CBL Case 1 - Gastro-Oesophageal Reflux Disease by Anna Kaye

Diagnosis

annamkaye — 2022-10-04 07:47:46 UTC

+ve Symptoms include;

Oesophageal:

- Heartburn; (burning, retrosternal discomfort after meals, lying, stooping or straining , relieved by antacids)
- Belching; Acid brash (acid or bile regurgitation) water brash (increase in saliva in the mouth
-Odynophagia; (painful swallowing e.g. from oesophagitis or ulceration

Extra-Oesophageal:

- Nocturnal Asthma
- Chronic Cough
- Laryngitis
- Sinusitis

References

annamkaye — 2022-10-04 07:49:02 UTC

Wilkinson, I B, Raine, T, Wiles, K, Goodhart, A, Hall, C, O'Neil, H. (2017). Oxford Handbook of Clinical Medicine. 10th ed. Oxford: Oxford University Press. p.254.

Gastro Medicine and Endoscopy (GME). (2020). Gastro - Oesophageal Reflux Disease GORD. [Online]. GME. Available at: https://www.gastromedicine.com.au/gastro-oesophageal-reflux-disease-gord/ [Accessed 4 October 2022].

National Institute for Health & Care Excellence. (2014). Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. [Online]. NICE. Last Updated: 19th October 2019. Available at: https://www.nice.org.uk/guidance/cg184/chapter/Introduction [Accessed 4 October 2022].

Risk Factors

annamkaye — 2022-10-04 07:58:40 UTC

- Lower Oesophageal Sphincter Hypotension
- Hiatus Hernia
- Oesophageal Dysmotility (e.g. systemic sclerosis)
- Obesity
- Gastric Acid Hypersecretion
- Delayed Gastric Emptying
- Smoking
- Alcohol
- Pregnancy
- Drugs (Tricyclics, anticholinergics, nitrates)
- Helicobacter pylori

Helicobacter Pylori

annamkaye — 2022-10-04 08:14:38 UTC

H. Pylori association with GORD is controversial, but eradication may help symptoms.

First line of treatment must be used before testing for and treating H.Pylori

Testing for H.Pylori involves The Urea 13C breath test (Blow into breath test bag after swallowing a urea and radioactive / non radioactive carbon isotope)

Stool Helicobacter Antigen Test (SAT) (STOOL SAMPLE)

https://www.nice.org.uk/guidance/cg184/chapter/Introduction

Positive Risk Factors for Juliet

annamkaye — 2022-10-04 08:24:45 UTC

- Smoking (30 pack years)
- Alcohol intake (over 20 units per week)
- Over Weight (BMI of 29.5)
- Taking NSAIDs (200mg Ibuprofen) regularly

Present Symptoms for Juliet

annamkaye — 2022-10-04 08:29:48 UTC

- Heartburn (esacerbated by bending and lying down, food and alcohol)
- Waterbrash
- Acid Brash
- Helped by taking Antacids (Rennie & Gaviscon)

Investigations

annamkaye — 2022-10-04 08:32:23 UTC

1st Test:
- trial proton-pump inhibitor for 8 weeks

Investigations to Consider if no improvement on PPI, or alarming symptoms:

-Oesophagogastroduodenoscopy

endoscopy for oesophagus, stomach, duodenum

-Ambulatory pH Monitoring

Wireless radiotelemetry capsule or naso-oesophageal catheter monitor abnormal presence of oesophageal acid
(pH < 4 for more than 4% of the time abnormal)

- Combined impedance-pH testing

Similar to Ambulatory pH monitoring, but catheter senses acid and non-acid presence in oesophagus for 24 hr period
Recommended for patients who have heartburn or regurgitation that has not responded to twice daily PPIs

-Oesophageal capsule endoscopy

Involves swallowing a capsule endoscope to visualise oesophagus.
Less invasive than upper endoscopy, can show oesophagitis or Barrett's oesophagus, but only moderate sensitivity/limited role

- Oesophageal manometry

evaluates oesophageal contractions and lower oesophageal function
UK guidelines recommend manometry performed prior to anti-reflux surgery

https://bestpractice.bmj.com/topics/en-gb/82/investigations

Proton-pump inhibitors

2022-10-04 09:43:32 UTC

Used as 1st line treatment/before investigation

omeprazole
omeprazole/sodium bicarbonate
esomeprazole
rabeprazole
pantoprazole
lansoprazole
dexlansoprazole

------> higher dose and further testing if incomplete response