase proton pump in parietal cells
*** Require an acidic       environment to be activated - may not work properly with       sucralfate/antacids
*** Maximal pharmacologic       effect occurs about 4 days after initiation, and effect lasts for the       life of the parietal cell (1 week)
*** Maximal: BD PPI
*** Side effects
**** Short-term: headache, abdo        pain, flatulence, constipation, diarrhoea
**** Reports of long-term        associations with dementia and bone density issues are based on        observational studies and are hard to prove. 2024 expert opinion is        that these risks should be de-emphasised. The true long-term risks are        probably slightly higher risk of gut infection and electrolyte        irregularities, including hypomagnesaemia.
** H2-receptor antagonists
*** Inhibit the histamine       receptor on the parietal cell
*** Famotidine is the most       potent, followed by ranitidine, nizatidine, and cimetidine
** Antacids
*** Contain aluminium       hydroxide, calcium carbonate, or magnesium trisilicate
*** Magnesium antacids - best       buffers, but can cause diarrhoea
*** Phosphorus antacids -       occasionally result in hypophosphataemia and constipation
*** Neutralise gastric acid and       decrease acid delivery to the duodenum, although the precise mechanism       is unclear
** Sucralfate
*** Sucrose octasulfate       complexed with aluminium hydroxide
*** Binds to injured gastric       tissue and simulates angiogenesis and granulation tissue formation
*** Lasts for about 6 hours

=== '''Surgery''' ===

** Indications:
*** Typical symptoms +       objective signs (significant oesophagitis, Barrett's, hiatus hernia) =       offer operation if medical management fails, generally with a screening       Barium swallow beforehand to exclude dysmotility (manometry if       concerning features for dysmotility)
*** Atypical symptoms and/or       lack of objective signs: refer for oesophageal manometry and pH, and       operate based on DeMeester score
*** Haematemesis
*** Iron deficiency anaemia due       to Cameron lesions
*** Chest pain due to recurrent       volvulus
** Predictors of good response:
*** Best results in those with       abnormal 24-hr pH score, typical primary symptoms and response to PPI       (=90% will have good or excellent result)
**** Typical symptoms =        heartburn, acid regurgitation
**** Atypical is cough, globus,        hoarse voice, odynophagia, sore throat, etc = less predictive of good        result from surgery
**** Be very wary of patients        with atypical symptoms or a history of not responding to PPI - should        confirm pathological acid reflux with at least two objective tests        prior to offering surgery
*** Best chance of positive       outcome in those <50yo
*** Recurrent reflux more       common in women, obese
***
** Hiatus hernia and GORD
*** Plan intervention based on       the degree that each problem is thought to be contributing to symptoms
*** Hiatus hernia is likely to       be the dominant process when main symptoms are dysphagia, food sticking,       early satiety, regurgitation, chest pain and vomiting
**** Will likely have relief        with abdominal gastropexy and partial wrap
** Obesity and GORD
*** RYGB can be a good way of       simultaneously controlling GORD and obesity - excludes most parietal       cells from contact with oesophagus, and also prevents duodenal acid from       contacting oesophagus
*** Consider RYGB instead of       fundoplication
*** Fundoplication should       rarely be considered in patients with BMI > 40
*** Avoid doing a sleeve       gastrectomy in patients with GORD
*** GORD with previous RYGB
**** Cause - overly large        gastric pouch, gastrogastric fistula, hiatal hernia
**** Hard to do fundoplication        due to lack of fundus
**** Options - close        gastrogastric fistula, correct hiatal hernia, revise large gastric        pouch, magnetic sphincter implantation
*** GORD with previous sleeve       gastrectomy
**** Hard to do fundoplication        due to lack of fundus
**** Options - convert to RYGB        or fix the hiatus hernia or magnetic sphincter implantation
** Ineffective oesophageal      motility
*** Toupet/Dor might be safer       than Nissen, to prevent dysphagia
*** However, remains       controversial, and total fundoplication will probably give better       control in the long run
*** If there is a total absence       of oesophageal body contractility, much stronger indication for partial       fundoplication only
** Barrett's oesophagus
*** About half of patients with       BE see endoscopic regression after anti-reflux surgery
*** Should not be considered an       indication for anti-reflux surgery alone
*** If you do operate, need to       continue endoscopic surveillance
** Young healthy patient with      small HH and GORD
*** Manage with PPI and       lifestyle until requiring BD PPI and getting breakthrough symptoms