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Proforma B Background to casePresentation Retrosternal chest pain, acid in mouth Unit number 8

Main diagnosis: GORD Case number 2

Incidence1: Most members of the population will experience heartburn at onepoint or another roughly 20-40% of these will be due to GORD.Age range: Incidence increases in those over 40Sex distribution: 3 : 1 Male : Female

DefinitionGastroesophageal reflux is a normal physiologic phenomenon experiencedintermittently by most people, particularly after a meal. Gastroesophageal reflux

disease (GORD) occurs when the amount of gastric juice that refluxes into theoesophagus exceeds the normal limit, causing symptoms with or withoutassociated oesophageal mucosal injury (oesophagitis).2

Risk factors/Causes1The risk factors and potential causes of the disease are multiple and range frommedical to environmental.

- Increased intra-abdominal pressure caused either through outsideinfluences or restrictive clothing or big meals.

-Inadequate cardiac sphincter

- Diet e.g. Smoking, alcohol and caffiene- Pregnancy and Obesity- Hiatus hernia causing a cardiac sphincter insuficiency- Drugs including tricyclics and anticholinergics which affect gastic

secretions.

Pathophysiology

The Pathophysiology of GORD is a change in the ability of the gastric cardiacsphincter to prevent the movement of acid up the oesophagus. The normalaction of the sphincter involves multiple aspects all working together to ensurethere is no outflow of acid and that a normal and healthy gastro-oesophagealreflux occurs these interlinking factors include:

- The sphincter requires a normal length and pressure with a normal number ofrelaxation periods unrelated to swallowing.

- The junction with the stomach and the oesophagus must be located in theabdomen in such position as to allow the diaphragmatic cura to assit in

applying pressure to the cardiac sphincter.

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- Clearance of the oesophagus through mechanical (peristalsis) and chemical(saliva) means should be able to neutralise any excess acid.

- There must be a normal emptying of the stomach with no abnormalities in itsfunction taking place.

When the symptoms of GORD are produced it means that something has gonewrong. Such problems can include:

- A functional or mechanical problem with the cardiac sphincter resulting inreduced tone. This could be caused by an increased degree of sphincterrelaxation (functional) or other factors such as a hypotensive sphincter.

- External stimulus can cause a decreased tone in the sphincter, such stimuluscan be caused by certain foods and drinks such as increased levels of caffeineor potentially by drugs that are ingested such as nitrates.

- An increased intra-abdominal pressure causes a sphincter with decreasepatency and as a result these cause GORD. Within this group of problems wouldbe obesity and pregnancy and to a lesser extent tight clothing and overeating.

Obesity is a contributing factor in gastro-oesophageal reflux disease (GORD),probably because of the increased intra-abdominal pressure.

PreventionLifestyle changes such as loosing weight or changing a patients diet. Depending

on the cause even a change from tight to baggy clothes may help to someextent in decreasing or preventing the onset of symptoms.

Commonly presenting featuresThe disease can present in a number of different ways and has both atypicaland typical signs and symptoms overall however it mustbe noted that thedisease can often present as a non descript syndrome which may also beconfused with multiple other pathologies from multiple other domains. The maincommonly presenting symptoms are:

- Heatburn, presenting as a burning feeling rising in the throat with arelation to meals

- Symptoms are worse lying down, stooping and straining (increased abdopressure)

- Antacids relieve symptoms experienced by the patient- Retrosternal discomfort- Acid brash ( the regurgitation of acid or bile into the mouth)- Water brash (excessive salivation)- Odynophagia (pain on swallowing as a result of oesophagitis or stricture

secondary to the GORD.

Atypically the condition may present as:- Chest pain

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- Epigastric pain- Bloating- Chronic hoarseness- Chronic cough (6-10% of patients with this suffer from GORD)

Natural history/prognosisMost cases are benign and 55% resolve within 10 months with 80% resolvedwithin 18 months. On the whole most patients are well controlled with drugtherapy and if this does not succeed the majority get a good outlook fromfundoplicaiton however there are a minority of patients who still struggle to gaineffective control of symptoms even after surgery.

Of those suffering GORD that is not controlled, roughly 50% will go on todevelop oesophagitis whilst a small minority may go on to further developbarretts oesophagus (risk of SCC from this!)

Most useful investigationsInvestigation tends not to be done in typical young patients and they can betreated without investigation. In middle aged or old aged patients investigationshould take place. This is also true if the symptoms are atypical or are worrying(weight loss, dysphasia and anaemia). NICE have stated on this topic thatreferral for endoscopy is appropriate for patients aged 55 years and older withunexplained treatment resistant dyspepsia of more than four weeks' duration.

Endoscopy: investigation of choice to visualise the lower oesophagus and the

stomach this allows other disease processes to be ruled out. A clear endoscopyshould not stop treatment of the disease.

If endoscopy does not make the diagnosis clear then

24 hour pH monitoring: A slim catheter is tethered above the gastro-oesophageal junction and the intralumina pH is measured by a radiotelemetrypH sensitive probe. The patient performs their normal daily activities andmoments of pan are noted down so they can be related to the pH levels. A pH