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gastro esophageal reflux disease and management
1. GASTROESOPHAGEAL
REFLUX DISEASE
UNDER THE GUIDANCE OF
• DR.S.VENKATA REDDY PROFESSOR
• DR.S.B.RATNA KISHORE ASSOCIATE PROF
• DR.S.SIMHADRI ASSISTANT PROF
• DR.P.VIJAYA ASSISTANT PROF
• By Dr.G.Maha Lakshmi
2nd yr Post Graduate
S4 Unit
3. • “A condition which develops when the reflux of stomach
contents causes troublrsome symptoms and/or
complications
• Troublesome – patient gets to decide reflux interfers with
lifestyle
Definition of GERD
4. Physiologic vs Pathologic
• Physiologic GERD
- Postprandial
- Short lived
- Asymptomatic
- No nocturnal symp
• Pathologic GERD
- Symptomatic
- Mucosal injury
- Nocturnal symp
5. Lower Esophageal Sphincter
1. Intrinsic distal esophageal muscles –
tonically contracted
2.Muscular sling fibers of the gastric cardia
3.diaphragmatic crura
4.Transmitted pressure of the abdomical
cavity
• Physiological relaxation of the LOS in
response to stretching of the gastric
fundus, particularly after a meal to allow
venting of swallowed air, is termed
transient LOS relaxations (TLOSRs).
6. Pathophysiology of GERD
1.The aetiology of GORD can be explained by the interaction between
the reflux barrier and the pressure diference between the thoracic
and abdominal cavity.
2.The reflux barrier consists of the crural diaphragm and the LOS.
3.An increased number of TLOSRs and a more compliant LOS would
increase refux.
4. Delay in acid refuxate clearance from the oesophagus, as a result of
defective oesophageal motility, also contributes to oesophageal
exposure.
7. • Hiatus hernia is associated with GORD, it is formed when the
weakened phreno-oesophageal ligament and widened crural opening
allow the proximal stomach to herniate through the diaphragmatic
hiatus
• An acid pocket is an area of unbufered gastric acid that accumulates
in the proximal stomach after meals and serves as a reservoir for acid
refux. Together with a hiatus hernia, it can exacerbate the severity
and symptoms of GERD.
12. Barium Swallow
• Objective and dynamic assessment of oesophagogastric anatomy.
• Useful first diagnostic test for patients with dysphagia
- Stricture (location,length)
- Mass (location,length)
- Hiatal hernia (size, type)
-also useful in assessing surgical complications after antireflux surgery like
disrupted wrap,slipped fundoplication or wrap herniation.
• Limitations
- Detailed mucosal examination erosive esophagitis , Barrett’s esophagus
13. • Xray barium swallow showing
1.Hiatal hernia (asterisk*)
2.Wide hiatus (thin arrows)
3. Shortened esophagus and
smooth esophagus at the
gastroesophageal junction (thick
arrow)
14. Esophago-gastro-duodenoscopy
• Endoscopy (with biopsy if needed)
- In patients with alarm signs/symptoms
- Those who fail a medication trail
- Those who require long-term tx
• Absence of endoscopic features does not exclude a GERD diagnosis
• Allows for detection , stratification and management of esophageal
manisfestations or complications of GERD
15.
16.
17.
18. Ambulatory refux and combined pH–
impedance monitoring
• Ambulatory refux monitoring is considered one of the most important
confrmatory tests for GORD.
• There are two types of monitoring devices: catheter based and
wireless capsule .
• Both measure the pH value at 5–6 cm above the upper border of the
LOS.
19. Wireless capsule device • The wireless capsule device is anchored
onto the mucosa of the oesophagus by
a pin and can transmit pH data for up to
96 hours.
• Parameters measured are
1.number of refux episodes (when pH
drops below 4)
2. oesophageal acid exposure time (the
percentage of time exposed to pH < 4).
An oesophageal exposure time of more
than 4% can be considered abnormal, and
one more than 6% is considered
diagnostic.
• A composite score (Johnson–
DeMeester) consists of six parameters
that can be calculated.
20. Catheter based device
The catheter-based pH monitoring device also
incorporates measurement of impedance.
Liquid refuxate has high conductivity and
therefore low impedance and air has low
conductivity and high impedance.
With the change in the temporal–spatial
patterns in different impedance sensors
spreading across different levels of the
monitoring catheter ,any bolus transit can be
assessed in its direction (antegrade or
retrograde) as well as by its nature (air or
liquid) can be distinguished like acid
reflux,aerophagia or belching.
21. • A 1-hour segment from a
24-hour ambulatory pH
study. Time is marked on
the x-axis, and pH is
marked on the y-axis.
Symptom events are
marked along the top of
the tracing.
22. Esophageal Manometry
• Manometry is used to diagnose oesophageal motility disorders and to
assess the oesophageal body and LOS function before surgery.
• HRM defnes important anatomical landmarks and abnormality of the
UOS, LOS and hiatus hernia.
• It also measures the contractility of the oesophageal body
• Limited role in GERD.
23. HRM is useful in
(i) detecting major oesophageal motility
disorder, e.g. achalasia, which can sometimes mimic GORD
(ii) defning the location of the LOS for accurate pH monitoring
placement
(iii) assessing the function and morphology of
the LOS, including the size of a hiatus hernia
(iv) assessing oesophageal body motility to tailor intervention,
especially the various antirefux procedures
24. • High-resolution manometry picture of a typical
swallow. The break at the UOS signifes the beginning of
a swallow.
• The oesophageal body contractility is represented by
the distal contractile integral (DCI), calculated by
multiplying the pressure (mmHg) and time (seconds)
along the whole length (cm) of the oesophageal body.
• There is a refex relaxation of the LOS upon each
swallow. The time between the start of a swallow to
the contractile deceleration point (CDP) is the distal
latency (DL).
25. • High-resolution manometry picture of
a typical swallow. The break at the
UOS signifes the beginning of a
swallow.
• The oesophageal body contractility is
represented by the distal contractile
integral (DCI), calculated by multiplying
the pressure (mmHg) and time
(seconds) along the whole length (cm)
of the oesophageal body.
• There is a refex relaxation of the LOS
upon each swallow. The time between
the start of a swallow to the
contractile deceleration point (CDP) is
the distal latency (DL).
27. Lifestyle Modifications
• Weight reduction of overweight
• Avoid clothing that is tight around the waist
• Modify diet
- Eat more frequent but smaller meals
- Avoid fatty/fried food , peppermint,
chocolate,alcohol,cardonated
beverages,coffee and tea, onions, garlic.
- Stop smoking
• Elevate head of bed 4-6 inches
• Avoid eating within 2-3 hours of bedtime
28. • PPI
• First line treatment in symptomatic patients
• Long term treatment
• reduce acid secretion
• Given for 8weeks if esophagitis also there
• Antacids: alginate preparations for quick and short term relief
• Better control of symptoms with PPIs vs H2RAs and better remission rates
• Faster healing of erosive esophagitis with PPIs vs H2RAs
Medical management
29. • Histamine H2-Receptor Antagonists :More effective than placebo
and antacids for relieving heartburn in patients with GERD
- Faster healing of erosive esophagitis.
- Can use regularly or on-demand
• Prokinetics : promote gastric emptying & reduce risk of gastric acid
reflux. Drugs metoclopramide and domperidone
• Potassium competitive acid blockers (PCAB): more rapid ,competitive
& reversible inhibitions of proton pump.
30.
31. SURGICAL MANAGEMENT
• The indications for surgery include
(i) incomplete symptom control with medical management,
(ii) intolerance of or unwillingness to comply with, long-term medical
therapy,
(iii) regurgitation despite medication (less well amenable to PPI)
(iv) presence of a large hiatus hernia
(v) complications arising from GERD
(vi) extraoesophageal symptoms.
32. The predictors of good surgical
outcome include
1. typical GORD
Symptoms
2. PPI responders
3. presence of hiatus hernia and
presence of GORD complications
e.g. refux oesophagitis (grade
B or above) and non-dysplastic
Barrett’s oesophagus.
Poor surgical outcomes are
1.Functional heartburn
2.EOO
3.connective tissue diseases
4. extreme obesity.
33. Antirefux operations have three essential components:
(i) restoration of an intra-abdominal segment of the oesophagus
(ii) crural repair
(iii) some form of reinforcement of the LOS by the upper stomach
(fundoplication) or by a prosthesis placed around the intra-
abdominal oesophagus
34. LAPAROSCOPIC FUNDOPLICATION
• laparoscopic fundoplication with hiatal reconstruction is the standard
approach.
• The mechanism of fundoplication is to create a ‘foppy’ valve around
the OGJ and to restore the angle of His.
• It has the effect of increasing LOS basal pressure, lessening TLOSR and
reducing the capacity of the gastric fundus, thereby enhancing gastric
emptying
35. • Port placement for
laparoscopic antireflux
surgery. The surgeon
operates through the two
cephalad ports, and the
assistant operates through
the two caudad ports.
36. • In the left crus approach
to the esophageal hiatus,
the fundus of the stomach
is mobilized early during
the operation to provide
early visualization of the
spleen, which helps
prevent splenic injury.
37. • After the fundus has been
mobilized, the
phrenoesophageal membrane
is incised at the left crus, with
care taken to avoid injury to
the esophagus, posterior
vagus nerve, and aorta.
38. • After the fundus has been
mobilized, the
phrenoesophageal membrane
is incised at the left crus, with
care taken to avoid injury to
the esophagus, posterior
vagus nerve, and aorta.
39. • Posterior crural closure is
performed with heavy
permanent suture.
• the peritoneum overlying the
crura is incorporated into the
closure.
• The exposure is facilitated by
displacement of the
esophagus anteriorly and to
the left.
40. • Creation of a 360-degree Nissen
fundoplication.
• The anterior and posterior fundus
must be grasped equidistant from the
greater curvature posterior to the
esophagus.
• After placement of the first suture of
the fundoplication, a 52 Fr bougie is
passed into the stomach, and the
fundoplication is completed.
• With the bougie removed from the
patient, the fundoplication is secured
to the diaphragm with right and left
coronal sutures ( inset ) and a single
posterior suture.
41. • A posterior gastric marking suture is helpful to
ensure proper geometric configuration of the
fundoplication.
• With the greater curvature of the stomach
rotated to the patient’s right, the posterior
stomach is exposed, and a marking stitch is
placed on the posterior fundus 3 cm from the
gastroesophageal junction (✩) and 2 cm from
the greater curvature of the stomach.
42. • A posterior gastric marking suture is
helpful to ensure proper geometric
configuration of the fundoplication.
• With the greater curvature of the
stomach rotated to the patient’s right,
the posterior stomach is exposed,
and a marking stitch is placed on the
posterior fundus 3 cm from the
gastroesophageal junction (✩) and 2
cm from the greater curvature of the
stomach.
43. Types of fundoplication
• Three types of fundoplication.
• (A) A 360-degree
fundoplication.
• (B) Partial anterior
fundoplication.
• (C) Partial posterior
fundoplication.
44. Side effects :
• Complete fundoplication (Nissen) is associated with a higherincidence
of short-term dysphagia but is most durable in reflux control.
• Partial fundoplication: posteriorly (Toupet) or anteriorly (Dor,
Watson), has fewer short-term side effects with higher longterm
failure rate.
• The most common side efect of fundoplication is shortterm dysphagia,
related presumably to tissue oedema and infammation. It usually
resolves within 3 months of surgery.
• ‘gas-bloat syndrome’, especially after a complete fundoplication,
patient complain of gaseous distension of the abdomen and failure to
belch or vomit and increase in fatulence.
45. Magnetic sphincter augmentation
Magnetic sphincter augmentation.
Intraoperative photograph
following hiatus hernia repair. The
magnetic sphincter is implanted
around the lower oesophagus, in
between the posterior valgus
nerve (white arrows) and the
oesophageal wall.
46. ENDOSCOPIC TREATMENTS
• Endoscopic treatments attempted to augment a failing LOS.
• Transoral incisionless fundoplication mimics classic fundoplication by
recreating the dynamics of the angle of His using an endoscopic stapling
device
• Radiofrequency ablation (RFA) is another strategy to remodel the LOS by
reducing compliance
• Antirefux mucosectomy makes use of the endoscopic mucosal resection
(EMR) technique to remove subcardiac mucosa while preserving a 1-cm
gap at the lesser and greater curves.
• Recent: argon plasma coagulation has been used to accomplish the same
subcardiac mucosal injury instead of EMR
47. References
• Bailey and love 28th edition
• Sabiston text book of surgery
• Schwartz’s principles of surgery
