GORD

Question 1

is GORD acute or chronic

Answer 1

usually chronic

Question 2

what is it

Answer 2

reflux of gastric contents (acid, bile, pepsin) back into oesophagus

Question 3

symptoms

Answer 3

heartburn
acid regurgitation

Question 4

less common symptoms, may happen if acid reflux reaches oropharynx/respiratory tract

Answer 4

chest pain
hoarseness
wheezing
cough
asthma
dental erosions

Question 5

what is non erosive GORD

Answer 5

symptoms of GORD but endoscopy is normal i.e. oesophagus unharmed by stomach acid

Question 6

what is erosive oesophagitis

Answer 6

oesophageal inflammation and mucosal erosions seen at endoscopy

Question 7

risk factors for developing GORD

Answer 7

• trigger and fatty foods
• pregnancy
• hiatus hernia
• FHx
• increased intra gastric pressure from straining and coughing
• stress
• anxiety
• obesity
• drug SE
• smoking
• alcohol

Question 8

complications of GORD

Answer 8

○ Oesophagitis (oesophageal inflammation)
○ Ulceration
○ Haemorrhage and stricture formation
○ Anaemia due to chronic blood loss
○ Aspiration pneumonia
○ Barrett’s oesophagus

Question 9

non drug treatment

Answer 9

• healthy eating
• weight loss if appropriate
• avoiding trigger food
• eating smaller meals
• evening meal 3-4h before going to bed
• raising head of bed
• smoking cessation
• reducing alcohol consumption
• stress and anxiety can exacerbate

Question 10

red flags - urgent endoscopy required

Answer 10

• Dysphasia
• Significant acute GI bleeding
• 55 and over with unexplained weight loss & symptoms of upper abdominal pain, reflux or dyspepsia

Question 11

what is Barrett’s oesophagus and diagnosis

Answer 11

some cells in the lining of the oesophagus have started to change, in some people these cells can develop into oesophageal cancer

consider endoscopy if pt has GORD
take into account pt preg and individual RF

Question 12

initial management - review drugs that can cause or exacerbate symptoms

Answer 12

○ Alpha blockers e.g. doxazosin, tamsulosin, alfuzosin, prazosin etc
○ Anticholinergics e.g. amitriptyline, olanzapine, oxybutynin, paroxetine, solifenacin etc
○ Benzodiazepines e.g. diazepam, chlordiazepoxide, lorazepam
○ Beta blockers e.g. atenolol, bisoprolol, carvedilol
○ Bisphosphonates e.g. alendronate, risendronate
○ CCBs e.g. amlodipine, nifedipine, verapamil, diltiazem
○ CCs e.g. prednisolone, dexamethasone, betamethasone,
○ NSAIDs e.g. ibuprofen, naproxen, diclofenac
○ Nitrates e.g. GTN, isosorbide mononitrate
○ Theophylline, aminophylline
○ TCAs e.g. amitriptyline, dosulepin, lofepramine, nortriptyline

Question 13

is long term continuous use of antacids recommended?

Answer 13

no

Question 14

pt with uninvestigated symptoms suggesting GORD should be managed as ….

Answer 14

uninvestigated dyspepsia

Question 15

In patients with endoscopy confirmed diagnosis of GORD, the following treatment should be offered… (+ severe oesophagitis)

Answer 15

○ PPI for 4 or 8 weeks
○ No response, then offer H2 receptor antagonist e.g. ranitidine, famotidine, nizatidine, cimetidine

- Severe esophagitis ○ PPI for 8 weeks ○ Consider pt pref and underlying heath conditions and drug interactions

Question 16

follow up management - what if the pt has refractory GORD

Answer 16

new alarm symptoms should be assessed and alternate diagnosis’ considered

• Other options include
  ○ Prescribing a further course of the initial PPI dose for one month
  ○ Double initial PPI dose for 1 month
  ○ Add a H2 receptor antagonist at bedtime for nocturnal symptoms or for short term use
• Also check patient’s adherence to initial management and reinforce lifestyle advice

Question 17

follow up management - for pt diagnosed with GORD whose symptoms recur after initial treatment

Answer 17

give a PPI at the lowest dose that can achieve symptom control and self management on PRN basis

Question 18

follow up management - what to do if treatment for severe oesophagitis fails

Answer 18

Use a higher dose of the same PPI or switch to another PPI taking into account patient preference tolerability, underlying health conditions and drug interactions

For patients with severe oesophagitis that failed to respond to long term maintenance PPI therapy, consider a clinical review and switching to another PPI and/or seeking specialist advice

Patients with severe oesophagitis or who have had dilatation of an oesophageal stricture should remain on long term PPI therapy (taking into consideration the aforementioned factors)

Question 19

GORD in pregnancy - symptoms, 1st line treatment, and alternatives

Answer 19

• Heartburn and acid reflux are symptoms of dyspepsia in pregnancy, commonly caused by GORD
• 1st line: dietary and lifestyle advise
• If this fails to control symptoms, offer an antacid or alginate
• If ineffective or if symptoms are severe, omeprazole or ranitidine (unlicensed) may help control symptoms

Question 20

What is the recommended drug treatment for someone with diagnosed GORD?

Answer 20

• PPI for 4 or 8 weeks
• E.g. omeprazole 20mg OD for 4 or 8 weeks

Question 21

What is the recommended drug treatment for someone with severe oesophagitis?

Answer 21

Omeprazole 40mg OD for 8 weeks, continue as maintenance is appropriate

Question 22

What is the recommended drug treatment for someone with severe oesophagitis, refractory to initial treatment

Answer 22

Omeprazole 40mg BD

Question 23

How should someone with suspected GORD be managed

Answer 23

For undiagnosed GORD, manage the patient as uninvestigated dyspepsia

Question 24

When should drug treatment be commenced in pregnancy, and what would you offer?

Answer 24

• 1st line pregnancy: lifestyle and dietary advice
• If inadequate, try antacid or alginate e.g.
• If inadequate, offer
  ○ omeprazole 20mg OD for 4 to 8 weeks OR
  ○ ranitidine 150mg BD for up to 8 weeks or if necessary 12 weeks, alternatively 300mg OD for up to 8 weeks or if necessary 12 weeks DOSE TO BE TAKEN AT NIGHT