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gord also known as gastroesophageal
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reflux disease is one of the most
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prevalent gastrointestinal disorders
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some stats show that up to 15% of
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individuals have heartburn and/or
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regurgitation at least once a week
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symptoms are caused by backflow of
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gastric acid and other gastric contents
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into the esophagus due to incompetent
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barriers at the gastroesophageal
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Junction as you can see as demonstrated
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by this diagram content from the stomach
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is going back up and irritating the
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esophagus let's recap some anatomy the
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esophagus can be divided into the upper
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2/3 and lower 3rd it's divided like so
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because there are some noticeable
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differences between them the upper 2/3
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of the esophagus contains stratified
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skeletal muscles whereas the lower third
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contains all smooth muscle and so is not
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under voluntary control the mucosal
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surface of the upper 2/3 is
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non-keratinized stratified squamous
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epithelial cells whereas the lower third
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there is transitional or stratified
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squamous epithelium - simple columnar
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epithelium this grammo columnar Junction
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has a zigzag appearance thus sometimes
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referred to as the Zed line the Zed line
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again is a change from the squamous
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epithelium to the columnar epithelia
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fortunately there is an esophageal
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sphincter which is a barrier for food
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and acid from going backwards from the
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stomach up to the esophagus however when
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the sphincter is incompetent good
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results it's important to recap some
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basic physiology of acid production in
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the stomach here the stomach is made up
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of pits which houses many different
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cells imagine here is your stomach lumen
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these cells of the stomach include a
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mucous cells parietal cells in terror
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chromaffin cells and some other hormone
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cells which I have not drawn parietal
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cells are the import
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cells which produce hydrochloric acid
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now there are two important channels for
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these cells one is the proton pump which
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is an anti porta pumping hydrogen ions
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out in exchange for potassium ion the
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other channel is a symporter which pumps
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both potassium and chloride
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thus with hydrogen and chloride in the
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lumen this forms hydrogen chloride which
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helps in digestion of food many things
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can stimulate parietal cell activity and
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thus stimulate acid production
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these include enteric chromaffin cells
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which release histamine histamine binds
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onto histamine receptors on parietal
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cells stimulating hydrochloric release
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so that was some basic gastric
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physiology when the lower
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gastroesophageal reflux disease results
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these factors include things that
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increase intra gastric volume pressure
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and these things include chronic
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coughing large meals and delays in
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gastric emptying other factors include
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things that decrease the esophageal
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sphincter tone which includes alcohol
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certain medications or drugs such as
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tricyclic antidepressants peptic
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strictures previous surgeries and
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idiopathic causes scleroderma is also
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another important cause of lower
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esophageal sphincter incompetency
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scleroderma is a condition characterized
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by thickening of tissue now let's talk
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about the pathological features of Gord
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Gord is further complicated by reflux
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esophagitis which develops when the
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mucosal defenses are unable to
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counteract the damage done by acid
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pepsin and bile this causes inflammation
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of this off
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this the other important pathological
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change that can occur is also a
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complication
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these are esophageal strictures or
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peptic strictures esophageal strictures
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results from fibrosis that causes
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luminal constriction these strictures
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occur in 10 percent of patients with
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untreated Gord and also present in the
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distal esophagus near the squamous
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columnar Junction the clinical
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presentation or the classic presentation
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signs and symptoms of gord reflux
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disease is a classic heartburn and
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enjoying a type pain worse after meal
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and worse lying down it's also
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characterized by acid brush or water
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brush and also sometimes identify Jo
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which is pain when swallowing reflux
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into the pharynx larynx and trachea
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bronchial tree can cause chronic cough
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laryngitis sinusitis morning hoarseness
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may also be noted many patients with
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gord remain asymptomatic and do not seek
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attention until severe complications
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usually occur the diagnosis of reflux
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disease is easily made by history alone
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diagnostic studies are indicated in
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patients with persistent symptoms or
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complications or those who do not
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respond to therapy usually if patients
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are under the age of 45 Gord is
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suspected and a trial of proton pump
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inhibitors are given if they fail with
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treatment investigations are warranted
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for people greater than 45 years old and
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have reflux trial of PPI which are
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proton pump inhibitors can be given or
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other investigations can be done
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especially if you are suspicious of
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complications associated with God a
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gastrostomy where an endoscope camera is
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inserted down the esophagus for
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visualizing any changes can also be
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performed although endoscopy is
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sensitive for diagnosis of esophagitis
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it can miss causes of reflux since some
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patients have symptomatic reflux without
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esophagitis unless invasive
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investigation is barium swallowing study
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where
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drink contrast and asked to swallow this
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process is captured by x-ray usually it
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is normal and abnormal when
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complications such as bad esophagitis
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and strictures are present a 24-hour
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ambulatory a pH monitor can be used
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which is the most sensitive test for
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diagnosing or again the most sensitive
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test for diagnosis of Gord is a 24-hour
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ambulatory pH monitoring the goal of
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treatment of Gord is to provide symptom
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relief heal erosive esophagitis and
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prevent complications management of mild
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cases of God include lifestyle changes
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these include weight loss smoking
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sensation eating small regular meals
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avoiding meals before sleep avoiding
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certain food and drinks such as fizzy
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drinks avoiding alcohol coffee citrus
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fruits and spicy foods pharmacological
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management is first slide for suspected
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gourd and is used in conjunction with
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lifestyle modification pharmacological
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management aim to reduce acid production
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these include proton pump inhibitors
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which inhibit the proton pump we talked
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about and thus inhibit the release of
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hydrogen islands the other medication
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include and acids which aim to
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neutralize hydrochloric acid another
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drug not commonly used are histamine
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receptor antagonists which inhibit the
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histamine receptors and thus inhibit the
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stimulation of parietal cells by the
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enteric relevant cells finally there is
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a surgical management and this is
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usually left when medical management has
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failed and should be considered as an
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alternative for patients who require
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long term high-dose proton pump
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inhibitors the anti reflux surgery is
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known also as the nisshin's operation in
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this operation the gastric fundus is
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wrapped around the esophagus
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fundoplication and this increases the
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lower esophageal sphincter pressure
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finally let's talk about the
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complications of cord and usually a
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complication of esophagitis so these
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include complications esophagitis which
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is inflammatory changes in a squamous
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line esophagus this inflammation can
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cause a dysphasia and can cause
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metaplasia a condition termed Barrett's
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esophagus Barrett's esophagus is
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characterized by changes of squamous
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cells to columnar cells as well as
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increased number of goblet cells in the
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area Barrett's esophagus is important
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because people with Barrett's esophagus
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are at a thirty to a hundred and twenty
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five time risk of developing esophageal
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adenocarcinoma than the general
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population
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other complications include structure
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formation or sirs erosive esophagitis
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and of course if bleeding occurs iron
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deficiency can occur
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you
