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GORD

In This Article

 

Summary

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Epidemiology

  • GORD induced dyspepsia affects about 30% of the population
 
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Aetiology

  • Hiatus hernia
  • Eating certain foods – fat, chocolate, caffeine
  • Smoking
  • Obesity
  • Dysfunction of the lower oesophageal sphincter (LOS)
  • Alcohol
 
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Pathology

Acidic stomach contents will spill out of the stomach and back up the oesophagus. The presence of a hiatus hernia increases the risk, but not everyone with a hiatus hernia gets GORD.There will usually be a problem with the LOS whereby it doesn’t contract normally. Certain foods make the sphincter less likely to contract. There is also often decreased gastric emptying.
 
The oesophagus may become inflamed, reddened and ulcerated, although the level of tissue damage is not related to the severity of symptoms. In some cases, the normal squamous epithelium may be replaced by a columnar epithelium, similar to that found in the stomach. This is known as Barrett’s oesophagus.
 
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Symptoms

Often asymptomatic, but symptoms may include:
  • ‘Heartburn’ – retrosternal chest pain, particularly after eating. May be worse on lying down
  • The pain is usually relieved by antacids
 
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Investigations

In patients under 65 with no red flag symptoms, diagnosis is usually clinical. Otherwise, investigations may involve:
  • Endoscopy
  • Barium swallow – may shows the presence of a hiatus hernia, or strictures
 
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Complications

  • Anaemia – due to blood loss
  • LOS stricture – due to fibrosis. Can cause a dysphagia that is worse for solids than liquids
 
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Treatment

  • Lose weight
  • Stop smoking
  • Reduce alcohol intake
  • Avoid eating late at night
  • Sleep with more pillow to keep the oesophagus higher than the stomach
  • PPI’s
  • Antacids
In severe cases, that fail to respond to the above methods, then surgery may be undertaken. Usually, part of the stomach is wrapped around the lower oesophagus to create a new functional sphincter. This procedure is known as a Nissen fundoplication.
 
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More Information

Gastro-intestinal reflux disease is a condition characterised by retrosternal, and sometimes epigastric pain, as a result of reflux of the acidic contents of the stomach into the oesophagus.
 
Lots of people get GI symptoms with stress – however, this is not because stress causes these symptoms! Stress just changes your perception of symptoms.
It is often difficult to differentiate GORD from the symptoms of MI, and many patients admitted to cardiac wards, are actually just suffering from GORD
 
Occasional feelings of ‘heartburn’ (dyspepsia) are normal. Acid reflux will cause peristaltic contraction of the oesophagus and alkaline saliva secretion, and normally this will cause the symptoms to go away.
It is only when pathological changes have occurred that allow gastric contents to be in prolonged contact with the oesophagus that we would call it GORD.
 
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Epidemiology

  • GORD resulting in heartburn affects about 30% of the population
 
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Pathology

There are several mechanisms by which GORD can occur:
  • Lower oesophageal sphincter (LOS) – This is formed by the bottom 4cm or oesophageal smooth muscle.Normally this is contracted at all times, except during swallowing. It is even capable of increasing its normal tone is response to increased intragastric and intra-abdominal pressures. Also, the action of the diaphragm contracting may help to close of the bottom of the oesophagus, and the folds of the stomach also offer some sort of protection. The natural angle between the cardia and the oesophagus will also prevent some reflux. Problems can occur when:
  • The LOS relaxes when it shouldn’t
  • LOS tone doesn’t increase when the patient is lying flat – as would normally happen
  • Hiatus Hernia – this is present in around 40% of the general population and often causes no problems. It is a congenital defect, where part of the stomach extends above the level of the diaphragm. Almost all patients with oesophagitis or Barrett’s oesophagus will have a hiatus hernia. (see Barrett’s oesophagus for more information)
  • Delayed oesophageal clearance – this is present in many people with oesophagitis, and often remains after treatment for the condition. It increases the amount of time that oesophageal muscoa will stay in contact with acid for.&n