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== '''Definitions:''' == * GORD: When reflux of stomach contents causes troublesome symptoms and/or complications ** Progressive disease if no intervention ** Real risk of primary and secondary complications * Refractory GORD: Defined as partial or lack of response to PPI BD == '''Anatomy:''' == * Defective lower oesophageal sphincter has: ** Pressure <6mm Hg or ** Total length <2cm or ** Abdominal length <1cm == '''Risk factors''' == * Factors increasing intra-abdominal pressure ** Obesity *** Increased intra-abdominal pressure, decreased LOS pressure, impaired oesophageal body peristalsis, more frequent transient LOS relaxations *** Can often be asymptomatic - 45% of patients getting worked up for bariatric surgery have silent reflux ** Pregnancy *** Oestrogen and progesterone decrease LOS tone *** Gravid uterus * Factors compromising GOJ ** Smoking ** Hiatus hernia *** Severity correlates with size of hernia *** Impaired crural diaphragmatic component of GOJ, low LOS pressure, reduced threshold for eliciting transient LOS relaxation in response to gastric distension ** Drugs *** Anticholinergics *** Nitrates *** Calcium channel blockers *** Tricyclic antidepressants *** Opioids *** Theophylline *** Diazepam *** Barbiturates * Factors increasing acidity of gastric secretions ** Lifestyle *** Fat, chocolate, peppermint, caffeine, alcohol ** Zollinger-Ellison syndrome * Other ** Structural ** Mechanical ** Genetic ** H Pylori possibly protective - negative risk factor for reflux - thought to be due to atrophic gastritis == '''Physiology''' == * Gastric acid production - parietal cells in fundus and body of stomach ** Neurological - vagus stimulates parietal cells through ACh ** Endocrine - gastrin activates parietal cells ** Paracrine - histamine from enterochromaffin-like cells * Normal mechanisms clearing acid from oesophagus: ** Peristalsis is usually effective in returning fluid to stomach ** Swallowed saliva contains bicarbonate, which can neutralise acid == '''Pathophysiology''' == * GORD occurs when intra-gastric pressure is greater than high-pressure zone of the distal oesophagus ** Resting LOS pressure is too low (frequently associated with hiatal hernia - displacement of GOJ into the posterior mediastinum) ** Inappropriate relaxation of LOS in the absence of peristaltic contraction of the oesophagus (can occur in normal anatomic position) * Some degree of GORD is physiological, occurring in the setting of a normal LOS. Allows us to rapidly evacuate swallowed air from the stomach, that would otherwise cause bloating and flatulence. ** Pathological GORD occurs with greater oesophageal acid exposure, worse symptoms, and the presence of mucosal damage of the oesophagus * Hiatal hernias often associated with GORD - abnormal anatomy compromises the LOS ** See separate topic == '''Symptoms''' - oesophageal, extra-oesophageal and complications == * '''Typical''' symptoms: heartburn, regurgitation, water brash ** Volume reflux which is worse lying down and responds to PPIs ** Heartburn - epigastric or retrosternal caustic or stinging sensation, which does not typically radiate to the back, and is not described as a pressure sensation ** Water brash - sour taste described as either acid or bile ** Regurgitation - generally of digested food. Regurgitation of undigested food suggests oesophageal diverticulum or achalasia. * Differentiate between pathological and physiological: ** Physiological - short-lived, asymptomatic, post-prandial, not during sleep ** Pathological - often occurs nocturnally. A/w symptoms or mucosal injury * Atypical symptoms: consider GORD in dysphagia, chest pain, globus, odynophagia, cough/hoarseness/wheeze, sometimes nausea ** Dysphagia occurs with reflux-associated inflammatory processes of the oesophageal wall (Schatzki ring, diffuse distal oesophageal inflammation, peptic stricture - pathognomic for long-standing reflux). Can functionally shorten the oesophagus, making operations harder. * Extra-oesophageal symptoms: ** Laryngeal - hoarseness/dysphonia, throat clearing, throat pain, globus, choking, post-nasal drip, laryngeal and tracheal stenosis, laryngospasm, contact ulcers. ** Pulmonary - cough, shortness of breath, wheezing, pulmonary disease (asthma) *** Patients with asthma and GORD can see an improvement rate of 90% of children and 70% of adults in their asthma symptoms after anti-reflux surgery *** Idiopathic pulmonary fibrosis is possibly caused by GORD in some cases (as many as 94% of patients with IPF have been shown to have GORD) ** Occur due to *** Proximal oesophageal reflux and micro-aspiration of gastroduodenal contents causing direct caustic injury to the larynx and lower respiratory tract *** Distal oesophageal acid exposure triggering a vagal cough/bronchospasm reflux, due to common vagal innervation of trachea and oesophagus ** Variable response to PPI, even if these symptoms are due to GORD ** Need to thoroughly evaluate these patients for other causes (?ENT/resp referral). If no other cause found, Sabiston says anti-reflux surgery has a 70% success rate. * Alarm symptoms (complications): dysphagia, early satiety, haematemesis, melaena, vomiting, weight loss == '''Examination''' == * Not really helpful * Supraclavicular lymphadenopathy * Yellow/poor dentition == '''Differentials:''' == * Dysphagia: Oesophageal rings/webs, oesophageal motility disorder * Slowly progressive dysphagia: Strictures/cancers * Odynophagia: infectious or medication-induced oesophagitis * PUD * Coronary artery disease * Cholelithiasis == '''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 | |- |B | |- |C | |- |D | |} * 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 == '''Approach:''' == === '''New patients with GORD:''' === ** Consider gastroscopy if: *** Alarm features *** Risk factors for Barrett's and no endoscopy past 5-10 years *** Atypical symptoms ** Consider investigation to exclude alternative diagnoses ** Trial 8 weeks PPI *** Improvement - no further investigation *** No improvement - more extensive investigation *** Still no improvement or diagnosis - treat as refractory GORD === '''Refractory GORD:''' === ** Review PPI compliance - serum gastrin level should generally be 200-400pg/mL and only rarely above 500 ** Gastroscopy if not already done ** Consider manometry and ambulatory pH monitoring ** Review associated factors below ** Manage medically as per UTD algorithm ** Consider whether they are likely to have a good response from surgery == '''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 == '''Refractory GORD:''' == * Note that recurrence of reflux symptoms and/or reflux oesophagitis on PPIs is closely related to status of LOS and oesophageal motility. If both are abnormal, 80% recurrence. If both are normal, 8% recurrence. ** ?medication timing and adherence ** ?Differences in PPI metabolism ** ?Residual acid reflux ** ?Non-acid reflux ** ?Reflux hypersensitivity ** ?Functional heartburn *** == '''Complications:''' == * Oesophageal ** Erosive oesophagitis - reflux causes necrosis of mucosa ** Barrett's oesophagus - metaplastic columnar epithelium replaces stratified squamous epithelium after chronic GORD. *** See separate topic *** Predisposes to CA *** No specific symptoms to allow it to be differentiated from GORD *** Can be complicated in turn by ulcerations, strictures, haemorrhage ** Strictures *** Occur as part of the healing process of ulcers - collagen is deposited, then contracts *** May get symptomatic eg obstruction *** Should be biopsied to exclude malignancy *** Treat with dilatation and acid-suppressive therapy, majority effectively *** Dilatation can be done with either a balloon dilator or Savary dilator *** Refractor strictures can be treated with anti-reflux surgery or steroid injections * Extra-oesophageal ** Asthma ** Chronic laryngitis ** Laryngo-tracheal stenosis ** Chronic cough ** Etc [[Category:UGIS]]
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