Patho Physiology of GORD PDF

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understanding GORD patho...

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Describe the pathophysiology of gastro-oesophageal (GORD) disease. The lower oesophageal sphincter (LOS) should remains closed most of the time. This prevents the contents of the stomach entering into the oesophagus (gastro-oesophageal reflux). Reflux oesophagitis, occurs in individuals whose muscle tone is lower than normal, leading to less constriction of the LOS which causes the stomach contents to back flow into the oesophagus. Activities such as vomiting, coughing, lifting or bending will increas abdominal pressure and force the stomach contents past the weakend sphincter. Severity of GORD is dependant on factors such as: 

stomach contents

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length of exposure of contents with the delicate oesophageal mucosa

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presence of bile salts and/or pancreatic enzymes

Other factors that can contribute to the development of GORD include: 

delayed gastric emptying which may be caused by gastric or duodenal ulcers

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pyloric oedema (swelling due to fluid)

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hiatal hernia, which can weaken the lower oesophageal sphincter

Craft, J. and Gordon, C. (2014) Understanding Pathophysiology, 2nd Edition. Mosby Australia. pg. 788

What are the common clinical manifestations of GORD? Are the signs and symptoms the same in adults and infants? In adults, the clinical manifestations include: heartburn acid regurgitation dysphagia (difficulty swallowing) chronic cough asthma upper abdominal pain within 1 hour of eating Often these symptoms worsen when individual lies down or if intraabdominal pressure increases. In infants, clincal manifestations include: excessively vomiting during the first week of life aspiration pneumonia (occurs in 33% of infants with GORD) chronic cough and recurrent pneumonia are common manifestations if GORD persists into childhood anaemia may occur due to blood loss Reference: Craft, J. and Gordon, C. Understanding Pathophysiology, 2nd Edition. Mosby Australia, Pages 788, 790. 

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How is GORD diagnosed? A diagnosis of reflux oesophagitis can be made using the following: 

clinical manifestations

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oesophageal endoscopy that shows oedema and erosion

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ambulatory pH monitoring of the oesophagus

As the constant irritation can lead to the developement of cellular changes that can develop into oesophageal carcinoma an endoscopy is recommended for pateints with symptoms of GORD. Reference: Craft, J and Gordon, C (2014) Understanding Pathophysiology, 2nd Edition. Mosby Australia. What are the non-modifiable risk factors for GORD? There are different risk factors between adults and children. Newborns often suffer from GORD as they have not yet gained full neuromuscular control of their lower oesophageal sphincter. This may last for 6-12 months. In adults there are several factors that are not modifiable. These include: 

Pregnancy (although this usually resolves after delivery)

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Hiatial hernia (although surgery may be able to correct this)

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Diabetes

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Vagus nerve damage, which controls the lower oesophageal sphincter, from surgery or injury.

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Any condition that effects the strength of the oesophageal sphincter muscles

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Nasogastric tube

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Resiratory disease

What are the modifiable risk factors for GORD? Many risk factors can be modified to help reduce the risk of GORD. These include: Medications - these may be able to be changed or ceased if GORD becomes problematic. Overweight/obesity - often when patients lose weight, their symptoms disappear. Eating pattern - people who have a large meal before lying down are more susceptible to reflux. Alcohol consumption - as it can relax the lower oesophageal sphincters in large amounts Smoking - studies suggest that cigarette smoke reduces the function of the lower oesophageal sphincters. 

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What treatment would be recommended for Mrs. Cook’s daughter? If Mrs. Cook's daughter only has mild gastro-oesophageal reflux then no treatment may be necessary as it often resolves without treatment. In order to manage this type of reflux, it is recommended that the infant be given small, frequent feedings. Frequent burping may also help minimise paediatric GORD. There are several medications that can be used to treat Mrs Cook's daughter. These work by increasing lower oesophageal sphinter pressure and increasing gastric motlility. If the child shows no signs of improvement despite medical intervention or has life-threatening events with reflux, an anti-reflux surgical procedure would be recommended. This may include gastropexy and fundoplication. Reference: Craft, J and Gordon, C (2014) Understanding Pathophysiology, 2nd Edition. Mosby Australia, 10/2014. . Mrs. Cook's Aunt also suffers from GORD. Would the treatment for Mrs. Cook’s aunt be different? If so, how? Adults often use over the counter antacids to relieve symptoms by neutralising the acidity of gastric contents. It is advised, that any person suffereing from GORD, seek medical advice and treatment in addition to this as, undiagnosed and untreated GORD is a risk factor for oesophageal carcinoma. Adults can also aim to to address modifiable risk factors to alliviate symptoms e.g. weight reduction, quit smoking etc. Some patients will require proton pump inhibitors to control symptoms and reduce inflammation. Other medications can be used to provide a barrier against the acid and increase lower oesophageal sphincter motility. Surgery may be required in pateints who are are non-responsive to the therapies listed above. Surgery narrows the lumen of the lower oesophageal sphincter and can be performed via laparoscopic surgery. Reference: Craft, J and Gordon, C. (2014) Understanding Pathophysiology, 2nd Edition. Mosby Australia, pg 789....