Gastro-Oesophageal Reflux (GORD)

🔥 Gastro-oesophageal reflux disease (GORD) is a chronic condition where stomach acid flows back into the oesophagus. 👉 Classic symptoms = heartburn + acid regurgitation. ⚠️ Complications include erosive oesophagitis, strictures, and Barrett’s oesophagus (risk of adenocarcinoma).

🧾 Aetiology

• Lower Oesophageal Sphincter (LOS) dysfunction → main mechanism. LOS tone is reduced, allowing reflux.
• LOS competence depends on: – Muscle tone – Acute angle of gastro-oesophageal junction – Intra-abdominal oesophagus acting as a pressure barrier
• Acid reflux causes progressive damage: oesophagitis → stricture → Barrett’s → adenocarcinoma.

⚠️ Risk Factors

• 👨 Male sex, 🤰 pregnancy, 🍺 alcohol, 🚬 smoking, and obesity.
• 💊 Drugs lowering LOS tone: nitrates, TCAs, CCBs, theophylline, corticosteroids, NSAIDs.
• Systemic conditions: scleroderma, diabetes (delayed gastric emptying).

🧬 Pathophysiology

• LOS relaxation partly mediated by nitric oxide (NO). Nitrates/GTN worsen reflux by increasing NO-mediated relaxation.
• Acid + pepsin exposure damages oesophageal mucosa → inflammation, erosions, and metaplasia (Barrett’s).
• Chronic inflammation → fibrosis and stricture formation.

🚨 Complications

• Chronic reflux oesophagitis → ulcers and bleeding.
• Barrett’s oesophagus → squamous epithelium replaced by columnar epithelium (↑ risk of adenocarcinoma).
• Oesophageal stricture → dysphagia, food bolus obstruction.

🩺 Clinical Features

• 🔥 Heartburn: burning retrosternal pain, worse after meals or lying flat.
• 💧 Regurgitation of sour/bitter fluid into throat or mouth.
• 🤢 Water brash: excess saliva due to acid reflux.
• 🫁 Atypical: nocturnal cough, asthma-like bronchospasm, hoarseness.
• ❗ May mimic angina — always consider cardiac causes.

🔎 Investigations

• 🧪 Bloods: FBC (anaemia from bleeding), U&E, LFTs.
• 📷 Endoscopy (OGD): visualises oesophagitis, strictures, Barrett’s; biopsy suspicious lesions.
• 📈 24h pH monitoring: gold standard for acid exposure (esp. in atypical symptoms).
• 💡 Always rule out ACS if pain is retrosternal → ECG, troponin.

🩻 Differential Diagnoses

• ❤️ Cardiac: angina, MI.
• 🫀 Biliary: cholecystitis, biliary colic.
• 🫁 Respiratory: asthma, chronic cough, aspiration.

🚩 Red Flags (Urgent Endoscopy)

• 📉 Unexplained weight loss or anorexia.
• 🤮 Persistent vomiting.
• 🍽️ Dysphagia (progressive or painful swallowing).
• 🩸 Haematemesis or melaena.
• ≥55 years with new onset dyspepsia.

💊 Management

• 🌱 Lifestyle: weight loss, avoid trigger foods (alcohol, caffeine, chocolate, fatty foods), smaller meals, elevate head of bed, smoking cessation, avoid late meals.
• 💊 Pharmacological:
  • Antacids & alginates (e.g. Gaviscon) → quick relief.
  • PPIs = mainstay (e.g. Lansoprazole 30 mg BD x 6 weeks, then step down).
  • H2 antagonists (ranitidine, famotidine) if PPI intolerance.
  • Review/stop reflux-inducing drugs (CCBs, nitrates, theophylline, NSAIDs).
• 🧫 H. pylori testing & eradication: urea breath test or stool antigen. – Triple therapy: PPI + clarithromycin + amoxicillin/metronidazole. – Note: eradication may ↑ gastric acid → worsening reflux in some.
• 🩺 Endoscopic therapy: radiofrequency or injection techniques (rare, specialist use).
• 🔪 Surgery: laparoscopic Nissen fundoplication for refractory/severe GORD or complications.

📚 References

• NICE Guidance: GORD and dyspepsia in adults (CG184)

💡 Teaching Pearls: – Heartburn + regurgitation = GORD unless proven otherwise. – Always ask about red flag symptoms → need OGD. – Water brash is classic but under-reported. – Barrett’s = premalignant, requires surveillance. – Lifestyle change + PPI trial is both diagnostic and therapeutic.