Post on 16-Jul-2015
GERD
DR. ANOOP S. ,
JUNIOR RESIDENT,
S5 UNIT.
Gastro esophageal reflux?
Backflow of gastric and/or duodenal contents into
the esophagus and past the lower esophageal
sphincter (LES), without associated belching or
vomiting
Reflux may cause symptoms or pathologic changes
Pathophysiology
LES – a physiological entity not a distinct
anatomical structure
Located just cephalad to the GEJ
Identifiable as a zone of high pressure during
manometric evaluation
Factors contributing to high
pressure zone
Intrinsic musculature of distal esophagus
Sling fibres of cardia
Diaphragm
Transmitted pressure of abdominal cavity
GASTRO ESOPHAGEAL REFLUX
OCCURS WHEN
Pressure of high pressure zone is too low to prevent
gastric contents from entering the esophagus
Sphincter of normal pressure undergoes spontaneous
relaxation, not associated with peristaltic wave in the
body of esophagus
Shortening of High pressure zone
Cephalad displacement
Gastric distension
GERD is often
associated
with
HIATAL HERNIA
Symptoms
•Pulmonary complications
• Asthma
• Chronic dry cough
• Aspiration Pneumonia
• Bronchiectasis
• Pulmonary Fibrosis• Miscellaneous
• Dyspepsia (nausea, vomiting, abdominal
Pain)
• Anorexia, Wt. Loss
• Anemia, Fatigue
• Hiccups
• Burning Mouth• Sleep disturbances
• Esophageal
• Heartburn and Regurgitation
• Dysphagia and Odynophagia (stricture
and
severe esophagitis)
• Barrett’s esophagus
• Esophageal adenocarcinoma
• Noncardiac chest pain• E.N.T Complications
• Sore Throat
• Hoarseness/Laryngitis
• Globus sensation
• Throat Clearing • Chronic Otitis media and Sinusitis
• Dental erosions
• Laryngeal cancer
Physical examination
Look for
Erosion of dentition
Chronic sinusitis
Injected oropharyngeal mucosa
Supraclavicular lymphnodes
Evaluation
Endoscopy
Manometry
pH monitoring
Esophagography
Imaging
Endoscopy
Exclude other diseases esp. tumour
Document presence of peptic esophageal injury
To assess the degree of injury
Biopsy
Other grading systems
Manometry
To rule out primary motility disorders
Station pull through and Rapid pull through measurement
Normal pressure for station pull through measurement - 12-30 mm
Hg
Added information like total length of LES, intra abdominal length,
location of sphincter relative to nares
Assessment of effectiveness of peristalsis
Peristaltic activity
Amplitude
Ineffective esophageal motility is defined as less
than 70% peristalsis or distal esophageal
amplitudes lower than 30mm of Hg
Often associated with significant GERD
pH monitoring
24 hr pH test- gold standard for diagnosing and
quantifying acid reflux
Assess
total number of reflux episodes ( pH <4)
Number of episodes >5 min
Extent of reflux in upright position
Extent of reflux in supine position
DeMeester score
Impedence pH testing
Can distinguish between a true reflux event and
intake of acid beverage
DeMeester Score
Esophagography
True value of the study is to determine the external
anatomy of esophagus and stomach
To rule out peptic esophageal strictures, diverticula,
tumors, hernias
Treatment
Medical
Surgical
Endoscopic
Medical and Lifestyle modifications
Weight loss
Head end elevation of bed
Avoidance of meal 2-3 hrs before bed time
Avoidance of chocolate, caffeine, alcohol, spicy/acidic
foods
8 week course of PPI ‘s
Proton pump inhibitors
Act by irreversibly binding to proton pumps in parietal cells of stomach – stops acid production
Effect occurs after 4 days of therapy and action lingers for the life of parietal cell
Patient needs to be off therapy for atleast a week before evaluation with pH monitoring
90% can expect full mucosal healing
Later step down of dosage
Side effects- head ache, flatulence, abd pain, constipation/ diarrhea
? Chronic acid suppression – risk of gastric cancer
Reasons for failure on PPI
Volume reflux
Hermit life style
Psychological distress
Poor compliance
Misdiagnosis
Surgical
Surgery is cost effective after 8 -10 years of medical
therapy
NISSEN FUNDOPLICATION
PARTIAL FUNDOPLICATION
NISSEN FUNDOPLICATION
NISSEN FUNDOPLICATION
Partial anterior fundoplication
- Dor and Thal
Partial posterior fundoplication
- Toupet
Endoscopic procedures
Plicating gastric mucosa just below cardia to
accentuate
Angle of His
Radiofrequency ablation of sphincter
Injection of submucosal polymers to lower esophagus
Complications
Operative
Pneumothorax
Gastric injuries
Esophageal injuries
Splenic injury
Liver injury
Post operative
Gas bloat syndrome
Dysphagia
FAILURE – 5 – 10%
Special Considerations
Stricture
Day case dilatation
PPI
Short esophagus
Collis gastroplasty
Collis Nissen
operation
Barrett esophagus
Questions