GORD (Gastro-oesophageal Reflux Disease) PDF

Gastro-oesophageal Reflux Disease Peptic Ulcer Disease Dr Kenji So Reflux and Heartburn Case 50 y.o. male Reflux symptoms for 2 years, occasional nocturnal symptoms Relief with PPI Weight gain of 10kg, smoking 5-10 cigarettes/day Normal bowel habits PMHx: IHD, Hypertension, T2DM, OA Meds: as...

Gastro-oesophageal Reflux Disease Peptic Ulcer Disease Dr Kenji So Reflux and Heartburn Case 50 y.o. male Reflux symptoms for 2 years, occasional nocturnal symptoms Relief with PPI Weight gain of 10kg, smoking 5-10 cigarettes/day Normal bowel habits PMHx: IHD, Hypertension, T2DM, OA Meds: aspirin, irbesartan, naproxen PRN  Definition Gastro-oesophageal reflux disease is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications Vakil et al, The Montreal Definition and Classification of Gastroesophageal Reflux Disease: A Global Evidence-Based Consensus. Am J Gastroenterol 2006;101:1900–1920 Some degree of reflux is physiologic. Physiologic reflux episodes typically occur post-prandially, are short-lived, asymptomatic, and rarely occur during sleep. Pathologic reflux is associated with symptoms or mucosal injury and often occurs nocturnally. GORD is classified based on the appearance of the oesophageal mucosa on upper endoscopy into the following: ◦ Erosive oesophagitis — Erosive oesophagitis is characterized by endoscopically visible breaks in the distal oesophageal mucosa with or without troublesome symptoms of GORD. ◦ Nonerosive reflux disease — Nonerosive reflux disease or endoscopy negative reflux disease is characterized by the presence of troublesome symptoms of GORD without visible oesophageal mucosal injury.  GORD A common problem 10-20% of population in Western countries, less in East Asia Prevalence is increasing Age>50 years, smoker, NSAID use and Obesity are risk factors Random sample survey in Western Sydney (n=1000) showed prevalence of 12% (at least weekly symptoms).2 1.Eusebi LH, et al. Gut 2018;67:430–440 2.Eslick and Talley, J Clin Gastroenterol 2009;43:111–17 Pathophysiology Pathological GORD happens if: ◦ Increased oesophageal exposure to gastric juice ◦ Reduced threshold for epithelial injury (epithelial resistance) ◦ Increased symptom perception (visceral hypersensitivity) Anti-reflux barrier ◦ Lower oesophageal sphincter (LOS) ◦ Crural diaphragm ◦ Supporting structures of the gastro-oesophageal flap valve  Anti reflux barrier http://www.medigus.com/healthcare-professional/clinical-presentations/273-anti-reflux-barrier-how-does-your-body-prev ent-acid-reflux  Hill Classification ansdotter Ida et al., Endoscopy International Open 2016; 04: E311–E317  Mechanisms of reflux TLESR ◦ Transient LES relaxations ◦ occur independently of swallowing ◦ not accompanied by peristalsis, accompanied by diaphragmatic inhibition ◦ persist for longer periods than swallow induced LES relaxations (>10 seconds) ◦ The dominant stimulus for tLESRs is distension of the proximal stomach ◦ Typically account for up to 90% of reflux events in normal subjects or GERD patients without hiatus hernia Tack and Pandolfino, Gastroenterology Vol. 154, No. 2  Mechanisms of reflux Low LES pressure Swallow-associated LES relaxations Straining during periods with low LES pressure ◦ These mechanisms are important when synergy between Crural diaphragm and LES is lost ◦ Hiatus hernia ◦ Advanced Scleroderma (very low LES pressure) ◦ After surgical myotomy Tack and Pandolfino, Gastroenterology Vol. 154, No. 2 Protective factors Oesophageal Clearance (determines reflux exposure time) ◦ Peristalsis ◦ Hiatus hernia impairs clearance by causing re-reflux ◦ Gravity ◦ Buffering of acid by swallowed saliva (HCO3) ◦ Saliva has growth factors, such as epidermal growth factor, which promote mucosal repair and defences ◦ Prolonged reflux exposure time in sleep and in smokers Oesophageal mucosal integrity ◦ Tight junctions ◦ Na+/H+ exchanger; and a sodium dependent Cl-/HCO3- exchanger ◦ Decreases with age, poor nutritional status  Oesophageal hypersensitivity Phenotypes of reflux differ despite similar symptoms ◦ Non erosive reflux disease ◦ No erosions/ulceration but increased acid exposure (correlates with symptoms) ◦ Reflux hypersensitivity ◦ Normal acid exposure but a correlation between symptoms and acid reflux event ◦ Functional heartburn ◦ Normal acid exposure and no correlation between symptoms and reflux events Shown through various clinical and lab investigations ◦ pH and impedence studies ◦ Oesophageal acid perfusion studies ◦ Oesophageal ballon distension test 1. Tack and Pandolfino, Gastroenterology Vol. 154, No. 2 2. Savarino, E. et al. Nat. Rev. Gastroenterol. Hepatol. 10, 371–380 3. Dunbar et al, JAMA. 2016;315(19):2104-2112  Obesity Even small Intragastric amounts of pressure is Increased Increased risk weight loss (4- higher in strain on anti- of hiatus 6 kg) can obese reflux barrier hernia reduce individuals symptoms Correlates with BMI and waist circumference Tack and Pandolfino, Gastroenterology Vol. 154, No. 2 Jacobson et al, N Engl J Med 2006;354:2340–2348 Clinical Features Other symptoms Typical Symptoms Epigastric pain, early satiety, belching and bloating could be associated with GORD Heartburn Dysphagia Stricture More common postprandially Odynophagia Regurgitation Oesophageal ulcer Globus sensation Chest pain Exclude cardiac causes More common after meals/ at night Relieved with antacids Extraoesophageal Symptoms GORD can be associated with: ◦ Chronic cough ◦ Laryngitis ◦ Asthma ◦ Dental caries GORD regarded as a co-factor rather than main causative factor Investigate for other causes Difficult to associate reflux if no typical symptoms ◦ pH impedence monitoring can help ◦ Pharyngeal pH catheter is being used now to check for proximal reflux in these cases Trial of PPI remains 1st line treatment  Diagnosis Clinical Endoscopy Classical symptoms Alarm symptoms Heartburn and regurgitation Patients at increased risk for Sensitivity for Erosive Barrett’s oesophagitis is only 30-76%, Long duration of GORD specificiy 62-96%1 symptoms Empirical PPI trial Age >50 PPI response has sensitivity of Obese esp. male 78% and Specificity of 54%2 Smoker Negative trial does not exclude Family History GORD Non response to PPI Non cardiac chest pain 1.Moayyedi et al, JAMA 2006 ; 295 : 1566 – 76. 2.Numans et al, Ann Intern Med 2004 ; 140 : 518 – 27 Endoscopy According to Lyon consensus, findings confirmatory for GORD are: ◦ LA grade C,D oesophagitis ◦ Barrett’s ◦ Peptic stricture LA grade A,B considered borderline Allows for: ◦ Diagnosis of Barrett’s ◦ Taking biopsies of strictures/exclusion of dysplasia ◦ Exclude other causes of symptoms e.g. EoE where suspected ◦ Routine biopsies are not recommended Ambulatory Reflux monitoring The only test that allows: ◦ Determining the presence of abnormal oesophageal acid exposure ◦ Reflux frequency ◦ Symptom association with reflux episodes Can be done through: ◦ Transnasal Catheter (24h) ◦ pH or impedence pH ◦ Telemetry Capsule (Bravo) (usually 48h) 24 hour pH monitoring Fig A time pH