Oesophagus: Heartburn / Gastro-oesophageal reflux disease (GORD) - medical definition, causes, symptoms
Gastro-oesophageal
reflux disease (GORD) is defined as symptoms or mucosal damage (oesophagitis)
resulting from the exposure of the distal oesophagus to refluxed gastric
contents. However, the symptoms of reflux oesophagitis do not equate with
mucosal damage, and patients with endoscopic evidence of oesophagitis do not
necessarily have the worst symptoms.
In primary
care GORD is therefore best thought of in terms of symptoms: symptom control is
the aim of most management strategies, and indeed typical symptoms can guide
doctors to the correct diagnosis. A variety of other tests are available to
diagnose and assess the severity of disease if symptoms are atypical and
results of endoscopy normal.
Terminology
and aetiology
Oesophagitis
refers to endoscopic or histological evidence of an acute inflammatory process
in the oesophagus. Only about 60% of patients in whom GORD is eventually diagnosed
have endoscopic evidence of oesophagitis. Some evidence suggests that among
patients in the community or those with atypical presenting symptoms the
proportion with oesophagitis may be even lower.
Hiatus
hernia is present when gastric mucosal folds are observed more than 2-3 cm
above the diaphragm by endoscopy or barium radiology and is found in about 30%
of people aged over 50 years. However, most patients with an hiatus hernia do
not have GORD, but about 90% of patients with marked oesophagitis have hiatus
hernia. Thus, hiatus hernia may not result in GORD but can contribute to the
disease. Hiatus hernia itself rarely gives rise to symptoms, although a large
hernia may undergo torsion (volvulus) to cause acute epigastric or retrosternal
pain with vomiting.
Both
oesophageal and gastric factors affect the occurrence of reflux. The critical
factor is lower oesophageal sphincter incompetence: most refluxoccurs during
transient relaxation of the lower oesophageal sphincter resulting from failed
swallows (swallows not followed by a normal oesophageal peristaltic wave) and
gastric distension (mostly after meals). Recent evidence has indicated that the
diaphragmatic crural fibres surrounding the oesophageal hiatus act as an
external sphincter in concert with the intrinsic lower oesophageal sphincter.
Failure of this crural mechanism may allow a hiatus hernia to occur. The
hernial sac may additionally provide a sump of gastric contents available for
refluxonce the lower oesophageal sphincter relaxes. Oesophageal acid clearance
depends both on swallowed saliva and intact lower oesophageal peristalsis,
which is impaired in about 30% of patients with GORD. Gastric acid production
is usually normal in GORD, while delayed gastric emptying occurs in about 40%.
Duodenogastro-oesophageal
reflux of bile may play a subsidiary role to that of gastric acid and pepsin in
patients with an intact stomach and has been implicated in the pathogenesis of
Barrett’s oesophagus and its sequelae.
Clinical
features and presentation
There is a
spectrum of clinical presentation, ranging from symptoms alone to complications
resulting from mucosal damage. Up to 40% of patients seen in hospital in whom
reflux is eventually diagnosed have symptoms other than classic heartburn or
pharyngeal acid regurgitation, including a variety of respiratory and
pharyngeal symptoms.
Natural
course of GORD
The
condition is characteristically chronic and relapsing: in follow up studies at
least two thirds of patients continue to take drugs continuously or intermittently
for refluxsymptoms for up to 10 years. Symptoms disappear in less than a fifth
of those taking no drugs, and in the short term endoscopic evidence of
oesophagitis may come and go independently of symptoms. There is no evidence
that patients inevitably go on to develop severe erosive oesophagitis,
Barrett’s oesophagus, or stricture. Symptomatic relapse after discontinuing
treatment is common and is chiefly dependent on initial severity of
oesophagitis. In studies with large proportions of patients having initial
severe oesophagitis, relapse rates of up to 80% at sixmonths have been
reported.
References:
- Robert PH Logan. 2002. ABC OF THE UPPER GASTROINTESTINAL TRACT. London: BMJ Books.
- Image
Source: http://www.webmd.com/heartburn-gerd/guide/complications-untreated-gerd
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Oesophagus: Heartburn / Gastro-oesophageal reflux disease (GORD) - medical definition, causes, and symtoms
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Author: Unknown
Thanks for visiting the blog Family Medical Center, If there are criticisms and suggestions please leave a comment
