Gastro-Esophageal Reflux Disease
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Gastro-Esophageal Reflux Disease
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Gastro-Esophageal Reflux Disease
Gastro-Esophageal Reflux Disease
( GERD )
Definition : Exposure of the lower esophageal mucosa to pH less
than 4 , more than 4% of the 24 hours period.
Normally , about 50 GER episode can occur every 24 hours ,
but all are of very short duration.
Incidence :
GERD is the commonest upper GIT disorder.
It affects 45% of population .
GERD & peptic esophagitis is the commonest upper GIT endoscopic
finding (25%).
Physiology :
Normally , there is a physiological sphincter at the cardio-esophageal
junction maintaining a high pressure zone of 15-25 cm H2O .
physiological sphincter at the cardio-esophageal junction is
attributed to:
1- The lower 3cm of the esophagus is intra-abdominal which create
a competent lower esophageal sphincter .
2- The sphincteric function of circular muscle fibers of the lower
part of esophagus.
3- The valve like action of the acute cardio-esophageal angle
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Gastro-Esophageal Reflux Disease
( angle of His ).
4- The mucosal rosette at the cardio-esophageal junction.
5-Action of the right crus of the diaphragm which close the lower
end of esophagus during deep inspiration or sudden increase of
intra-abdominal pressure eg. Cough…etc .
5- A band of circular muscle which commences in the fundus of the
stomach and passes around the cardio-esophageal junction.
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Gastro-Esophageal Reflux Disease
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Gastro-Esophageal Reflux Disease
Clearance of refluxate from lower end of esophagus by 2
mechanisms :
1- Normal petristalsis of lower esophagus during swallowing .
2- Chemical neutralization of the swallowed alkaline saliva .
Aetiology :
I) Dysfunction of lower esophageal sphincter due to :
1-Short intra-abdominal part of the esophagus as in sliding hiatus
hernia .
2- Weakness of lower esophageal sphincter.
3- Increase in transient relaxation of lower esophageal sphincter.
II) Gastric distension :
Usually functional due to food which slow gastric emptying like
fat , coffee & chocolate .
Complications :
1- Reflux esophagitis with variable degree of erosions & ulceration .
2-Upper GIT bleeding which is mild iron deficiency anemia .
3- Strictures & shortening of esophagus (early due to spasm & later on
due to fibrosis ) .
4- Sliding hiatus hernia .
5-Respiratory complications .
6- Barrett’s esophagus :
It is a columnar metaplasia of the lower esophagus in response
to chronic acid irritation .
The metaplasia is usually intestinal or rarely gastric type .
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Gastro-Esophageal Reflux Disease
Intestinal type is precancerous which may turn into
adenocarcinoma of the esophagus .
Regular endoscopic follow up & multiple biopsies are
essential .
Endoscopic mucosal resection using photodynamic
therapy or argon beam coagulation or radiofrequency
ablation can be used in marked dysplasia before development of
carcinoma .
Clinical picture :
I) High risk patient : Obesity , fast foods , caffeine, alcohol , smoking
and certain drugs as antihistaminics & calcium channels blockers .
II) Typical symptoms :
1-The classical triade of GERD is heat burn is the (commonest
symptom ) , regurgitation & dysphagia .
2- Water brush (Regurgitation of watery acidic fluid
from the stomach to the throat ) .
3- Odynophagia ( painful swallowing due to esophagitis , pharyngitis
& laryngitis ) .
All previous symptoms are aggravated by large heavy meal ,
lying flat or bending forewards & more by night and relieved by
sitting.
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Gastro-Esophageal Reflux Disease
III) Atypical symptoms :
1- Chest pain simulating angina .
2- Respiratory manifestations simulating bronchial asthma .
3- Laryngeal manifestations as cough , choking & changes of voice .
4- Anemia , melaena or haematemesis in sever esophageal
ulcerations .
Investigations :
1-Upper GIT endoscopy : ( most important )
It shows the grade of esophagitis , presence of hiatus hernia and
biopsy to exclude Barret’s esophagus or malignancy .
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Gastro-Esophageal Reflux Disease
Endoscopic grading of reflux esophagitis :
Grade I : Hyperaemic mucosa .
Grade II : Superficial ulceration of mucosa only .
Grade III : Deep ulceration.
Grade IV : Stricture or Barrett’s esophagus .
2-Barium meal in Trendenlenburg’s position show reflux of contrast
medium into the esophagus .
3-Esophageal manometry : to detect weakness of lower esophageal
sphincter .
4- PH study :
24 hours pH monitoring is most reliable test to diagnose GERD.
A small probe is passed through the nose to the lower
esophagus and pH is recorded and analysed for 24 hours.
In GERD , there is low pH in the esophagus for long period .
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Gastro-Esophageal Reflux Disease
The patient is asked to record when he gets the symptoms .If
symptoms coincides with the low pH record , this show that these
symptoms are due to reflux .
Treatment :
I) Conservative :
Indications : the main line of treatment in 90% of cases .
Methods :
Weight reduction markedly improve the symptoms .
Antacids , H2 receptors blockers & proton pump inhibitor ( main
treatment )
Avoid smocking , alcohol , spicy food , coffee , chocolate , fatty &
large meal .
Avoid recumbence after meals for at least 2 hours .
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Gastro-Esophageal Reflux Disease
Elevation of the head and bed 15 degree to reduce reflux .
II) Surgical :
Indications : failure of medical treatment or complications .
Method : Laparoscopic Nissen’s fundoplication .
Complete wrapping of the fundus of the stomach around the lower
esophagus to creat a high pressure zone .
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Gastro-Esophageal Reflux Disease
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