Gastroesophagial Reflux Disease

 

Gastroesophageal reflux disease (GORD)

• Pathophysiology

  Reflux of stomach content into oesophagus, usually due to lower oesophageal sphincter dysfunction.

• Signs and symptoms

  • Heartburn, a burning chest/epigastric pain. Worse after eating, on lying, and bending forward. Relieved by antacids.
  • Cough, hoarseness, nocturnal asthma.
  • Belching, acid brash (acid regurgitation).

• Risk factors

  Medical:

  • Hiatus hernia.
  • Gastric acid hypersecretion.
  • Pregnancy

  Lifestyle:

  • Obesity
  • Overeating
  • Smoking
  • Alcohol

  Drugs, BACON:

  • β-blockers
  • Anticholinergics
  • Calcium channel blockers.
  • Oral contraceptives.
  • NSAIDs

• Investigations

  Diagnosis is usually clinical, involving a PPI trial.

  Refer for urgent endoscopy if there is suspicion of malignancy:

  • Alarm signs for gastric or oesophageal cancer: >55 years old at onset of dyspepsia (and persistent), persistent vomiting, dysphagia, weight loss, upper GI bleeding (or iron-deficiency anaemia), epigastric mass.
  • Endoscopy may show oesophagitis (erosions, strictures, ulceration), Barret's oesophagus, or oesophageal cancer.
  • Stop PPIs 2 weeks before test.

  pH monitoring if clinical picture and endoscopy not diagnostic:

  • Naso-oesophageal catheter or wireless radiotelemetry.
  • pH <4 for >4% of 24 hour period is diagnostic.

• Management

  Management of dyspepsia:

  1. Review meds and try lifestyle changes for 1 month. Endoscopy if there are alarm signs.
  2. Empirical PPI therapy for 1-2 months if GORD suspected (rather than ulcer) i.e. heartburn predominates.
  3. H. pylori testing if still symptomatic. Needs 2 weeks PPI washout first.

  If GORD confirmed on endoscopy, go straight to PPI.

  Lifestyle changes:

  • Reduce alcohol and smoking.
  • Lose weight and exercise.
  • Reduce spicy and fatty foods.
  • Have small, regular meals.

  Long-term:

  • Low dose PPI if symptoms recur, but ideally aim to just use antacids.

• Complications

  • Oesophagitis
  • Oesophageal ulcers.
  • Benign oesophageal strictures (aka peptic stricture).
  • Barrett's oesophagus in 10%.
  • All are potential causes of dysphagia.

• Proton pump inhibitors (PPIs)

  Drugs

  Omeprazole, esomeprazole, lansoprazole, and pantoprazole.

  Mechanism

  Inhibits the H+/K+ ATPase (proton pump) of gastric parietal cells.

  Side effects

  • GI (common): diarrhoea, constipation, nausea, vomiting, abdo pain.
  • CNS: headache, dizziness.
  • C. diff, especially if taken with antibiotics.
  • ↓Mg2+, ↓Na+.
  • Osteoporotic fracture.
  • Acute interstitial nephritis.

  Interactions

  • Inhibits CYP3A4 → ↑warfarin, ↑BZD, ↑tramadol.
  • Inhibits CYP2C19 → ↓clopidogrel efficacy.