Gastroenterology training and education

Link to teaching module

What is GORD?

GORD is a condition that develops when the reflux of gastric content causes troublesome symptoms or complications. Heartburn and regurgitation are the characteristic symptoms of GORD. Heartburn is defined as a burning sensation in the retrosternal area. Regurgitation is defined as the perception of flow of refluxed gastric contents into the mouth or hypopharynx.GORD can also cause episodes of chest pain that resemble ischemic cardiac pain, without accompanying heartburn or regurgitation. Epigastric pain can also be the major symptom of GERD

GORD symptoms may occur when upright or supine or both. Symptoms occurring when supine may cause sleep disturbance. Physical exercise may induce troublesome symptoms of GERD in patients who have no/minimal symptoms at other times (exercise-induced gastroesophageal re?ux)

Discuss the mechanism of GORD?

• OG junction incompetence- due to
  • Transient LOS relaxation. There may not be increased frequency of non swallow related relaxation of LOS in pts with GORD but they have higher frequency of acid reflux (as opposed to gas reflux) during LOS relaxation. LOS is relaxed by fat, chocolate, ethanol, peppermint, drugs (nitrates, CCB, theophylline, morphine, diazepam).
  • LOS hypotension without anatomic abnormality.
  • Anatomic distortion of the OG junction inclusive of but not limited to, hiatus hernia
• Delayed oesophageal acid clearance- due to impaired oesophageal emptying and impaired salivary function.

Discuss the diagnosis of GORD?

The typical reflux syndrome can be diagnosed on the basis of the characteristic symptoms, without diagnostic testing.

What are the complications of GORD?

Reflux oesophagitis, haemorrhage, stricture, Barrett’s oesophagus, and adenocarcinoma.
There is no increased risk of Barrett’s or oesophageal cancer with non erosive reflux disease. However 10-15% of NERD progress to erosive disease in US and Europe.

What is the role of endoscopy?

Endoscopy is a poor diagnostic test. Most patients (>50%) with GORD have no visible evidence of oesophagitis at endoscopy, making endoscopic appearance a poor guide to diagnosis and management of GORD. Further, the correlation between endoscopy findings and symptom severity is poor.
Endoscopy may be requested in patients with:

• Long-standing (> 5years) symptoms (to diagnose Barrett’s oesophagus)
• Symptoms unresolved by PPI
• Presence of alarm features like vomiting, gastrointestinal bleeding or anaemia, abdominal masses or unexplained weight loss, and progressive dysphagia

Discuss the endoscopic grading for severity of oesophagitis?

The severity of erosive oesophagitis on endoscopy is usually graded using the Los Angeles classification:
Grade A- One or more mucosal breaks no longer than 5 mm, none of which extends between the tops of the mucosal folds
Grade B- One or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds
Grade C- Mucosal breaks that extend between the tops of two or more mucosal folds, but which involve less than 75% of the oesophageal circumference
Grade D-Mucosal breaks which involve at least 75% of the oesophageal circumference

What is the role of pH monitoring?

Indicated primarily for the investigation of atypical or persistent symptoms despite appropriate therapy

Discuss the management of GORD?

• Mild and infrequent symptoms- antacids or H2RA on a prn basis
• More severe symptoms- PPI once a day. PPIs are superior to H2RA for the reduction of symptoms and healing of oesophagitis with equivalent safety. Standard once daily doses of PPI are esomeprazole 40mg, lansoprazole 30 mg, omeprazole 20mg, pantoprazole 40mg and rabeprazole 20 mg.
• Twice daily PPI is generally not required as initial therapy for typical GORD symptoms. However twice daily standard dose PPI may be used for patients who have severe oesophagitis (LA grade C or D). Twice daily PPI is also used in patients with NCCP or extra oesophageal manifestations of GORD.
• Prokinetic agents are not recommended either alone or in combination with antisecretory agents for the routine initial treatment of GORD

How long to continue the PPI?

The PPI may be discontinued after a period of 4-8 weeks to confirm the need for ongoing therapy. However, the risk of recurrent endoscopic erosions is extremely high without maintenance therapy. Thus long term therapy is recommended for erosive oesophagitis with the aim of preventing recurrent oesophageal injury, in addition to complications such as stricture, haemorrhage, ulceration or Barrett’s epithelium. Currently there is no evidence that PPI therapy prevents the development or progression of Barrett’s epithelium.
Long term maintenance therapy is given at the lowest dose and frequency that is sufficient to achieve optimal control of the patient’s symptoms. Half dose PPI therapy is sufficient to maintain endoscopic remission in about 35% to 95% of patients with erosive oesophagitis. On demand therapy may also be acceptable because oesophagitis recurrence, in the absence of symptoms, occurs in fewer than 9% of patients

What is the role of supplementary night time H2RA therapy?
Supplementary nighttime H2RA therapy is not generally recommended for individuals who have responded incompletely or have failed to respond to standard dose or double dose PPI therapy of adequate duration.

Discuss H. Pylori and GORD?

H. Pylori testing is not necessary before starting treatment for typical symptoms of GORD. Further, it is not necessary to test routinely for H Pylori in a patient taking long term PPI therapy for GORD symptoms.

Eradication of H. Pylori has no clinically relevant adverse effect on the long term outcome of GORD

Background to this debate- There were concerns that the progression of H. pylori gastritis to metaplasia and gastric carcinoma might be hastened by long term PPI therapy for GORD. There is no evidence that PPI is an additional risk factor or that H. Pylori eradication affects the risk of gastric cancer in presence of PPI therapy.
In addition, eradication does not alter the therapeutic dose of PPI or cause an increase in reflux symptoms

What are the indications for antireflux surgery?

• Regurgitation-dominant or volume related reflux symptoms (although there is no proven superiority for surgery for this indication)
• Persistent or recurrent symptoms despite PPI therapy
• Dissatisfaction at continuing long term PPI
• Poor compliance (for example due to costs of PPI)
• Presence of large hiatus hernia

Limitations of surgery
Relapse needing repeat surgery
PPI may be needed after a period
Absence of documented benefit in preventing Barrett’s oesophagus

Prerequisites before surgery
Typical reflux symptoms and erosive oesophagitis on endoscopy or evidence of reflux on pH study

Discuss the extra oesophageal manifestations of GORD?
There is a significant association between GORD and cough, laryngitis, asthma, and dental erosions. Important features:

• These syndromes are usually multifactorial with GORD as one of the several potential aggravating cofactors
• In the absence of heartburn or regurgitation, unexplained asthma and laryngitis are unlikely to be related to GORD
• Medical and surgical treatment trials aimed at improving presumed GORD related extra oesophageal symptoms by treating GERD are associated with uncertain and inconsistent treatment effect.
• A therapeutic trial of a PPI in twice daily dose is indicated in such patients. This trial should be for four months, as a symptomatic response may be delayed. (BSG)
• Potential causal mechanisms of reflux cough, reflux laryngitis, and reflux asthma syndromes include direct (aspiration) or indirect (neurally mediated) effects of gastroesophageal reflux Experimental evidence has demonstrated reflex stimulation of bronchospasm and cough as a response to oesophageal acidification

It is unclear whether gastroesophageal reflux is a significant causal or exacerbating factor in the pathogenesis of sinusitis, pulmonary fibrosis, pharyngitis, or recurrent otitis media

It is unclear whether gastroesophageal reflux plays a role in triggering apnoeic episodes in patients with obstructive sleep apnoea

Discuss the approach to a patient with GORD and non response to twice daily PPI?

Step 1- Check compliance. Exclude contributory causes like alendronate, NSAIDS, KCL, doxycycline etc
Step 2- Consider other diagnoses:

• Look for skin changes- some skin diseases can affect oesophagus like epidermolysis bullosa acquisita, bullous pemphigoid, cicatricial pemphigoid and lichen planus. Lichen planus of oesophagus present with nodules. The diagnosis may be difficult as the skin disease may not be active when their oesophageal disease is problematic.  Oesophageal biopsy from the uninvolved areas usually helps in the diagnosis. These patients require very aggressive immunosuppressive therapy.
• ZES- about 60% patients with ZE syndrome will have associated esophageal complaints.
• Eosinophilic oesophagitis.
• Functional heartburn- A normal 24 hr pH study in the presence of symptoms raises the possibility

Ref

1. The Montreal De?nition and Classi?cation of Gastroesophageal Re?ux Disease: A Global Evidence-Based Consensus. Am J Gastroenterol 2006; 101:1900–1920
2. Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults- Update 2004. Can J Gastroenterol Vol 19 No 1 2005
3. The British Society of Gastroenterology Guidelines for oesophageal manometry and pH
4. Monitoring.