gastroesophageal reflux disorder- gerd

GastroesophagealGastroesophageal RefluxReflux

(GERD)(GERD)


(GERD)(GERD)S

V

AN OVERVIEW AN OVERVIEW

V

M

C

DR.B.SELVARAJ,MS;MchDR.B.SELVARAJ,MS;Mch;;FICSFICSDR.B.SELVARAJ,MS;MchDR.B.SELVARAJ,MS;Mch;;FICSFICS

S

V• PEDIATRIC SURGEON

• SVMCH&RC

• PONDICHERRY-605102

• INDIA

V

M

C


(GERD)(GERD)


(GERD)(GERD)

•Definition

•Etiology

S

V•

•Pathophysiology

•Clinical Features

•Complications

•Investigations

•Management

V

M

C

S

V

Definition of GERDDefinition of GERD

•Montreal consensus panel (44 experts):

“a condition which develops when the reflux of V

M

C

“a condition which develops when the reflux of

stomach contents causes troublesome symptoms

and/or complications”

•Troublesome—patient has to decide when reflux

interferes with lifestyle

S

V

Why do we care about reflux?Why do we care about reflux?

• Patients experience reflux symptoms

• 44% monthly

• 20% weekly

• 4-7% dailyV

M

C

• 4-7% daily

• Most common gastrointestinal diagnosis on outpatient

physician visits

• Frequency and severity does not predict esophagitis,

stricture, or cancer development

S

V

GE JunctionGE Junction

V

M

C

S

V

Anti Reflux MechanismsAnti Reflux Mechanisms

•Esophageal Sphincter Tone and Length.

•Sling Fibres of the Cardia.

•V

M

C

•Esophageal Hiatus Tone.

•Positive Intra Abdominal Pressure.

•Gastroesophageal acute angle of His

S

V

AntirefluxAntireflux BarrierBarrier

•Normally, the lower esophageal sphincter exists as a

zone of high pressure between esophagus and

stomach; when the HPZ is lost, reflux occurs

• Three components of high pressure zoneV

M

C

• Three components of high pressure zone

•Resting pressure if <8mmHg Reflux

•Overall length if < 3cms Occurs

•Intra-abdominal length if < 1cm

S

V

ETIOLOGYETIOLOGY

•Sliding Hiatus Hernia.

•Alteration of Phreno esophageal Ligament.

•Altered Obliquity of GE junction.V

M

C

•Altered Obliquity of GE junction.

•Reduced pinching action of Crus of Diaphragm.

•Reduced LES Pressure.

•Altered Transient Relaxation period in LES

S

V

ETIOLOGYETIOLOGY

•Raised Intra

Abdominal

Pressure.V

M

C

Pressure.

•Raised Intra

Gastric Pressure.

•Gastric Acid

Hypersecretion

S

V

PathophysiologyPathophysiology of GERDof GERD

• Fundic distention (overeating) &

delayed gastric emptying (high fat)

• Lower esophageal sphincter is pulled

distally by expanding fundusV

M

C

• Squamous epithelium exposed to

gastric juice

• Repeated exposure �� columnarization

S

V


•Extension of inflammation into muscularis propria causes progressive loss in length and pressure of the

LES— “esophageal shortening”

V

M

C

• Loss of LES leads to regurgitation, heartburn, and

subsequent severe esophagitis

S

V


•Spectrum of disease theory:

Nonerosive disease � erosive disease � Barrett’s �

esophageal adenocarcinomaV

M

C

esophageal adenocarcinoma

S

V

Clinical presentationClinical presentation

•Heartburn- Pyrosis

•1-2 hours after eating, often at night, antacid relief

•Regurgitation (Waterbrash)V

M

C

•Regurgitation (Waterbrash)

•Spontaneous return of gastric contents proximal to GE

jxn; less well relieved with antacids

•Dysphagia (40%)—difficulty with swallowing

should prompt search for pathologic condition

S

V

Clinical presentationClinical presentation

•Hoarseness of Voice / Dysphonia

•Respiratory Symptoms

•Cough / ExpectorationV

M

C

•Cough / Expectoration

•Wheeze / Breathlessness

•Aspiration

S

V

ComplicationsComplications

•Peptic Ulceration

•Hemetemesis

•Stricture Esophagus

•V

M

C

•Barrett’s esophagus

•Adeno Carcinoma esophagus

•Laryngeal Complications

•Respiratory Complications

S

V

InvestigationsInvestigations

•Upper G.I. Endoscopy

•Upper G.I. Contrast StudiesV

M

C

•Upper G.I. Contrast Studies

•Ambulatory pH Monitoring

•Esophageal Manometry

S

V

Upper GI EndoscopyUpper GI Endoscopy

V

M

C

S

V

Upper GI EndoscopyUpper GI Endoscopy

Grade BGrade A

V

M

C

Grade C&D

S

V

Barrett’s EsophagusBarrett’s Esophagus

•Intestinal / Gastric Columnar

Metaplasia of the Distal

esophagus.

•Diagnosed on Upper G.I. V

M

C

•Diagnosed on Upper G.I.

Endoscopy.

•Pre Malignant condition, leads

to Adeno Carcinoma.

•Multiple Biopsies are required

to exclude Malignancy.

S

V

HiatalHiatal HerniaHernia

V

M

C

S

V

Upper GI Contrast StudiesUpper GI Contrast Studies

•Only 40% of patients with classic symptoms of GERD will have reflux observed on radiography

•Assess for:V

M

C

•Assess for:•Esophageal shortening

•Hiatal hernia (80%)

•Paraesophageal hernia

•Stricture or obstructing lesion

•Beading or corkscrewing (motility disorders)

S

V

Upper GI Contrast StudiesUpper GI Contrast Studies

V

M

C

S

V

Ambulatory 24 Hrs pH MonitoringAmbulatory 24 Hrs pH Monitoring

•Rationale: gold standard

for diagnosis of GERD

•Quantifies actual time the

esophageal mucosa is V

M

C

esophageal mucosa is

exposed to gastric juice

•Measures the ability of

the esophagus to clear

refluxed acid

S

V


•Correlates esophageal acid exposure with

patients symptoms

•Without abnormal pH study, surgery is V

M

C

•Without abnormal pH study, surgery is

unlikely to benefit

•Gives a composite score (Johnson-

DeMeester score) highly sensitive and

specific (>96%) for diagnosing GERD

S

V


V

M

C

S

V

Component Mean Standard

deviation

Normal

value

Total % time pH <4 1.49% 1.38 <4.2%

% time pH < 4 in upright

position2.33% 1.98 <6.3%

V

M

C

position

%time pH <4 in lying down

position0.29% 0.47 <1.2%

Total No of episodes longer

than 5mts0.6 1.24 </= 3

Duration of longest episode 3.87 min 2.69 <9.2 min

Total No of Episodes 20.6 14.7 <50

S

V

Esophageal Esophageal ManometryManometry

�Rules out esophageal

motility disorders

V

M

C

�Esophageal body

dysfunction (achalasia or

aperistalsis) should change

management.

S

V

Esophageal Esophageal ManometryManometry

V

M

C

S

V

ManagementManagement

Treatment Goals for GERDTreatment Goals for GERD

••Eliminate symptomsEliminate symptoms

••Heal Heal esophagitisesophagitisV

M

C

••Heal Heal esophagitisesophagitis

••Manage or prevent complicationsManage or prevent complications

••Maintain remissionMaintain remission

S

V

ManagementManagement

Lifestyle Modifications are Cornerstone of GERD Lifestyle Modifications are Cornerstone of GERD

TherapyTherapy

•• Elevate head of bed 4Elevate head of bed 4--6 inches 6 inches

••Avoid eating within 2Avoid eating within 2--3 hours of bedtime3 hours of bedtime

•• Lose weight if overweightLose weight if overweightV

M

C

•• Lose weight if overweightLose weight if overweight

•• Stop smokingStop smoking

••Modify dietModify diet

•• Eat more frequent but smaller mealsEat more frequent but smaller meals

••Avoid fatty/fried food, peppermint, chocolate, alcohol, Avoid fatty/fried food, peppermint, chocolate, alcohol,

carbonated beverages, coffee and teacarbonated beverages, coffee and tea

••OTC medications OTC medications prnprn

S

V

ManagementManagement-- MedicalMedical

V

M

C

S

V

ManagementManagement-- SurgicalSurgical

• Need for continuous drug treatment or escalating dose of PPI

IndicationsIndications

• Factors predictive of successful outcome following antireflux surgery (n = 199)

•Abnormal score on 24-hour esophageal pH monitoring (p < V

M

C

PPI

• Relatively young

• Financial burden or noncompliance with PPI

• Patient choice

esophageal pH monitoring (p < 0.001)

• Presence of typical symptoms of GERD (heartburn and regurgitation) (p< 0.001)

• Symptomatic improvement in response to acid suppressive therapy (p = 0.02)

S

V


Principles of surgery

•Establish effective LES pressure

•Position the LES within the abdomenV

M

C

•

•Sphincter is under positive (intra-abdominal)

pressure

•Close any associated hiatal defect

S

V


Key points of surgery

• Complete dissection of esophageal hiatus and both

crura

•Mobilization of the gastric fundus

• Closure of the associated hiatal defectV

M

C

• Closure of the associated hiatal defect

• Creation of a tensionless gastric wrap around

esophagus

• 50- to 60-French intraesophageal dilator

• Limiting the length of the wrap to 1.5 to 2.0 cm

• Stabilizing the wrap

S

V


Lap Nissen’s Fundoplication

V

M

C

S

V

GERDGERD

V

M

C

S

V

GERDGERD-- AlgorithmAlgorithm

V

M

C

S

V

Take Home MessageTake Home Message

�PPI’s work to control symptoms and esophagitis, but require life-

long treatment

�Successful antireflux surgery is based on abnormal 24-hr pH

score, typical GERD symptoms, and symptomatic improvement in V

M

C

score, typical GERD symptoms, and symptomatic improvement in

response to acid –suppression therapy

�Having antireflux surgery is a patient-centered decision with a

risk:benefit ratio that can really only be weighed by the patient

S

VV

M

C