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