ESOPHAGEAL AND EXTRAESOPHAGEAL MANISFESTATION OF

GERD.

WHAT IS GERD ? When the amount of gastric juice that

refluxes into esophagus exceeds the normal limit causing symptoms with or without associated esophageal mucosal injury( esophagitis).

Spechler et al 1997 Harvard.

Presence of heartburn = / > 1 day per week without mention of regurgitation.

Kahrilas et al 2000 university of chicago.

Presence of heartburn = / > 3 per week controlled by acid supression

.

Monteral vakil N et al Amj Gastroentreol 2006

Condition which develop when reflux of stomach contents causes troublesome symptoms and or complications.

EPIDEMEOLOGY 40 % suffer heartburn at least 1/ month. 10 – 15% daily All ages but incidence is more > 40 yrs. Increasing in asian countries. GERD common in men and women. Esophagitis 2:1 – 3:1. Barretts esophagus 10 : 1 Adenocarcinoma – white males.

Esophagus , LES & stomach – Simple Plumbing circuit.

esophagus – antegrade pump, LES as valve & stomach as reservoir.

BRIEF ANATOMY Esophagus – cervical , thoracic & abdominal. Proximal 1/3rd – straiated muscle. Distal 2/3rd – smooth muscle. UES – cricopharyneus , thyropharyngeus & proximal

esophagus. Final gatekeeper in acid reflux. Distal thoracic esophagus is located left side of midline. Esophageal hiatus – right crus of diaphragm which forms a

sling around esophagus with right & left pillars. LES not anatomical sphincter. Distal 3 – 5cm of esophagus. Most critical antireflux defence mechanism.

PATHOPHYSIOLOGY1) ESOPHAGEAL DEFENSE MECHANISM –

mucosal resistance. esophageal clearance – mechanical &

chemical.

MECHANICAL CHEMICAL neuromuscular disease. Sicca syndrome achlasia , scleroderma laryngectomy. Xerostomia alcohol esophageal &

oral cavity radiotherapy

2) DYSFUNCTIONAL LES

. Primary barrier to gastroesophageal refulx is LES.

. LES works in conjucation with diaphragm.

. Three dominant mechanism of GE junction incompetence :-

1) transient LES relaxation ( vasovagal reflex ) most common mechanism.

2) LES hypotension. 3) anatomic distortion of junction –

hiatal hernia.

Decrease LES pressure – diet ( fat , chocolate, onion , soda , milk products, citrus juice )

tobaccoAlcohol Drugs – theophylline , nitrates , ca channel

blocker , anticholinergic , oral contraceptives, estrogen etc.

3) Delayed gastric emptying gastric contents intragastric pressure pressure against LES REFLUX.DietAlcohol , tobacco.Outlet obstruction – ulcer , neurogenic ,

neoplasm.

increase intrabdominal pressure – tight clothing , overeating , obesity , pregnancy , occupation , exercise.

Gastric hypersecretion – tobacco , alcohol , drugs & stress.

Classification Physiological – asymptomatic. post prandial. no abnormality.

Functional - asymptomatic. +ve pH study.

Pathological – local symptoms. secondary manisfestation.

Secondary – underlying condition ( asthma & gastric outlet obstruction).

Signs & symptoms Esophageal/ typical symptoms :- Heartburn- pyrosis (most common) 30 to 90 min after meal , retrosternal burning

pain

relived by antacid.

spread fingers spanning sternum ( open hand sign ).

Early cases – voluminous & late meal. Severe cases – drinking water , lying down or

bending over.

Regurgitation – sudden , effortless appearance of gastric contents in throat or mouth without nausea , retching or abdominal contractions.

Water bash. Dysphagia – occur approx 1/3rd of

patients. food is stuck in

retrosternal area. can be advanced symptom

or can be due to primary underlying esophageal motility

disorder . secondary to esophagitis or

sticture.

Esophageal complications Reflux esophagitis :- most common

complication of GERD.

Occur in approx 50 % of patient.

Left untreated – ulcers , bleeding and sticture formation.

Endoscopic classification of esophagitis.

savary miller classifiaction.

Grade 1: single erosion above gastro-esophageal mucosal junction.Grade 2: multiple, non-circumferential erosions above gastro-esophageal mucosal junction.Grade 3: circumferential erosion above mucosal junction.Grade 4: chronic change with esophageal ulceration and associated stricture.Grade 5: Barrett's esophagus with histologically confirmed intestinal differentiation within columnar epithelium. 

Esophageal stricture.Narrowing of the distal esophagus because of long-

term chronic acid-induced inflammationShortened, thick, noncompliant region of scarring Typically short and less than 1 cm in lengthIf they are longer, other causes, should be sought. Further evidence of esophagitis is often seen

proximal to the stricture

Barretts esophagus Acid damages lining of esophagus and causes

chronic esophagitis Damaged area heals in a metaplastic process

and abnormal columnar cells replace squamous cells

This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma

Extraesophageal / atypical symptoms

2 mechanism - . microaspiration of gastric contents. .Vagally mediated events

Pulmonary manifestations1) Chronic cough – GERD 1 of 3 most

common cause along with PND & asthma. Predominantly day time & standing position. Non productive & long standing nature. > 50 % cases sole manifestation. Chest xray – normal. No evidence of asthma.

2) asthma :- GERD is a potential trigger in many cases of asthma.

Pneumonia

Chronic bronchitis

Chronic obstructive pulmonary disease.

Idiopathic pulmonary fibrosis.

ENT manifestations1) Reflux laryngitis :- gastric contents in larynx ,

pharynx and upper aerodigestive tract. 2) Mucosal damage.3) Direct effect on mucocilliary cleareance.4) Vagally mediated reflex.

4 – 10 % GERD.

SYMPTOMS :- hoarsness Globus sensation Chronic throat clearing Vocal fatigue , break Sore throat Neck pain Excessive throat mucus PND

Signs:- edema , erythema , increase vascularity . Red , inflammed larynx.( posterior larynx). Thickening of posterior laryngeal mucosa with

hyperkeratosis (pachyderma laryngeus). Increase mucosal thickening with increase granularity &

rough cobbelstone appeareance – granular mucositis. Increse mucus formation. Pseudosulcus vocalis

Complications

Ulceration Granuloma Polyp Leukoplakia Subglottic stenosis Cancer.

2) Recurrent otitis media ( pepsin & pepsinogen effusion).

GERD nasopharyngeal inflammation

obstruction of eustachian tube

3) chronic sinusitis – direct effect on mucociliary cleareance.

4) dental erosions :- oral ulcers , halitosis.

Heartburn & regurgitation- 66%

Cervical dysphagia – 33%

Globus pharyngeus – 19%

Sore throat – 17%

Chronic throat clearing – 4%

GERD IN CHILDREN

NEONATES/ INFANTS OLDER CHILDREN/ ADOLESCENT

Regurgitation – post prandially

Signs of esophagitis – irritability, arching , gagging , chocking , feeding aversion.

Failure to thrive. Poor weight gain.

Early morning nausea

Abdominal discomfort.

Substernal pain. Recurrent vomiting. Heartburn.

Non GI manifestations

Pulmonary Asthma Recurrent

pneumonia Chronic cough Apnoea

Chronic otitis media

Hoarsness Globus sensation Sore throat Irritability Poor appetite Sleep disturbance

DIAGNOSIS ACG published guidelines T/t of GERD

2005.

According to guidelines patient with symptoms & h/o suggestive of uncomplicated GERD , the diagnosis of GERD must be assumed & empirical therapy should begin.

Patient showing signs of GERD complications & not responding to therapy should undergo further diagnostic testing.

INVESTIGATIONS 1) ENDOSCOPY :- first

choice. with biopsy if needed. Allows for detection,

stratification, and management of esophageal manisfestations or complications of GERD.

Lacks sensitivity for identifying pathologic reflux

Absence of endoscopic features does not exclude a GERD diagnosis.

FEES & VEES. FEESST.

Videofluroscopy

Dynamic fluroscopic imaging procedure. Visualization of rapid & integrade movement of

oral cavity , pharynx , larynx , trachea & esophagus.

All stages of swallowing Amount of aspirated Structural & anatomical abnormality. Done in sitting position – bolus coated with

barium given. Disadvantages- radiation exposure Patient intolerance. Limited information.

Esophageal function test

MANOMETRY:- measures amplitude & duration of contraction & relaxation pressure in pharynx , UOS, esophagus & LES.

the equipment & methodology are inadequate for pharyngeal & upper esophageal manometry , where catheters with miniature strain gauge pressure transducer sensors required.

difference in anatomy & physiology & frequency of recordings.

High resolution manometry Consist of closely spaced

recording sensors which provide several procedural advantages over conventional manometry.

36 solid- state pressure sensor placed at interval of 1 cm.

12 circumferentially dispersed small sensing elements.

Spans entire esophagus & detects segmental abnormalities of esophageal function.

pH monitoring

Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes.

Standard 24 hr pH monitoring. bravo capsules. Combined multiple intraluminal

impedance – pH ( MII- pH).

24 hr pH monitoring Single monitoring

site – 5cm above LES.

Multiple monitoring sites – 5 & 20 cm above

LES. Esophagus &

proximal stomach Esophagus &

hypopharynx.

Bravo capsule

Attachement of a pH capsule to the esophageal mucosa at the time of endoscopy.

Better tolerance by patients.Fixed position of capsule 6 cm above SCJ.Prolonged monitoring under more

physiological conditions upto 48 hrs.

Disadvantages :- chest pain , odynophagia.

Capsule detachment. Failure to disloge.

MII – pH(impedance testing) A measure of the electrical conductivity

of an organ and its contents . Impedance is inversely proportional to

conductivity When the organ is empty and relaxed,

the impedance is high

When the organ contains a bolus and expands, the impedance is low

Advantages of MII – pH

Contents of refluxate – liquid , gas & mixed.

Direction of bolus – antegrade & retrogade.

Height of reflux. Ph characterstics – acid. Weakly acid. Weakly alkaline. Acid re- reflux.

Restech Dx pH measurement system Highly sensitive & minimally invasive device

for detection of reflux in the posterior oropharynx.

Nasopharyngeal catheter measure pH in liquid or aerosolized droplets.

Wireless digital transmitter attached to shirt collar.

Tip of catheter has LED for visualization Sensing element consist of circular 1 mm

antimony surface & a reference electrode . Sensor records pH value twice every second. For extraesophageal reflux disease.

MANAGEMENT

Treatment goals Eliminate symptoms.

Heal esophagitis.

Manage or prevent complications.

Maintain remission.

MANAGEMENT

LIFESTYLE MODIFICATIONS Loose weight Avoid food ( citrus, alcohol, coffee, chochlate). Large meals. Decrease fat intake. Avoid medicines that potentiate GERD. Waiting 2- 3hrs after meal before lying down. Elevating head of bed by 4- 5 inches. Stop smoking. Decrease throat clearing , couching , conserve

voice use.

PHARMACOLOGICAL TREATMENT

Antacids Reduce gastric acidity. Use on an as - needed basis. Symptomatic relief – but no healing of lesion.

Histamine ( H2 receptor ) antagonistFirst line t/t for patients with mild to moderate symptoms &

grade I- II esophagitis. Decrease gastric acid secretion. Symptomatic relief. May require life long therapy. Ranitide , cimetedine, famotoidine.

Proton pump inhibitor If symptoms doesn’t

respond to H2 receptor blocker then change to PPI once daily.

Irreversible blockage of gastric acid secretion.

Faster healing rates for erosive esophagitis.

Drug maintenance therapy may be needed depending on the severity of disease & recurrence of symptoms after initial drug therapy is stopped.

Indications for surgery

Symptoms not controlled with PPI after 8wks.

Presence of GERD complications. Atypical symptoms with reflux

documented on 24 hr pH monitoring. Anatomical changes.

Nissen fundoplication Open or laproscopic Upper portion of stomach wrapped around distal

esophagus & sutured , creating tight LES. Combined with vagotomy.

Stretta procedure

Radiofrequency energy delivered system used to provide thermal burn to GE junction.

Endocinch procedureUses endoscopic sewing device to create pleats

with a series of suture passed through adjoining folds at the proximal fundus.

Antireflux surgery may not eliminate the need for future pharmacological treatment

Enteryx

Injectable biocompatible polymer.

Endoscopicaly implanted device.

Once injected forms small mass inside.

May eliminate the need for pharmacological treatment.

THANK YOU