Dysphagia: gastro-oesophageal reflux disease (GORD)

Summary

Definition

Reflux of gastro-duodenal contents into the oesophagus, causing symptoms that are sufficient to interfere with quality of life.

Incidence

20 to 25% of population have symptoms of GORD, oesophagitis is detected in 25 to 40% of gastroscopies performed on symptomatic patients. It is thought to be predisposed to by obesity, smoking and alcohol. Dietary factors such as excess fat, caffeine and citrus fruits; drugs such as atropine, calcium channel blockers and anti-histamines, various hormones and prostaglandins have also been described.

Aetiology and pathophysiology

Incompetence of lower oesophageal sphincter (LOS) due to predisposing factors or distortion of the acute angle of His as in hiatal hernia as well as absence of adequate length of intra-abdominal segment of oesophagus (< 2cm), destroyed mucosal rosette and deficient diaphragmatic crural mechanism. Finally, diminished oesophageal clearance by peristalsis and lowered mucosal resistance, normally maintained by its histological and biochemical properties; all these factors lead to reflux of gastric secretions into lower oesophagus exposing the mucosa to harmful gastric acid.

Natural history

90% asymptomatic. 10% of asymptomatic individuals develop complications such as reflux oesophagitis, ulceration and peri-oesophagitis; strictures and webs (Shatski's ring), which if severe can cause intermittent total obstruction (Steakhouse syndrome); columnar metaplasia (Barrett's oesophagus), where 10% of these progress to dysplasia which is precancerous.

Symptoms

Heartburn, regurgitation, water brash and dysphagia. Symptoms are aggravated with posture and are greater at night. Severity can be assessed by DeMeester scoring system which grades each of heartburn, regurgitation and dysphagia 0–3 according to severity. Clinical examination is usually performed to exclude other pathologies.