Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease Definition Oesophagus exposed to acidic gastric contents. Happens when the intraabdominal pressure exceeds the LES pressure or inappropriate LES relaxation. Present if the symptoms are frequent – at least twice a week or impair quality of life or if complications of GORD are present. Key Info Some degree of reflux is a normal physiological process Symptom severity does not indicate disease severity Risk Factors Obesity – most common? Alcohol Pregnancy Smoking Caffeine Fatty foods Large meals Hital hernia Clinical Features Heartburn – most common Retrosternal burning that arises in throat Present in 15 to 20% of adults. Regurgitation of gastric contents into the throat Less common than heart burn Chest pain Usually intermittent and related to diet. Some have daily symptoms Extra-oesophageal symptoms Chronic cough Vocal cord dysfunction Hoarseness Asthma Investigations Diagnosis can be made on clinical grounds Ambulatory pH or impedance monitoring Direct measurement Gold standard for confirming a pathological acid reflux. Upper gastrointestinal endoscopy Not sensitive 2/3rds of patients with reflux have no evidence of microscopic inflammation -> nonerosive reflux disease (NERD) Indications Unclear diagnosis Red flag features -> anaemia, dysphagia, vomit and weight loss New symptoms in older patients Changing symptoms Severe or frequent symptom Inadequate response to treatment Atypical symptoms Barium swallow and nuclear studies -> not recommended as are not sensitive or specific Management If clinical features are mild – diet and lifestyle modifications If frequent or severe symptoms that cause significant lifestyle impairment – drug or surgical therapy. Diet and lifestyle modification Limit -> high fat meals, alcohol, coffee, chocolate, citrus fruit, tomato products, spicy foods and carbonated beverages. Measures: Eat smaller meals and eat slow Avoid lying down after eating Avoid eating or drinking 2 to 3 hours before sleep or heavy exverisse Positional therapy e.g. wedge billow or elevate head if symptoms happen at night Smoking cessation. Pharmacological therapy Severity Therapy First line Antiacid plus alginate orally (if needed) at 10 to 20 mls OR magnesium hydroxide plus aluminium hydroxide Mild intermittent symptoms (1 to 2 symptoms a week) orally, if required. If first line fails H2 receptor antagonist or PPI at standard dose H2 -> Famotidine at 20 mg or nizatidine at 150 mg orally PPI -> esomeprazole at 20 mg or omeprazole at 20 mg or lansoprazole at 20 mg Return if symptoms persist First line PPIs -> omeprazole at 20 mg orally -> half to one hour after meals -> at standard dose Take before breakfast if symptoms are mainly during the day Take before dinner if symptoms mainly at night Initial course -> 4 to 8 weeks If improve -> maintenance therapy Aims to control symptoms, reduce risk of GERD complications and risk of PPIs. At lowest dose and frequency Frequent or severe symptoms (more than twice a week) or have complications If symptoms re-occur -> return to lowest effective dose Explain to patients that symptoms vary overtime e.g. depending on meds and diet. Long term therapy only recommended in a small portion of patients. If initial therapy fails Confirm compliance and it is taking other meds that may interfere Refer for gastroenterology review once above ruled out. May consider combination therapy: PPIs and H2 antagonists. If Los Angeles grades A and B -> manage as per symptom severity If severe mucosal disease -> Los Angeles grades C and D (happen in only 10% of patients With known oesophageal findings Manage in consult with a gastroenterologist Need higher degree of acid suppression High dose PPI regimes: Omperazole twice daily ot pantoprazole 40 mg orally twice daily For 8 weeks? With extra-oesophageal symptoms Manage using high dose PPIs for 8 to 12 weeks PPI most effective when taken half to one hour before people Effectiveness decreases when taken with or after meals Pharmacology Notes Some H2 receptor antagonists and PPI are available without prescription. If have endoscopic findings -> therapy is guided by findings Surgical management Provide long term symptom control Similar efficacy to PPIs. Fundoplication Wraps the fundus around the lower oesophagus Strengthens valve Indications: Problematic heartburn or regurgitation despite pharmacological treatment (maximal dose) Works best for these patients. Symptoms with large hiatus hernia Complications such as Barret’s oesophagus or strictures Patients with atypical symptoms and no mucosal changes at endoscopy and poor response to PPIs usually don’t improve Low mortality rate Adverse effects: Inadequate symptom control, dysphagia, increase flatus, delayed gastric emptying, dumping syndrome and gas bloat syndrome in severe cases. Failure may be due to: Wrap disruption Recurrence of hiatus hernia Slippage of the fundoplication The above can happen due patient and surgery factors Endoscopic therapies Still under development?