Pathophysiology of GORD

Occasional episodes of GORD are common in health, particularly after eating. Gastro-oesophageal reflux disease develops when the oesophageal mucosa is exposed to gastric contents for prolonged periods of time, resulting in symptoms and, in a small proportion of cases, this leads to oesophagitis.

Abnormalities of the lower oesophageal sphincter related to GORD In health the lower oesophageal sphincter is tonically contracted, relaxing only during swallowing. Some patients with GORD have reduced lower oesopha-geal sphincter tone, permitting reflux when intra-abdominal pressure rises. In others basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter relaxation.

Hiatus hernia

A hiatal hernia occurs when part of the stomach protrudes through the diaphragm and into the thoracic cavity. Such hernias are extremely common in older people and more common in women than in men. A hiatus hernia causes reflux because the pressure gradient between the abdominal and thoracic cavities, which normally pinches the hiatus, is lost. In addition the oblique angle between the cardia and oesophagus disappears. Many patients who have large hiatus hernias develop reflux symptoms, but the relationship between the presence of a hernia and symptoms is poor. Hiatus hernias are very common in individuals who have no symptoms, and some symptomatic patients have only a very small or no hernia.

Important features of a hiatus hernia include:

• Occur in 30% of the population over the age of 50 years.

• Often asymptomatic.

Heartburn and regurgitation can occur.

• Gastric volumes may complicate large hernias.

The role of gastric contents in GORD

Gastric acid is the most important oesophageal irritant and there is a close relationship between acid exposure time and symptoms. Alkaline reflux, due to bile reflux following gastric surgery, is of uncertain importance.

Increased intra-abdominal pressure

Pregnancy and obesity are established predisposing causes. Weight loss commonly improves symptoms and patients should be encouraged to avoid tight-fitting garments.

Dietary and environmental factors

Dietary fat, chocolate, alcohol and beverages such as tea and coffee relax the lower oesophageal sphincter and may provoke symptoms. There is little evidence to incriminate smoking or non-steroidal anti-inflammatory drugs (NSAIDs) as causes of gastro-oesophageal reflux disease.

Delayed oesophageal clearance

Defective oesophageal peristaltic activity can be seen in patients who have GORD. Poor oesophageal clearance leads to increased exposure to acid from the stomach.

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