GORD
Gastro-Oesophageal Reflux Disease
- Fundamental abnormality is incompetence of the oesophageal-gastric junction as an anti-reflux barrier
- Peristaltic dysfunction becomes progressively more common going from non-erosive to erosive oesophagitis, to Barrett’s oesophagus.
- motility is commonly measured to be normal
- Diagnosis is primarily clinical and testing more often useful in scenarios of failed treatment
- Typical GORD symptoms (heartburn and acid regurgitation) are more likely than atypical symptoms to respond to treatment.
- With atypical symptoms (chest pain, chronic cough, laryngitis, etc), PPI response rates are much lower than with heartburn, thereby reducing the ability to use the response to PPI to substantiate the Dx
- up to 2/3 with GORD will not have visible signs of oesophagitis on endoscopy.
- for those where there is no sign of oesophagitis, symptoms are thought to result from the presence of abnormal spaces in the epithelium of the mucosa, causing excessive stimulation of nerve endings and peripheral sensitisation
- gas reflux is also thought to stimulate pain by distending mechanoceptors in the oesophagitis
- consider H pylori infection as cause
- risk of oesophageal adenocarcinoma is correlated with the frequency, severity and duration of symptoms. Symptoms of GORD, X3/week = 17X more likely compared with people without GORD.
Red flags
- dysphagia
- Odynophagia (pain with swallowing)
- haematemesis
- LOW without explanation
- age >55yo with new onset or persistent symptoms
Treatment
- PPI's = 1st line
- beware of rebound acid secretion after withdrawal of PPI's due to increased production of gastrin
- omeprazole 20mg, pantoprazole 20mg or lanzoprazole 30mg daily are equally effective
- in cases of need to double dose, nocturnal 2nd dose preferred
- H2-receptor antagonists are 2nd line if PPI not effective
- may be adjunctive Rx with PPI -added nocturnally in some cases who experience nocturnal dyspepsia
- beware - tachyphylaxis occurs in some after single dose
Oesophageal Spasm
2 main types:
- Distal oesophageal spasm (DOS) previously known as Diffuse ~ - normal amplitude, uncoordinated oesophageal contractions, with several sections of the oesophagus simultaneously contracting.
- Hypertensive or Nutcracker - contractions are co-ordinated but with an excessive amplitude.
- Hypercontractile oesophagus, also known as Jackhammer oesophagus - extreme phenotype of hypertensive contractions. Contractions are of very high amplitude, involving the majority of the oesophagus, and whose duration occurs for a prolonged period with a jackhammer-type appearance on high-resolution manometry
- cause unknown but gastric reflux or a primary nerve or motor disorder are thought possible. A defect in the nitric oxide pathway and smooth muscle hypertrophy are also considered possibilities.
May present with:
- Chest pain - distinguishing oesophageal pain from cardiac pain is virtually impossible. Pain can be similar with similar radiation and associated symptoms.
- Dysphagia
- Reflux-related symptoms - eg, heartburn, regurgitation, cough and hoarseness.
Management
no treatment definitively known to be effective. Proposed:
- Nitrates. Mechanism unknown. May be reduced vasospasm in the brainstem, (similar to Ca++ channel blockers), or direct effect on myocytes.
- Calcium-channel blockers - eg, nifedipine or diltiazem. Reduce amplitude of contractions.
- Antidepressants - eg, trazodone, imipramine or sertraline - unknown mechanism.
- Phosphodiesterase inhibitors - sildenafil. Inhibit cGMP-specific phosphodiesterase relaxing smooth M.
- Peppermint oil -
- Theophylline - proposed use as may relax the oesophageal wall.
- Botulinum toxin injection - block ACh release.
- Surgery