Editing GORD (section)

== '''Workup:''' ==

* '''Barium     swallow''' 
** Not diagnostic, although      mucosal changes may be seen. Useful for excluding differentials      (diverticula, tumours, strictures, achalasia, dysmotility, gastroparesis)
** Allows definition of hiatal      hernia
* '''Gastroscopy'''
** Indications for gastroscopy:
*** Alarm features present and       no endoscopy within three months
**** New onset of dyspepsia in        patient >60 years
**** Evidence of GI bleeding
**** Iron deficiency anaemia
**** Anorexia
**** Unexpained weight loss
**** Dysphagia
**** Odynophagia
**** Persistent vomiting
**** Gastrointestinal cancer in        first-degree relative
*** Screen for Barrett's       oesophagus if they have multiple risk factors and also have had GORD for       5-10 years:
**** Age >50
**** Male
**** White
**** Hiatal hernia
**** Obesity
**** Nocturnal reflux
**** Smoker
**** First-degree relative with        Barrett's and/or adenocarcinoma
** Findings:
*** 70-85% of patients with       symptoms defined as GORD have no evidence of oesophagitis on endoscopy
*** Should be classified on       upper endoscopy to
**** Erosive oesophagitis -        visible breaks in distal oesophageal mucosa
**** Nonerosive reflux disease        - no visible breaks
*** Ulcerations in distal       oesophagus
*** Look for peptic strictures,       Barrett's metaplasia, oesophageal adenocarcinoma
*** Assess GOJ - retroflex 180       degrees in the stomach to visualise from below, and grade according to       Hill classification (see 'gastroscopy technique')
*** Note any hiatus hernia
*** Grade severity of erosive       oesophagitis. Most common scheme is Los Angeles classification (LA)
****

{| class="wikitable"
|A
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|-
|B
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|-
|C
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|-
|D
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|}

* Peptic strictures and LA     class C and D oesophagitis can be considered pathognomic for GORD,     rendering pH monitoring unnecessary

* '''Oesophageal     manometry''' 
** Assesses function of      oesophageal body and LOS
** Indications:
*** Can be used in patients       that might have a motility disorder - chest pain, dysphagia, normal       upper endoscopy.
*** Also should be done prior       to anti-reflux surgery
*** Main reason is to exclude       motility disorders which might be made worse by an operation
* '''Ambulatory     pH monitoring''' -     gold standard
** Indications:
*** Refractory GORD/typical       symptoms but no improvement with PPI
*** Useful to correlate       symptoms with reflux and quantify oesophageal acid exposure
*** Doubt over cause of       oesophagitis - as in LA class A and B oesophagitis
** Technique:
*** Need to stop       PPI/antisecretory/antacids 2 weeks before
*** One way is via trans-nasal       probe, alternatively implant a Bravo capsule just above GOJ which       communicates with a bluetooth device
*** Patient also tracks their       symptoms for correlation
*** Calculate DeMeester score:       >14.72 confirms pathologic GORD
**** Uses factors for the score        such as total number of reflux episodes, length of episodes, number of        episodes lasting >5 minutes, percentage of time spent in reflux in        upright and supine positions
** Peptic strictures can cause      false-negative pH studies - ideally done after dilatation of the      stricture and biopsied
* '''Oesophageal     impedance monitoring'''
** Identifies episodes of      non-acid reflux
** Often done in conjunction      with pH monitoring
* Gastric emptying study
* CT
* Colonoscopy