Definitions
Gastro-oesophageal reflux disease (GORD) is a condition caused by the retrograde passage of gastric contents into the oesophagus resulting in inflammation (oesophagitis), which manifests as dyspepsia. A hiatus hernia is an abnormal protrusion of the proximal stomach through the oesophageal opening in the diaphragm resulting in a more proximal positioning of the oesophagogastric junction and predisposition to GORD. Sliding (common) and rolling or para-oesophageal (rare) hiatus hernias are recognized.
Key Points
- The majority of GORD is benign and uncomplicated.
- Barrett’s oesophagus is a recognized association predisposing to adenocarcinoma of the oesophagus.
- Consider malignancy in patients >55 years or with GORD symptoms.
- Surgery for GORD indicated for complications or patients resistant to medical therapy.
Common Causes
- tLOSRs: transient lower esophageal sphincter relaxation (normal continence mechanisms: LOS pressure, length of intra-abdominal LOS, angle of His, sling fibres around the cardia, the crural fibres of the diaphragm, the mucosal rosette).
- LOS pressure reduced by smoking, alcohol and coffee and some drugs (calcium-channel blockers, nitrates, beta-blockers, progesterone).
- Anatomical disruption of sphincter by hiatus hernia.
Clinical Features
- Retrosternal burning pain, radiating to epigastrium, jaw and arms. (Oesophageal pain is often confused with cardiac pain.)
- Regurgitation of acid contents into the mouth (waterbrash).
- Back pain (a penetrating ulcer in Barrett’s oesophagus).
- Dysphagia from a benign stricture.
- Coughing or wheezing, hoarseness (due to aspiration of gastric contents).
Investigations
- Oesophagoscopy: assess oesophagitis, biopsy for histology, dilate stricture if present.
- Barium swallow and meal: sliding hiatus hernia, oesophageal ulcer, stricture.
- Ambulatory 24-hour pH monitoring: assess the degree of reflux.
- Oesophageal manometry.
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