Diapositiva 1

FISIOPATOLOGAAlumno :Gabriel crdenas ENFERMEDAD REFLUJO GASTROESOFGICOEnfermedad reflujo gastroesofgicoESFAGOERGE

Qu es ERGE?

El paso del contenido gstrico hacia el esfago con o sin vmitos o regurgitacin debido a la alteracin en los mecanismos de barrera a ese nivel, normal en personas sanas.La ERGE es una condicin sintomtica causada por el reflujo de materia nocivo desde el estomago al interior del esfago

Mecanismos defensivos BARRERA ANTIREFLUJO

ACLARAMIENTO ESOFGICO

DEFENSA TISULAR

Factores lesivos ACIDO CLORHIDRICO

PEPSINA

BILIS

TRIPSINA

MECANISMOS ETIOPATOGNICOS ETIOLOGA

Otro de los factores que determinan la aparicin de la enfermedad por reflujo es el aclaramiento esofgico, es decir, la capacidad del esfago para vaciar de forma rpida y completa el contenido gstrico refluido.

La ERGE es un trastorno gastrointestinal muy frecuente: Se estima que 40% de los adultos tiene pirosis y/o regurgitacin al menos una vez al mes. 20% una vez a la semana 7% diariamente

EPIDEMIOLOGAFISIOPATOLOGASINTOMAS

Pirosis (75%).Regurgitacin cida.Disfagia.Odinofagia.Hipo.Dolor torcico o epigstrico.Prdida de esmalte dental.Nuseas.

CUADRO CLNICOSignos y sntomas tpicos.

Esofagitis pptica Inflamacin de la mucosa El grado de afectacin puede venir por: Clasificacin de Savary-Miller Clasificacin de Los ngeles

Estenosis ppticaEs una complicacin frecuente en la enfermedad por reflujo (10-15% de los P)Factores que predisponen a la aparicin son: Edad avanzada Historial de reflujo prolongado Coexistencia de un trastorno esofgico asociado

Sntomas asociados: Disfagia para alimentos solidos Obstruccin esofgica episdica

COMPLICACIONES MS FRECUENTES

DIAGNOSTICOSe realiza fundamentalmente con la historia clnica del paciente, los pacientes que se quejan de pirosis tpicas y regurgitacin y que responden rpido a la terapia de suspensin acida, las pruebas diagnosticas no son necesarias

SISTEMAS DE CLASIFICACION ENDOSCOPICA DE ESOFAGITIS POR REFLUJO

Aspecto normal

Hetzel-Dent 021Figure 6-52. Endoscopic views of gastroesophageal reflux disease. A, Grade 1: normal squamocolumnar junction and esophageal mucosa. B, Grade 2: esophageal erosions in less than 10% of the mucosa. C, Grade 3: esophageal erosions in 10% to 50% of the mucosa. D, Grade 4: esophageal ulcers and ulcerations without stricture. See also Color Plate.

Lesion en menos de 10% de esofago distal

Savary Miller I Los Angeles B Hetzel II 22Figure 6-52. Endoscopic views of gastroesophageal reflux disease. A, Grade 1: normal squamocolumnar junction and esophageal mucosa. B, Grade 2: esophageal erosions in less than 10% of the mucosa. C, Grade 3: esophageal erosions in 10% to 50% of the mucosa. D, Grade 4: esophageal ulcers and ulcerations without stricture. See also Color Plate.

Lesion en mas de 10 a 50% de esofago distal

Savary Miller II Los Angeles C Hetzel -Dent III 23Figure 6-52. Endoscopic views of gastroesophageal reflux disease. A, Grade 1: normal squamocolumnar junction and esophageal mucosa. B, Grade 2: esophageal erosions in less than 10% of the mucosa. C, Grade 3: esophageal erosions in 10% to 50% of the mucosa. D, Grade 4: esophageal ulcers and ulcerations without stricture. See also Color Plate.

Ulceras circunferenciales

Savary Miller III Los Angeles D Hetzel - Dent IV 24Figure 6-52. Endoscopic views of gastroesophageal reflux disease. A, Grade 1: normal squamocolumnar junction and esophageal mucosa. B, Grade 2: esophageal erosions in less than 10% of the mucosa. C, Grade 3: esophageal erosions in 10% to 50% of the mucosa. D, Grade 4: esophageal ulcers and ulcerations without stricture. See also Color Plate.

Esofago de BarrettSavary Miller V

25Figure 6-29. Barrett's esophagus. The endoscopic appearance of a long segment (= 3 cm) of columnar-lined lower (Barrett's) esophagus is shown. The typical red coloration of the columnar epithelium is readly distinguished from the lighter pink or orange stratified squamous epithelium. Endoscopic biopsy, however, is essential for histologic confirmation. Barrett's esophagus is characterized by a specialized columnar epithelium with prominent goblet cells containing acidic mucin (see Figure 6-30). Esophageal segments of less than 3 cm but with similar histopathologic features have been designated as short segment Barrett's esophagus. Short segment Barrett's esophagus has been reported in approximately 18% of subjects undergoing endoscopy irrespective of complaints or evidence for reflux disease [28]. In many instances, it is difficult to distinguish short segment Barrett's esophagus from metaplasia of the gastric cardia, which also exhibits the same histopathology (ie, a lining containing specialized columnar epithelium). (From Tytgat [28]; with permission.)

References:[28]. Tytgat GJJ, Upper gastrointestinal endoscopy. In Textbook of Gastroenterology. Edited by Yamada T, Alpers DH, Owyang C. et al. Philadelphia: JB Lippincott; 1991 435-436TRATAMIENTOModificaciones del estilo de vida Elevar el cabecero de la cama 10-15 cm Evitar alimentos que faciliten el reflujo

Dejar el tabaco

Perder peso si existe sobrepeso

Frmacos usados en reflujo gastroesofgico Procinticos

Anticidos y alginatos

Antisecretores

Inhibidores de la bomba de protones

Mdico.

Quirrgico.

Endoscpico.

TRATAMIENTO QUIRRGICO.Funduplicatura de Nissen.Funduplicatura de Lind.Funduplicatura de Belsey.Tcnica de Lortat.Prtesis de Angelchik.Operacin de Allison.Operacin de Thal.Operacin de Hill.Operacin de Watson.Toupet.

GASTROPEXIA DE HILL

29Figure 6-45. Surgical management. Patients who are successfully controlled with acid suppressant therapy but do not desire to remain on medications lifelong are candidates for antireflux surgery. The most commonly performed surgical procedures for gastroesophageal reflux disease are the Hill gastropexy (A), Belsey (partial) fundoplication (B), and Nissen (complete) fundoplication (C) [28]. The Nissen procedure is the most popular and can be performed either as an open procedure or using the laparoscopic approach. The laparoscopic Nissen procedure has an initial failure rate of approximately 10% and an approximate 1% breakdown of the wrap each year. The procedure itself carries little mortality risk, but morbidity rates, including esophageal perforations, wound infections, splenic tears, postoperative dysphagia, and gas bloat, occur in about 10% of patients. The cost of a successful Nissen procedure is estimated to be equivalent in cost to 10 years of chronic proton pump inhibitor (PPI) therapy, but this analysis will change in favor of PPI therapy after a generic version is available in 2002. (Adapted from Pope [43].)

References:[28]. Tytgat GJJ, Upper gastrointestinal endoscopy. In Textbook of Gastroenterology. Edited by Yamada T, Alpers DH, Owyang C. et al. Philadelphia: JB Lippincott; 1991 435-436[43]. Pope CE II, Gastroesophageal reflux disease (reflux esophagitis). In Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. Edited by Sleisenger MH, Fordtran JS. Philadelphia: WB Saunders; 1983 449FUNDOPLICACION PARCIAL DE BELSEY

30Figure 6-45. Surgical management. Patients who are successfully controlled with acid suppressant therapy but do not desire to remain on medications lifelong are candidates for antireflux surgery. The most commonly performed surgical procedures for gastroesophageal reflux disease are the Hill gastropexy (A), Belsey (partial) fundoplication (B), and Nissen (complete) fundoplication (C) [28]. The Nissen procedure is the most popular and can be performed either as an open procedure or using the laparoscopic approach. The laparoscopic Nissen procedure has an initial failure rate of approximately 10% and an approximate 1% breakdown of the wrap each year. The procedure itself carries little mortality risk, but morbidity rates, including esophageal perforations, wound infections, splenic tears, postoperative dysphagia, and gas bloat, occur in about 10% of patients. The cost of a successful Nissen procedure is estimated to be equivalent in cost to 10 years of chronic proton pump inhibitor (PPI) therapy, but this analysis will change in favor of PPI therapy after a generic version is available in 2002. (Adapted from Pope [43].)

References:[28]. Tytgat GJJ, Upper gastrointestinal endoscopy. In Textbook of Gastroenterology. Edited by Yamada T, Alpers DH, Owyang C. et al. Philadelphia: JB Lippincott; 1991 435-436[43]. Pope CE II, Gastroesophageal reflux disease (reflux esophagitis). In Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. Edited by Sleisenger MH, Fordtran JS. Philadelphia: WB Saunders; 1983 449FUNDOPLICACION TOTAL DE NISSEN

31Figure 6-45. Surgical management. Patients who are successfully controlled with acid suppressant therapy but do not desire to remain on medications lifelong are candidates for antireflux surgery. The most commonly performed surgical procedures for gastroesophageal reflux disease are the Hill gastropexy (A), Belsey (partial) fundoplication (B), and Nissen (complete) fundoplication (C) [28]. The Nissen procedure is the most popular and can be performed either as an open procedure or using the laparoscopic approach. The laparoscopic Nissen procedure has an initial failure rate of approximately 10% and an approximate 1% breakdown of the wrap each year. The procedure itself carries little mortality risk, but morbidity rates, including esophageal perforations, wound infections, splenic tears, postoperative dysphagia, and gas bloat, occur in about 10% of patients. The cost of a successful Nissen procedure is estimated to be equivalent in cost to 10 years of chronic proton pump inhibitor (PPI) therapy, but this analysis will change in favor of PPI therapy after a generic version is available in 2002. (Adapted from Pope [43].)

References:[28]. Tytgat GJJ, Upper gastrointestinal endoscopy. In Textbook of Gastroenterology. Edited by Yamada T, Alpers DH, Owyang C. et al. Philadelphia: JB Lippincott; 1991 435-436[43]. Pope CE II, Gastroesophageal reflux disease (reflux esophagitis). In Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. Edited by Sleisenger MH, Fordtran JS. Philadelphia: WB Saunders; 1983 449Son estudios de investigacin que aun no han dado resultados convincentesAblacin por radiofrecuencia

Endocinch

Sutura endoscpica

Plicator

Esophyx Tratamiento endoscpico

La mayora de las personas responde a los cambios en el estilo de vida y medicamentos.Varios pacientes deben de seguir tomando los medicamentos toda la vida para poder controlar sus sntomas.

PRONOSTICOBIBLIOGRAFAHARRISON, 18 Edicin-volumen 2, Pag 2427-2435Scott L. Friedman, Kenneth R. McQuaid, James H. Grendell- Diagnstico y tratamiento en gastroenterologa Manual moderno 2da edicin 2003 pag 283-299

G R A C I A SBONITO DAClasificacionGradoCaracteristicas

De Savary-MillerILesion unica (erosiva o exudativa) involucra solo 1 pliegue longitudinal

IIMultiples lesiones (erosivas or exudativas) involucrando mas de un pliegue longitudinal pero no circunferencial

IIILesiones circunferenciales (erosivas o exudativas)

IVLesiones cronicas: ulceras, estenosis, o esofago corto lesiones grado I a III

VEpitelio de Barrett lesion de grado I a IV

De Los AngelesAUna o mas solucion de continuidad de la mucosa (erosiones) confinadas al pliegue y no mayor de 5 mm

BAl menos una erosion mucosa mas de 5 mm fr largo confinadas al pliegue pero no continuas en mas de un pliegue

CAl menos una erosion que involucra 2 o mas pliegues pero no circunferencial

DErosion circuferencial

De Hetzel (Hetzel-Dent)OMucosa de apariencia normal

IMucosa edematosa, hiperemica, o friable

IIErosiones que involucra < 10%; de los ultimos 5cm del esfago

IIIErosiones que involucran entre 10% a 50% del esofago distal

IVUlceracion profunda o erosiones que involucran mas de 50% del esofago distal