Presenter

+Dr Aswin P

GERD +Post graduate trainee 2nd year

Investigations +Unit 1 General surgery

and Management Moderator

+Dr Rishikesh
+Assistant Professor
+Unit 1 General surgery
Introduction
+as common in men as in women
+occurs in all age groups.
+The prevalence of GERD increases in
people older than 40 years.
+Gastroesophageal reflux may be classified into
three categories, as follows:
+Physiologic (or functional) gastroesophageal
reflux:
+no underlying predisposing factors or conditions
+pharmacologic treatment is typically not necessary
+Pathologic gastroesophageal reflux
+Primary or GERD:
+Patients frequently experience complications
+Requires careful evaluation and treatment [26]
+Secondary gastroesophageal reflux:
+an underlying condition may predispose to
gastroesophageal reflux
+Eg: gastric outlet obstruction
Relevant anatomy
+ As the thoracic esophagus enters the abdomen
through the esophageal hiatus in the diaphragm, it
becomes the abdominal esophagus
+ hiatus is formed by the right crus of the diaphragm,
which forms a sling around the esophagus
+ phrenoesophageal ligament or membrane
+reflection of the subdiaphragmatic fascia onto the
transversalis fascia
+also encircles the esophagus
Phrenoesoph
ageal
ligament,

GE junction
Protective factors
+ acute angle (hiss) and the length of abdominal esophagus
both contribute to the normal closure of the esophagus when
intragastric and intra-abdominal pressures are high
+The lower esophageal sphincter—or, more accurately, the distal
esophageal high-pressure zone (HPZ)—is the distal most
segment of the esophagus (3-5 cm in adults) and can be
anywhere from 2-5 cm in length
+adequate intra-abdominal HPZ is crucial in preventing GERD
+This HPZ does not correspond to any visible anatomic structure.
It is a zone created by a complex architecture of smooth muscle
fibers, and it is typically identified during manometry.
+The intrinsic musculature of the distal esophagus
is in a state of tonic contraction.
+Within 0.5 seconds of the initiation of a swallow, these muscle
fibers relax to allow passage of liquid or food into the
stomach, and then they return to a state of tonic contraction.
+Sling fibers of the gastric cardia are oriented
diagonally from the cardia-fundus junction to the lesser
curve of the stomach.
+contribute significantly to the high-pressure zone of the LES
+The crura of the diaphragm surround the esophagus
as it passes through the esophageal hiatus.
Pathophysiology
• functions as an
Poor esophageal motility
Esop antegrade decreases clearance of
hag acidic material
ous pump

• valve dysfunctional LES allows

reflux of large amounts
LES
of gastric juice

Delayed gastric emptying

Sto • reservoir can increase the volume
mac and pressure in the
h reservoir until the valve
mechanism is defeated
Dysfunction of the lower esophageal sphincter

Mechanic
Functional
al

Increased transient Hypotensiv

relaxation e LES

foods (coffee, alcohol,

chocolate, fatty meals)

medications (beta-agonists, [24] nitrates,

calcium channel blockers, anticholinergics)

hormones (eg, progesterone), and nicotine

Delayed gastric emptying
+increase in the gastric contents resulting in
increased intragastric pressure
+ultimately, increased pressure against the lower
esophageal sphincter
+This pressure eventually defeats the LES and
leads to reflux
Hiatal hernia
+ Hiatal hernias can be encountered frequently in
patients with reflux disease
+Pathophysiology:
+lower esophageal sphincter may migrate proximally into the
chest and lose its abdominal high-pressure zone (HPZ), or
+ the length of the HPZ may decrease
+The diaphragmatic hiatus may be widened by a large hernia,
which impairs the ability of the crura to function as an
external sphincter
+gastric contents may be trapped in the hernial sac and reflux
proximally into the esophagus during relaxation of the LES
Hiatal
hernia
Obesity
+Some studies have shown that GERD is highly prevalent
in patients who are morbidly obese
+mechanism by which a high BMI increases esophageal
acid exposure is not completely understood
+Increased intragastric pressure and gastroesophageal
pressure gradient may have a role
Complication
s
+Esophagitis
+most common
complication of GERD
+occurring in
approximately 50% of
patients
+ Severity of reflux
esophagitis (Los Angeles
Classification):
+MILD: A,B
+SEVERE: C,D
GRADE A One or more mucosal breaks < 5 mm in
maximal length

GRADE B One or more mucosal breaks > 5mm, but

without continuity across mucosal folds

GRADE C ≥ 2 mucosal folds, but involving less than

75% of the esophageal circumference

GRADE D Mucosal breaks involving more than 75% of

esophageal circumference
+Stricture
+advanced forms of esophagitis and are caused by circumferential
fibrosis due to chronic deep injury
+mid-to-distal esophagus
+present with dysphagia
+can be visualized on upper GI tract studies and endoscopy
+Management would involve evaluation of stricture for malignancy
+Barrett esophagus
+8%-15% of patients with GERD
+caused by the chronic reflux of gastric juice into the esophagus
+metaplastic conversion of the normal distal squamous
esophageal epithelium to columnar epithelium
+Histologic examination of esophageal biopsy specimens is
required to make the diagnosis
+ Barrett esophagus with
intestinal type metaplasia has
malignant potential and is a
risk factor for the development
of esophageal adenocarcinoma
+ risk of adenocarcinoma 30-40
times normal population
+ Endoscopy: red velvety mucosa
in distal esophagous
+ When high-grade dysplasia is
discovered and confirmed by a
second pathologist, endoscopic
ablation is the standard of care
Signs and symptoms
• esophageal symptoms:
+Heartburn (pyrosis):sensation of burning or discomfort that
usually occurs after eating or when lying supine or bending
over.
+Regurgitation: effortless return of gastric and/or esophageal
contents into the pharynx
+Dysphagia: Dysphagia can be an advanced symptom and can
be due to a primary underlying esophageal motility disorder, a
motility disorder secondary to esophagitis, or stricture
formation
+sour taste in the mouth
Signs and symptoms
+atypical (extraesophageal) symptoms
+Coughing and/or wheezing:
+ aspiration of gastric contents into the tracheobronchial tree
+ vagal reflex arc producing bronchoconstriction
+Hoarseness, sore throat
+ irritation of the vocal cords by the gastric refluxate and is often
experienced by patients in the morning
+Noncardiac chest pain:
+ Reflux is the most common cause of noncardiac chest pain
+Enamel erosion or other dental manifestations
Diagnosis

+Upper gastrointestinal
endoscopy/esophagogastroduodenos
copy
+Esophageal manometry
+Ambulatory 24-hour pH monitoring
Upper Gastrointestinal Endoscopy
+demonstrates the anatomy
+identifies the possible presence and severity of
complications of reflux disease
+ esophagitis, Barrett esophagus, strictures
+EGD also excludes the presence of other diseases (eg,
peptic ulcer) that can present similarly to GERD
+Limitation:
+EGD is frequently performed to help diagnose GERD, it
is not the most cost-effective diagnostic study,
because esophagitis is present in only 50% of
+Indications for esophageal manometry and
prolonged pH monitoring
+Persistence of symptoms while taking adequate
antisecretory therapy, such as PPI therapy
+Recurrence of symptoms after discontinuation of
acid-reducing medications
+Investigation of atypical symptoms, such as chest
pain or asthma, in patients without esophagitis
+Confirmation of the diagnosis in preparation for
antireflux surgery
Ambulatory 24-Hour pH Monitoring
+criterion standard in establishing a diagnosis of GERD
+ sensitivity of 96% and a specificity of 95%
+quantifies the gastroesophageal reflux and allows a
correlation between the symptoms of reflux and the episodes
of reflux
+Patients with endoscopically confirmed esophagitis do not
need pH monitoring to establish a diagnosis of GERD.
Esophageal Manometry
+Esophageal manometry defines the function of the LES and
the esophageal body (peristalsis)
+ Esophageal manometry is essential for correctly positioning
Other investigations
+Chest images may demonstrate a large hiatal hernia,
but small hernias can be easily missed.
+Upper GI contrast-enhanced studies are the initial
radiologic procedure of choice in the workup of the
patient in whom GERD is suggested.
+Esophageal inflammatory and neoplastic diseases are better
detected with double-contrast techniques.
+single-contrast techniques are more sensitive for structural
defects such as hiatal hernias and strictures or esophageal
rings
Management
+Treatment of gastroesophageal reflux disease:
+goals are to
+control symptoms,
+to heal esophagitis,
+to prevent recurrent esophagitis
+Treat complications if any
+treatment is based on Step wise approach
+lifestyle modifications
+control of gastric acid secretion through
+medical therapy with antacids or proton pump inhibitors
+surgical treatment with corrective anti reflux surgery
+80% of patients have a recurrent but
nonprogressive form of GERD that is controlled with
medications
+ 20% of patients who have a progressive form of
the disease is important, because they may develop
severe complications, such as strictures or Barrett
esophagus
+For patients who develop complications, surgical
treatment should be considered at an earlier stage to
avoid the sequelae of the disease that can have serious
consequences
Nonpharmacotherapy
+Lifestyle modifications
+Losing weight (if overweight)
+Avoiding alcohol, chocolate, citrus juice, and tomato-
based products
+Avoiding peppermint, coffee, and possibly the onion
family [7]
+Eating small, frequent meals rather than large meals
+Waiting 3 hours after a meal to lie down
+Refraining from ingesting food (except liquids) within 3
hours of bedtime
+Elevating the head of the bed by 8 inches
 Pharmacotherapy
+H2 receptor antagonists
+eg, cimetidine, famotidine, nizatidine
+US Food and Drug Administration recalled ranitidine (Zantac) after
about drug contamination with the impurities of the carcinogenic
molecule N-nitrosodimethylamine (NDMA)
+Proton pump inhibitors
+eg, omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole
+PPIs are superior to H2 receptor antagonists for the resolution of GERD
symptoms at 4 weeks and healing of esophagitis at 8 weeks
+S/E: bone fractures in postmenopausal women, chronic renal disease,
acute renal disease, community-acquired pneumonia, and Clostridium
difficile intestinal infection
+Prokinetic agents (eg, metoclopramide)
Surgical options
+Fundoplication:
+Approaches:
+ Trans Intraoral Fundoplication
+ Transthoracic fundoplication
+ Transabdominal fundoplication
+ Open
+ Laparoscopic

+Magnetic sphincter augmentation

Indications for fundoplication
+Patients with symptoms that are not completely controlled by PPI
therapy
+presence of Barrett esophagus
+whether acid suppression improves the outcome or prevents the
progression of Barrett esophagus remains unknown
+presence of extra esophageal manifestations of GERD
+Postmenopausal women with osteoporosis
+Patients with cardiac conduction defects

(Dor fundoplication is used along with hellers myotomy in achalasia

cardia)
Advantages of fundoplication over PPI
+PPI do not eliminate the reflux of bile, which some
believe to be a major contributor to the pathogenesis of
Barrett epithelium
+fundoplication offers the only possibility of stopping any
kind of reflux by creating a competent LES
Steps of fundoplication
+position: reverse Trendelenburg
position with low lithotomy
+surgeon stand between the patient’s
legs; the assistant stands at the
patient’s left
+Access to the abdomen is obtained with
a Veress needle at Palmer point in the
left upper quadrant of the abdomen
+surgeon operates through the two most
cephalad ports, and the assistant
operates through the two caudal ports
Achieving intra abdominal length
+minimum of 3 cm of intra abdominal esophagus should
be obtained
+mobilization of the esophagus from its
adhesions in mediastinum
+division of both vagus nerves
+stapled wedge gastroplasty
360 degree Fundoplication
+posterior aspect of the fundus is marked with a suture 3
cm distal to the GEJ and 2 cm off the greater curvature
+posterior fundus is then passed behind the esophagus
from the patient’s left to right
+anterior fundus on the left side of the esophagus is then
grasped 2 cm from the greater curvature and 3 cm from
the GEJ
+both portions of the fundus are positioned on the anterior
aspect of the esophagus
Nissen: 360
Dor: Ant 180
Toupet:Post 270
Tal: Ant 270
Operative Complications of
fundoplication
+Pneumothorax.
+one of the most common intra operative complications,
+Result of accidental pleural injury
+Gastric and esophageal injuries.
+<1% cases
+Primary repair should be done if identified intraoperatively
+Splenic and liver injuries or bleeding
+splenic injury occurs during mobilization of the fundus and
greater curvature of the stomach
+Care must be taken during mobilization of the fundus to avoid
Postoperative Side effects
+Bloating
+ fundoplication can alter the mechanical ability of the
stomach to eliminate swallowed air by belching leading to
an accumulation of gas in the stomach k/a Gas bloat
syndrome
+Dysphagia.
+postoperative edema or hematoma
+Usually, self resolving
+If persisting beyond 3 months, a UGI series should be
obtained to ensure no anatomic abnormality that could
Transoral Incisionless Fundoplication

+performed with a flexible, multichannel endoluminal

device
+full-thickness gastric plication is done to create an
antireflux valve at the GEJ
+ endoluminal fundoplication can be created up to 4 cm
in length and 270 degrees.
Magnetic Sphincter Augmentation

+series of magnetic beads that is positioned around the

distal esophagus to increase LES resting pressure to
counteract GER
+During peristaltic swallows, the propagated bolus of
liquid or food separates the beads, opening the GEJ and
allowing the bolus to pass into the stomach, after which
the beads return to their original position to augment
the LES resting pressure
+Complications: device migration, erosion, dysphagia
THANK YOU