Gastroesophageal Reflux

GASTROESOPHA GEAL REFLUX

Prof. Dr. Turgut IPEK

GERD in t he 2 0th C ent ury 

GERD was probably not recognized before the mild of the 1930’es. At the time Winkelstein described a patient with an esophageal stricture and in his paper he wondered if the stricture was caused by acid regurgitation from the stomach into esophagus. As radiology was the available investigation it was discovered that a number of patient had a hiatal hernia and GERD became synonymous with a hiatal hernia.

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Later endoscopy became part of the diagnostic armamentarium, and now esophagitis became the dominant term. Finally pH studies were developed and focus was directed more towards acid regurgitation into stomach. Initially antacids and alginates were the supplements to general advices; but from the late 1970’es first H2-reseptor antagonists, later PPI became available

Ethnic and geographical variation GERD is predominant among Caucasians and occurs rarely among blacks. Prevalence of GERD-symptoms A huge number of studies have focused on the prevalence of heartburn. Prevalence on the basis of investigations The important investigations in GERD is endoscopy and pHstudies. Both these investigations are available and associated with considerable discomfort. Sex and age distrubution There is, however, a tendency towards a higher prevalence of macroscopic esophagitis with increasing age. It is noteworthy that most series on antireflux surgery includes more men than women.

Gastro özofageal Re flü H astalı ğı GERD 

GERD, mukozal lezyonlar olmadan (NERD) semptomatik hastalıktan eroziv özofajitin komplikasyonlarına (özofageal striktür,ülserasyon yada Barrett’s özofagus) kadar bir spektrum hastalıktır.

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Oldukça yaygındır (% 15-20). Ciddi özofajit yaş ile artar 60 yaş üzeri ciddi özofajit oranı %75 Ciddi özofajit kadınlara göre erkeklerde daha sık gözlenir

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Günlük heartburn Haftalık heartburn Aylık heartburn

%7 %20 %44

Amerika’da gastroenteritis ve kolelitiasis takiben en sık görülen gastrointestinal hastalıktır (19 milyon/yıl)

a- Heartburn ve regürjitasyon gibi tipik semptomları olan ancak non-eroziv reflü hastalığı (NERD) olarak adlandırılan reflü özofajiti olmayan grup b- Komplikasyon olsun yada olmasın reflü özofajitli grup c- Atipik semptomları olan grup

Ris k F aktörler Obezite  İleri yaş  Hiatal herni varlığı  Semptomların ciddiyeti 

Erkek hasta Alkol kullanımı Sigara kullanımı 1yılı aşkın GERD anamnezi

Natural history of GERD  GERD can present in a number of different ways varying from non-erosive GERD to complications as stenosis, Barrett and adenocarcinoma of the esophagus .  Symptom severity is independent of the grade of macroscopic esophagitis  When patients have consulted their doctor for GERD the disease is usually chronic. Long term studies (around 10 years) have shown that only 10% are asymptomatic without treatment.  Non-erosive disease usually does not (<25%) progress into esophagitis. However, only few long term studies are available.

Pathophysiology of GERD  The disease is present when pathologic exposure of the esophageal lumen to gastric juice occurs and this can be a pathologic amount of duodenal components such as bile. The most frequent condition in gastroesophageal reflux disease is pathologic acid exposure and therefore this is often used synonymously.

The antireflux barrier  The main reason for pathologic reflux is a malfunction of the antireflux barrier at the level of the gastroesophageal junction.  The intraabdominal portion of the lower esophageal sphincter is involved in preventing reflux during the swallowing of the patient. Both the intraabdominal sphincter length and the pinching effect of the diaphragm helps to close the sphincter during elevation of intraabdominal pressure.

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The mechanical incompetence of the lower esophageal sphincter has been described by the De Meester, using as relevant criteria the overall length of the sphincter which is in the physiologic situation 3-4cm long at the distal end of the esophagus. The resting tone of the sphincter characterized by the lower esophageal sphincter pressure varies in healthy volunteers in relation to the gastric pressure between 10 and 30 mmHg.

Esophageal peristalsis  Esophageal clearance and peristaltic function of the esophageal body is also involved in producing increased esophageal exposure to gastric juice. The physiologic swallowing function is involved in the neutralizing acid of reflux by enabling to swallow saliva.

Mucosal resistance  It is however an important factor in assessing the ability of gastric juice to cause toxic effects in the esophageal wall. Duodeno-gastroesophageal reflux: Gastric disorders  The backup of gastric contents in the intraduodenal segment due to delayed gastric emptying can cause pathologic acid reflux into esophagus.

Ph ysiol ogy  The

antireflux mechanism consists of a valvular cardia, the propulsive pump action of the esophagus and a reservoir function of the stomach. Failure of any may lead to abdominal esophageal exposure to gastric juice.

Pu mp Physiology: Esophageal clearance of refluxed material involves:  The volumic clearance related to the esophageal peristalsis and gravity.  The chemical clearance related to salivation Failure: f) Reduction of the volumic clearance (hiatal hernia) g) Reduction of the chemical clearance (reduction of saliva)

Valve Physiology: the antireflux valve includes: b) The LOWER ESOPHAGEAL SPHINCTER (LES)

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c)

the intrinsic esophageal sphincter (competency: pressure-overall length-intraabdominal length)

Anatomical factors:

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Hiss angle phrenoesophageal ligament.

Failure: e) Low LES pressure f) Transient inappropriate LES relaxion g) Hiatal hernia

Re serv oir  Gastric

functions abnormalities causing GERD include increased intragastric pressure, gastric dilatation, decreased emptying rate and increased acid secretion

GERD ’de Ta nı Yö ntemle ri      

Anamnez Endoskopi Bernstein test 24 saatlik ambulatuar pH Kısa süreli asid supresyon tedavisi Yeni teknikler magnetoencephalography PET fonksiyonel MRI chromoendoskopi high resolution-magnification endoskopi

En doskopi 

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Tipik reflü semptomlu hastaların %30-40’ında eroziv özofajit saptanır Eroziv özofajitli hastalarda 24 saatlik pH ölçümü pozitif NERD olgularının %37-60’ında 24 saatlik pH ölçümü normal Chromoendoskopi Barrett’s tanısında etkin sensitivite %95, spesifisite %97

Evaluation: Evaluation of the GERD can be divided into mandatory and selective tests. The selection of the test is based on a decisional algorithm starting with the evaluation of the symptom of the patient. Mandatory tests - endoscopy - esophageal monometry - barium swallow

Selective tests - 24 hrs pH monitoring - 24 hrs monometry - 24 hrs bilimetry - gastric emptying

En dos copy  in

patients with symptoms of GERD who have undergone endoscopic examination 50-60% have been reported to have reflux esophagitis  the presence of esophagitis is recorded and graded by the Savary Miller Score, the MUSE classification

Normal özofagus

Grade I özofajit

Grade II özofajit

Grade III özofajit

Grade IV özofajit

Grade IV özofajit Ülser

Grade V özofajit Barrett’s

Esophageal Monometry

• is the gold standard for assessment of the body of •

the esophagus (pump) is mandatory before antireflux operations (valve)

Assesment of the LES

• resting pressure • relaxation • length overall-abdominal length • transient relaxation

Barium swallow

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barium upper gastrointestinal series are routinely performed preoperatively and postoperatively.

Parameters

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esophageal motility (5 single swallow of barium)

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anatomic situation of the esophagogastric junction(short esophagus)

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Macroscopic esophageal alterations Hiatal hernia: size reducibility Rings Esophagitis Stricture

24 hrs PH monitoring

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may be performed selectively in patients when the diagnosis is in doubt. may be omitted in symptomatic patients with documented esophagitis and typical symptoms is mandatory:

 in patients with atypical symptoms  in patients who present typical symptoms non responding to adequate antacid medical therapy

Parameters

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quantifies the amount of reflux (De Meester Score) quantifies esophageal acid clearance allows a correlation between reflux and symptoms

De Me es ter S co re Percent of time ph<4 Total period Upright period Supine period Number of episodes: Total Longer than 5 minutes Duration of longest episode Symptom index: (numbers of reflux related symptoms episodes / total number of symptom episodes) X 100%

24 hrs esophageal monometry to identify esophageal motility abnormalities as the cause of non cardiac chest pain  evaluation of esophageal motility in patients with GERD  combined with 24 hrs ph monitoring  evaluation of esophageal clearance function  completion of the evaluation in patients presenting with abnormal esophageal function on standard monometry 

24 h rs B il imet ry  allows

spectrophotometric measurements of esophageal luminal bilirubin concentration  in patients non responding to medical therapy and in patients with Barret’s esophagus  may be combined with ph study.

Gastric emp tyin g s tud ies  the

radionuclide measurement of gastric emptying is used selectively in patients who have postprandial abdominal bloating or fullness that suggest delayed gastric emptying.

GER D S emp tomları TİPİK  Pirozis (Heartburn)  Epigastrik ağrı  Geğirme  Regürjitasyon

ATİPİK  Farengeal ağrı  Disfoni  Uykuda apne  Noktürnal astım  Halitozis  Hıçkırık  Noktürnal öksürük  Sırt ağrısı  Nonkardiak göğüs ağrısı  Palpitasyon

ALARM • Kanama • Disfaji • Odinofaji

Surgery 

The goal of the antireflux operations is to increase the efficancy of the LES and the cardia.

Techn ique s 

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in corporation of a portion of the distal esophagus into the stomach to ensure that it will be a affected by changes in intraabdominal pressure through the into gastric pressure. total 360 degree fundoplication (Nissen) partial fundoplication (Toopet,Lind,Belsey) Collis-Nissen cardiopexy associated with some sort of wrapping of the stomach (Hill-Watson)

Pre nsi ple r AMAÇ •

Distal özofagusta yeterli basıncı oluşturmak ve fonksiyonel bir açı meydana getirmek

HIAT AL H ER NIA Physiology

• Classification: Currently three hernias are generally

recognized: 85% of all hiatal hernias are of the sliding kind.

Sliding Hiatal Hernia

• There is relaxation of the phrenoesophageal ligaments

and enlargement of the hiatal muscular tunnel. Thus, the gastric cardia may be allowed to herniate upward into the enlarged hiatus. If the hernia is large the entire fundus of the stomach can slide into the thorax

Paraesophageal Hernia

• It represents herniation of the gastric fundus through the esophageal hiatus along side the esophagus, while the cardiaesophageal junction is maintained in normal position

Mixed Hiatal Hernia

• The gastroesophageal junction slips above the diaphragm and the localized defect permits protrusion varying amount of stomach

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tüm popülasyonun %5’inde GERD’li popülasyonun %50-60’ında mevcuttur. HH’lerin %94’ünde reflü mevcuttur. Paraözofageal herniler HH’lerin %5-10’ında rastlanır.

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En sık gözlenen tip I (sliding) HH

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Hiatal Herni Nüksü % 0-42 oranında görülür.

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Hiatal Herni

Symptoms

• most individuals with hiatal hernia are asymptomatic • gastroesophageal reflux is the major complication related hiatal hernia. Ph monitoring reveals reflux in 83% of patients with hiatal hernia versus 43% in those without; bleeding chest pain dyspnea and substernal discomfort dysphagia

Evaluation • Barium upper GI series

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Endoscopy Esophageal monometry

In the herniated stomach, the pressure is negative (intrathoracic pressure).The characteristical feature in monometric study is the gap between the RIP and the high pressure zone of the LES. Monometry allows also study of associated esophageal motility disorder.

Surgery Principles of surgical repair involves: • placement of the hernias contents in the abdominal cavity • repair of the crural defect • combined antireflux procedure (65% of postoperative reflux if not)

DIAGNOSTIC ASS ESS ME NT OF GAS TR OE SOPHAGE AL R EFLU X DIS EASE COMP LIC ATIO NS OF LAPA ROSCO PIC AN TIR EFLU X SU RGE RY OPERATIVE COMPLICATIONS  Perforations  Pneumothorax  Bleeding  Conversion to open surgery POSTOPERATIVE COMPLICATIONS  Mortality  Herniation of the wrap  Slipped Nissen  Disrupted Nissen  Dysphagia  Recurrent reflux  Epigastric pain and gas bloat