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Gastro Oesophageo
Reflux Disease (GORD)
JMJ 1
Contents
• Pathophysiology
• Oesophageo mucosal defense mechanisms
• Clinical features
• Diagnosis and investigations
• Treatment
• Complications
JMJ 2
Pathophysiology
• Between swallows,
• Muscles of oesophagus are relaxed,
• Except for those of sphincters.
• LOS remains closed usually
• Muscles of LOS get relaxed when swallowing is initiated
• Transient lower oesophageal sphincter relaxations (TLESRs)
• Part of normal physiology
• But occurs more frequently in GORD patients
• Little amount of reflux is normal
• Sphincter pressure also increases in response to
• Rises in intra abdominal and intragastric pressures.
JMJ 3
The main anti reflux mechanisms
JMJ 4
Other anti reflux mechanisms
• Intra abdominal segment of oesophagus
• Acts as a flap valve
• Mucosal rosette formed by folds of gastric mucosa &
• the contraction of the crural diaphragm at the LOS
• Acting like a pinchcock,
• Prevents acid reflux
• Large hiatus hernia can impair this mechanism
• Oesophagus is rapidly cleared normally or refluxate
• By secondary peristalsis
• By gravity
• By salivary bicarbonate
JMJ 5
Factors associated with gastro
oesophageal reflux
• Pregnancy and obesity
• Fat, chocolate, coffee or alcohol ingestion
• Large meals
• Cigarette smoking
• Drugs
• Antimuscuranics
• Calcium- channel blokers
• Nitrates
• Systemic sclerosis
• After treatment of achalasia
• Hiatus hernia
JMJ 6
Factors associated with gastro
oesophageal reflux
• Pregnancy and obesity
• Fat, chocolate, coffee or alcohol ingestion
• Large meals
• Cigarette smoking
• Drugs
• Antimuscuranics
• Calcium- channel blokers
• Nitrates
• Systemic sclerosis
• After treatment of achalasia
• Hiatus hernia
JMJ 7
Osophageal mucosal defense
mechanisms
• Surface
• Mucus and the unstirred water layer trap bicarbonate
• This is a weak buffering mechanism, compared to that in the
stomach and duodenum
• Epithelium
• Apical cell membrane and junctional complexes between cells act to
limit diffusion of H+ into the cells.
• In oesophagitis – junctional complexes are damaged.
JMJ 8
Osophageal mucosal defense
mechanisms
• Postepithelium
• Bicarbonate normally buffers acid, in the cells and intracellular
spaces
• Hydrogen ions impair the growth and replication of damaged cells
• Sensory Mechanisms
• Acid stimulates primary sensory neurons in the oesophagus by
activating the VANILOID RECEPTOR 1 (VR1)
• This can initiate inflammation and release pro-inflammatory
substances from the tissue to produce pain
• Pain can also be due to - contraction of longitudinal oesophageal
muscle
JMJ 9
Clinical fetures
Clinical
Features
Heartburn Regurgitation
JMJ 10
Heartburn
• Is the major feature
• Aggravated by
• Bending
• Stooping
• Lying down
• Relieved by
• Oral antacids
• Patient complains pain on drinking
• Hot liquids
• Alcohol
JMJ 11
Which promotes acid exposure
Heartburn
• Correlation between heartburn and esophagitis is poor
• Differentiation of cardiac and oesophageal pain can be
difficult
• In addition to the clinical features,
• a trial of PPI is always worthwhile and
• if symptoms persist,
• ambulatory pH and impedance monitoring should be
performed
JMJ 12
Regurgitation of food and acid
• Particularly on bending or lying flat
• Aspiration pneumonia is unusual without an accompanying
stricture
• But cough and asthma can occur & respond slowly (1-4
months to a PPI
JMJ 13
JMJ 14
Hiatus Hernia
Hiatus Hernia
Sliding Hiatus
Hernia
Rolling or para-
oesophageal
hernia
JMJ 15
Sliding hiatus hernia
JMJ 16
• Oesophageal-gastro junction and part of stomach
• ‘slides’ through the hiatus
• That it lies above the diaphragm
• Present in 30% of people over 50 years
• Produces no symptoms
• Any symptoms are due to reflux
Rolling or para-oesophageal hernia
JMJ 17
• Part of the fundus of the stomach,
• Prolapses through the hiatus,
• Alongside the oesophagus
• LOS remains below the diaphragm & remains competent
• Occasionally severe pain occurs due to volvulus or
strangulation
Rolling or para-oesophageal hernia
JMJ 18
Features of pain in GORD and Cardiac
ischemia
GORD
• Burning, worse on bending,
stooping or lying down
• Seldom radiates to the
arms
• Worse with hot drinks or
alcohol
• Relieved by antacids
Cardiac ischemia
• Gripping or crushing
• Radiates to neck or left arm
• Worse with exercise
• Accompanied by dyspnea
JMJ 19
Diagnosis and Investigations
JMJ 20
• Clinical diagnosis can be made
• Unless there are alarm signs, (esp.dysphagia),
• Patients under 45 years,
• Can safely be treated initially without investigations
Investigations
Assess oesophagitis &
hiatus hernia by
endoscopy
Document reflux by
intraluminal monitoring
Intraluminal Monitoring
JMJ 21
• 24 hour luminal Ph monitoring or,
• Impedance combined with manometry is helpful
• if there is no response to PPI &
• should always be performed to confirm reflux before
surgery
• Excessive reflux
• pH <4 for >4% of the time
Treatment
JMJ 22
• Loss of weight
• Raising head end of the bed at night
• Precipitating factors should be avoided,
• With dietary measures
• Reduction in alcohol and caffeine consumption &
• Cessation of smoking
Treatment
JMJ 23
Treatment
Life style
modifications
Drugs
Endolunimal
gastroplication
Surgery
Treatment
JMJ 24
Drugs
Alginate-
containing
antacids
Dopamine
antagonist
prokinetic
agents
H2-
receptor
antagonists
Proton
pump
inhibitors
Alginate-containing antacids
JMJ 25
• 10 ml tds
• ‘over the counter’ agents for GORD
• They form a gel or ‘foam raft’ with gastric contents to
reduce reflux
• Magnesium containing antacids
• Tends to cause diarrhea
• Aluminum containing compounds
• Cause constipation
Dopamine antagonist prokinetic agents
JMJ 26
• Metoclopramide and domepridone
• Enhances peristalsis &
• Speed gastric emptying
H2- receptor antagonists
JMJ 27
• Cimetidine
• Ranitidine
• Famotidine
• Nizatidine
• Acid suppressors
• If antacids fail
• They can be often obtained over the counter
Proton Pump Inhibitors
JMJ 28
• Omeprazole
• Rabeprazole
• Lansoprazole
• Pantoprazole
• Esomeprazole
• Inhibit gastric hydrogen/potassium- APTase
• Reduce gastric acid secretion by 90%
• DOC for all mild cases
• Most respond well
• 20-30% will persist with heartburns
• Severe symptoms – bd dosing & prolonged Tx
Endo luminal gastroplication
JMJ 29
• In this endoscopic procedure,
• multiple plications or pleates are
• made below the gastro-oesophageal junction.
Surgery
JMJ 30
• Never be performed to hiatus hernia alone
• Best predictor
• Typical reflux symptoms with documented acid reflux
• Current surgical techniques –
• Return the oesophageal junction to the abdominal cavity
• Mobilize the gastric fundus
• Close the diaphragmatic crura snugly
• Involve a short tension-free fundoplication
Surgery
JMJ 31
• Indications for operation
• Not clear
• Intolerance to medication
• Desire for freedom from medications
• Expense of therapy
• Concern of long-term side effects
• Patients with oesophageal dysmotility unrelated to acid
reflux,
• patients with no response to PPIs and
• those with undelying functional bowel disease
• should NOT have surgery
JMJ 32
JMJ 33
Complications
• Peptic stricture
• Barrett’s oesophagus
JMJ 34
Peptic Stricture
• Due to usage of PPI – strictures are uncommon in this era
• Usually occurs in – patients over the age of 60
• Present with intermittent dysphagia for solids
• which worsens gradually over a long period
• Mild cases
• May respond to PPI alone
• Severe cases
• Need endoscopic dilatation
• Long term PPI therapy
JMJ 35
Barrett’s Oesophagus
• Part of normal oesophageal squamous epithelium is
• replaced by metaplastic coloumnar mucosa
• to form a segment of ‘columnar-lined oesophagus’ (CLO)
• There is almost always a hiatus hernia
• Diagnosis is made by
• Endocopy showing proximal displacement of squamo coloumnar
mucosal junction
• Biopsies demonstrating coloumnar lining above the proximal gastric
folds
• Interstinal metaplasia is no longer a requirement – (British Society
of Gastroenterology guidelines)
JMJ 36
Barrett’s Oesophagus
JMJ 37
Barrett’s Oesophagus
JMJ 38
Barrett’s Oesophagus
JMJ 39
Barrett’s Oesophagus
• Barret’s oesophagus may be seen as
• Continual circumferential sheet
• Finger like projections extending upwards from the squamo-
coloumnar junction
• Islands of coloumnar mucosa interspersed in areas of residual
squamous mucosa
• Central obesity increases risk of Barrett’s by 4.3 times
• Commonest in middle aged obese men
• 0.12-0.5% - develop oesophageal adenocarcinoma
JMJ 40

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Gastro oesophageo reflux disease (GORD)

  • 2. Contents • Pathophysiology • Oesophageo mucosal defense mechanisms • Clinical features • Diagnosis and investigations • Treatment • Complications JMJ 2
  • 3. Pathophysiology • Between swallows, • Muscles of oesophagus are relaxed, • Except for those of sphincters. • LOS remains closed usually • Muscles of LOS get relaxed when swallowing is initiated • Transient lower oesophageal sphincter relaxations (TLESRs) • Part of normal physiology • But occurs more frequently in GORD patients • Little amount of reflux is normal • Sphincter pressure also increases in response to • Rises in intra abdominal and intragastric pressures. JMJ 3
  • 4. The main anti reflux mechanisms JMJ 4
  • 5. Other anti reflux mechanisms • Intra abdominal segment of oesophagus • Acts as a flap valve • Mucosal rosette formed by folds of gastric mucosa & • the contraction of the crural diaphragm at the LOS • Acting like a pinchcock, • Prevents acid reflux • Large hiatus hernia can impair this mechanism • Oesophagus is rapidly cleared normally or refluxate • By secondary peristalsis • By gravity • By salivary bicarbonate JMJ 5
  • 6. Factors associated with gastro oesophageal reflux • Pregnancy and obesity • Fat, chocolate, coffee or alcohol ingestion • Large meals • Cigarette smoking • Drugs • Antimuscuranics • Calcium- channel blokers • Nitrates • Systemic sclerosis • After treatment of achalasia • Hiatus hernia JMJ 6
  • 7. Factors associated with gastro oesophageal reflux • Pregnancy and obesity • Fat, chocolate, coffee or alcohol ingestion • Large meals • Cigarette smoking • Drugs • Antimuscuranics • Calcium- channel blokers • Nitrates • Systemic sclerosis • After treatment of achalasia • Hiatus hernia JMJ 7
  • 8. Osophageal mucosal defense mechanisms • Surface • Mucus and the unstirred water layer trap bicarbonate • This is a weak buffering mechanism, compared to that in the stomach and duodenum • Epithelium • Apical cell membrane and junctional complexes between cells act to limit diffusion of H+ into the cells. • In oesophagitis – junctional complexes are damaged. JMJ 8
  • 9. Osophageal mucosal defense mechanisms • Postepithelium • Bicarbonate normally buffers acid, in the cells and intracellular spaces • Hydrogen ions impair the growth and replication of damaged cells • Sensory Mechanisms • Acid stimulates primary sensory neurons in the oesophagus by activating the VANILOID RECEPTOR 1 (VR1) • This can initiate inflammation and release pro-inflammatory substances from the tissue to produce pain • Pain can also be due to - contraction of longitudinal oesophageal muscle JMJ 9
  • 11. Heartburn • Is the major feature • Aggravated by • Bending • Stooping • Lying down • Relieved by • Oral antacids • Patient complains pain on drinking • Hot liquids • Alcohol JMJ 11 Which promotes acid exposure
  • 12. Heartburn • Correlation between heartburn and esophagitis is poor • Differentiation of cardiac and oesophageal pain can be difficult • In addition to the clinical features, • a trial of PPI is always worthwhile and • if symptoms persist, • ambulatory pH and impedance monitoring should be performed JMJ 12
  • 13. Regurgitation of food and acid • Particularly on bending or lying flat • Aspiration pneumonia is unusual without an accompanying stricture • But cough and asthma can occur & respond slowly (1-4 months to a PPI JMJ 13
  • 15. Hiatus Hernia Hiatus Hernia Sliding Hiatus Hernia Rolling or para- oesophageal hernia JMJ 15
  • 16. Sliding hiatus hernia JMJ 16 • Oesophageal-gastro junction and part of stomach • ‘slides’ through the hiatus • That it lies above the diaphragm • Present in 30% of people over 50 years • Produces no symptoms • Any symptoms are due to reflux
  • 17. Rolling or para-oesophageal hernia JMJ 17 • Part of the fundus of the stomach, • Prolapses through the hiatus, • Alongside the oesophagus • LOS remains below the diaphragm & remains competent • Occasionally severe pain occurs due to volvulus or strangulation
  • 19. Features of pain in GORD and Cardiac ischemia GORD • Burning, worse on bending, stooping or lying down • Seldom radiates to the arms • Worse with hot drinks or alcohol • Relieved by antacids Cardiac ischemia • Gripping or crushing • Radiates to neck or left arm • Worse with exercise • Accompanied by dyspnea JMJ 19
  • 20. Diagnosis and Investigations JMJ 20 • Clinical diagnosis can be made • Unless there are alarm signs, (esp.dysphagia), • Patients under 45 years, • Can safely be treated initially without investigations Investigations Assess oesophagitis & hiatus hernia by endoscopy Document reflux by intraluminal monitoring
  • 21. Intraluminal Monitoring JMJ 21 • 24 hour luminal Ph monitoring or, • Impedance combined with manometry is helpful • if there is no response to PPI & • should always be performed to confirm reflux before surgery • Excessive reflux • pH <4 for >4% of the time
  • 22. Treatment JMJ 22 • Loss of weight • Raising head end of the bed at night • Precipitating factors should be avoided, • With dietary measures • Reduction in alcohol and caffeine consumption & • Cessation of smoking
  • 25. Alginate-containing antacids JMJ 25 • 10 ml tds • ‘over the counter’ agents for GORD • They form a gel or ‘foam raft’ with gastric contents to reduce reflux • Magnesium containing antacids • Tends to cause diarrhea • Aluminum containing compounds • Cause constipation
  • 26. Dopamine antagonist prokinetic agents JMJ 26 • Metoclopramide and domepridone • Enhances peristalsis & • Speed gastric emptying
  • 27. H2- receptor antagonists JMJ 27 • Cimetidine • Ranitidine • Famotidine • Nizatidine • Acid suppressors • If antacids fail • They can be often obtained over the counter
  • 28. Proton Pump Inhibitors JMJ 28 • Omeprazole • Rabeprazole • Lansoprazole • Pantoprazole • Esomeprazole • Inhibit gastric hydrogen/potassium- APTase • Reduce gastric acid secretion by 90% • DOC for all mild cases • Most respond well • 20-30% will persist with heartburns • Severe symptoms – bd dosing & prolonged Tx
  • 29. Endo luminal gastroplication JMJ 29 • In this endoscopic procedure, • multiple plications or pleates are • made below the gastro-oesophageal junction.
  • 30. Surgery JMJ 30 • Never be performed to hiatus hernia alone • Best predictor • Typical reflux symptoms with documented acid reflux • Current surgical techniques – • Return the oesophageal junction to the abdominal cavity • Mobilize the gastric fundus • Close the diaphragmatic crura snugly • Involve a short tension-free fundoplication
  • 31. Surgery JMJ 31 • Indications for operation • Not clear • Intolerance to medication • Desire for freedom from medications • Expense of therapy • Concern of long-term side effects • Patients with oesophageal dysmotility unrelated to acid reflux, • patients with no response to PPIs and • those with undelying functional bowel disease • should NOT have surgery
  • 33. JMJ 33 Complications • Peptic stricture • Barrett’s oesophagus
  • 34. JMJ 34 Peptic Stricture • Due to usage of PPI – strictures are uncommon in this era • Usually occurs in – patients over the age of 60 • Present with intermittent dysphagia for solids • which worsens gradually over a long period • Mild cases • May respond to PPI alone • Severe cases • Need endoscopic dilatation • Long term PPI therapy
  • 35. JMJ 35 Barrett’s Oesophagus • Part of normal oesophageal squamous epithelium is • replaced by metaplastic coloumnar mucosa • to form a segment of ‘columnar-lined oesophagus’ (CLO) • There is almost always a hiatus hernia • Diagnosis is made by • Endocopy showing proximal displacement of squamo coloumnar mucosal junction • Biopsies demonstrating coloumnar lining above the proximal gastric folds • Interstinal metaplasia is no longer a requirement – (British Society of Gastroenterology guidelines)
  • 39. JMJ 39 Barrett’s Oesophagus • Barret’s oesophagus may be seen as • Continual circumferential sheet • Finger like projections extending upwards from the squamo- coloumnar junction • Islands of coloumnar mucosa interspersed in areas of residual squamous mucosa • Central obesity increases risk of Barrett’s by 4.3 times • Commonest in middle aged obese men • 0.12-0.5% - develop oesophageal adenocarcinoma