Gastro-Oesophageal Reflux
Disease (GORD)
Presented by:
ANISH DHAKAL
Final Year
2nd May, 2019
Sample Case Presentation in
AOPD:
36-years-old married male patient, Mr. Ram
Prasad consulted Patan Hospital Male Clinic with the
complaints of hyper-acidity & water brash since last
2 years. He also experienced heartburn and a lot of
heaviness and regurgitation since one and a half
years. His symptoms used to bother him almost
everyday, especially at night. His condition used to
get aggravated mostly by having heavy meals, by
eating the meal late in the night and by consuming
certain spicy food items. He liked spicy and sweet
food a lot, but he didn’t have any strict and specific
food preference.
Reflux: is backward flow of gastric content
Regurgitation: is defined as the perception of flow of refluxed gastric content into
the mouth or hypopharynx
Etiology
• Normal competence of the gastro-esophageal junction
is maintained by the LOS
• In normal circumstances, the LOS transiently relaxes
– swallowing, vomiting, stretching of the
gastric fundus
• Physiological reflux – postprandial transient lower
esophageal sphincter relaxation (TLOSRs)
• Pathological reflux:
❖ In early stages of GORD occurs due to
increased number of TLOSRs
❖ In severe GORD occurs due to decreased LOS
pressure
❖ Loss of the normal anatomical configuration
exacerbates GORD. e.g. hiatal hernia
Risk factors
• Prolonged gastric emptying
• Obesity
• Pregnancy
• Hiatal hernia
• Transient LES relaxation -
nocturnal, postprandial
CLINICAL
FEATURES
TRIAD of Heartburn, epigastric pain with dysphagia
and regurgitation:
• Heart burn is deeply placed burning pain behind sternum and
radiates to the throat. Occurs after meals, brought on by
bending, lifting weight and straining. Occurs on lying down
and relieved by sitting up.
• Regurgitation of gastric contents into mouth
• Bleeding if there is mucosal erosion or Barret’s ulcer,
Iron Deficiency Anemia due to blood loss
Extraesophageal manifestations
❖ Due to reflux of gastric contents into the pharynx, larynx,
tracheobronchial tree, nose, and mouth causes chronic
cough, laryngitis, and pharyngitis
• Morning hoarseness may be noted
• Recurrent pulmonary aspiration may cause or aggravate
chronic bronchitis, asthma, pulmonary fibrosis, COPD or
pneumonia.
• Chronic sinusitis and dental decay
Diagnosis
• Mostly is a clinical diagnosis
• Investigation is required when the diagnosis is in
doubt, when the patient does not respond to a
proton pump inhibitor (PPI) or if dysphasia is
present
• Endoscopy with biopsy if lesion present
• 24 hour esophageal pH recording is gold standard.
Management of GORD
GENERAL
1. WeightMEASURES
reduction
2. Cessation of smoking
3. Small volume, frequent feeds
4. Diet:
-Avoid alcohol, fatty food, caffeine, mint, orange
juice, some medications.
-Avoid late night meals.
5. Avoid weight lifting, stooping and bending at waist.
6. Head end of bed should be elevated to 15 degrees if
experiencing nocturnal symptoms
Sleeping on several pillows could create further compression on your
abdomen by bending you at the waist (similar to “sit ups”), and might
promote reflux episodes while you are sleeping.
Medical Management
o Proton Pump Inhibitor are most effective
o Duration of 8 weeks
o Step-down pattern
o In non-respondent patient, increase dose of PPI
OR addition of H2 receptor antagonist.
• Endoscopic treatments
Endoscopic suturing devices that plicate gastric
mucosa just below the cardia to accentuate the
angle of His
Radiofrequency ablation applied to the level of
the sphincter and
Injection of submucosal polymers into the
lower esophagus
Generally applied to patients with only small
hiatus hernias or none at all
Surgical
Treatment:
• Risks of surgery
• mortality rate (0.1–0.5 %,)
• failed operation (5–10 %)
• side effects: dysphagia, gas bloat or abdominal discomfort (10%)
Surgical Management
❖ Total fundoplication (Nissen)
– more short-term dysphagia but most durable repair
– creation of an over competent cardia, resulting in the
‘gas bloat’ syndrome in which belching is
impossible
❖ Partial fundoplication, performed posteriorly
(Toupet) or anteriorly (Dor, Watson)
– fewer short-term side-effects but slightly higher
long-term failure rate
Laparoscopic fundoplication
• Five cannula are inserted in
the upper abdomen
• Cardia and lower
esophagus are separated
from the diaphragmatic
hiatus
• Appropriate length of
esophagus is mobilized in
the mediastinum
• Hiatus is narrowed by
sutures placed behind the
esophagus
• Total (Nissen) fundoplication, the fundus is
drawn behind the esophagus and then sutured
to itself in front of the esophagus
• Partial fundoplication, the fundus is drawn
either behind or in front of the esophagus and
sutured to it on each side, leaving a strip of
exposed esophagus either at the front or at the
back.
Complications:
1. Esophagitis
▪ Mild redness to severe, bleeding ulceration
with stricture formation are recognized
▪ Appearance may be completely normal
2.Barrett’s
•
esophagus
Premalignant condition occurs in
response to chronic GORD
• Normal squamous lining of
esophagus is replaced by
columnar mucosa that may
contain area of intestinal
metaplasia
• Presence of mucus secreting
goblet cells (hallmark of
‘specialized’ Barrett's
epithelium)
Cont.…
3. Anaemia : due to blood loss by esophagitis and
neck of hiatus hernia
4. Benign esophageal stricture
▪ As a consequence of long standing esophagitis
▪ Dysphagia which is worse for solids than liquid
5. Gastric volvulus
▪ Massive intra-thoracic hiatus hernia may twist upon
itself causing volvulus
6. Esophageal shortening
References
• Bailey and Love short practice of surgery,
27th edition
• Davidson’s Principles of Medicine,
23rd Edition
• https://www.massgeneral.org/generalsurger
y
/assets/pdfs/gastroesophageal-surgery-case
- scenario-gerd-rattner.pdf
• SRB’s Manual of Surgery, 5th Edition
Thank you
