GASTRO OESOPHAGEAL REFLUX DISEASE GERD BY NISHANT KURIAN

GASTRO OESOPHAGEAL REFLUX DISEASE (GERD) BY: NISHANT KURIAN

NORMAL PHYSIOLOGY OF LES MANOMETRIC RECORDINGS OF INTRALUMINAL PRESSURE HAS IDENTIFIED 2 high pressure areas n n A 3 cm segment in the proximal esophagus at level of cricopharyngeus muscle called UPPER ESOPHAGEAL SPHINCTER Another 2 -4 cm segment just proximal to anatomic GEJ called LOWER ESOPHAGEAL SPHINCTER BOTH ARE “physiological” in that there are no anatomic landmarks that delineate these areas

LES MUSCULATURE IS TONICALLY ACTIVE BUT RELAXES DURING SWALLOWING COMPONENTS OF LES : 1. OESOPHAGEAL SMOOTH MUSCLES AT THE GASTRO ESOPHAGEAL JUNCTION(INTRINSIC SPHINCTER) 2. FIBRES OF CRURAL PORTION OF DIAPHRAGM , EXERT PINCH CORK EFFECT ON ESOPHAGUS 3. OBLIQUE OR SLING FIBRES OF STOMACH WALL CREATE A FLAP VALVE.

CONTROL OF LES TONE THE LES TONE IS UNDER NEURAL CONTROL: n ACETYLCHOLINE FROM VAGAL NERVE ENDINGS n PHRENIC NERVE STIMULATION OF THE DIAPHRAGM INTRINSIC & EXTRINSIC ACT IN CONCERT TO PERMIT ORDERLY FLOW OF FOOD FROM ESOPHAGUS TO STOMACH

UPPER ESOPHAGEAL SPHINCTER: It recieves ots innervation dierctly from brain(NUCLEUS AMBIGUOUS) n IT IS CONTINUOUSLY IN A STATE OF TONIC CONTRACTION WITH A RESTING PRESSURE OF ABOUT(100 mm HG)AP AXIS. n PREVENTS ENTRY OF AIR FROM THE PHARYNX TO ESOPHAGUS AND REFLUX OF ESOPHAGEAL CONTENTS INTO THE PHARYNX

PATHO-PHYSIOLOGY OF GERD REFLUX WILL OCCUR ONLY WHEN PRESSURE GRADIENT BETWEEN STOMACH AND ESOPHAGUS IS LOST. THIS CAN BE CAUSED BY SUSTAINED OR TRANSIENT DECREASE OF LES TONE.

CAUSES: 1. PRIMARY MUSCLE WEAKNESS WITHOUT ANY APPARENT CAUSE 2. SECONDARY CAUSES: n SCLERODERMA LIKE DISEASE n MYOPATHIES ASSOCIATED WITH CHRONIC INTESTINAL PSEUDO OBSTRUCTION n PREGNANCY n SMOKING n ANTICHOLINERGIC DRUGS n SMOOTH MUSCLE RELAXANTS n SURGICAL DAMAGE TO LES

TLESR(transient lower esophageal sphincter relaxation): THIS IS A VAGAL MEDIATED RESPONSE TO DISTENSION OF STOMACH. Increased no. tlesr without esophageal contractions is associated with GERD HIATAL HERNIA: gerd is also associated with hiatal hernia; although amy type may give rise to symptoms most common type is TYPE 1 hernia also called – SLIDING HIATAL HERNIA

SYMPTOMS n HEARTBURN : most common, very reliable when it is typical. characteristics of the heart burn 1. confined to retrosternal & epigastric areas 2. should be identified as a stinging sensation 3. should not radiate to the back 4. should not be felt as a pressure sensation n n REGURGITATION : of shorter duration is suggestive progression of the disease distinction should be made between regurgitation of digested and undigested food material DYSPHAGIA : denotes mechanical obstruction -more pronounced for solids than for liquids… if dysphagia present in equal intensity for both solids and liquids think of other causes: 1. tumour 2. diverticula 3. motility disorders

APART FROM GI SYMPTOMS GERD PATIENTS MAY HAVE SYMPTOMS INVOLVING RESPIRATORY TRACT: EXTRA ESOPHAGEAL SYMPTOMS Include: 1. Aspiration 2. Wheezing 3. hoarseness

Evaluation of a GERD PATIENT n PHYSICAL EXAMINATION: advanced diseases observations help to identify patients discomfort salient points: a)A PATIENT WHO CONSTANTLY DRINKS WATER b)patient leaning forward during interview and talking with lungs inflated upto tidal volume c)erosion of dentition, injected oropharyngeal mucosa

Physical examination may help evaluate other Causes: example a patient with a left supra clavicular lymh node on examination having dysphagia and heart burn is pointing to a diagnosis of Ca stomach , Ca esophagus rather than GERD

PRE- OPERATIVE WORK UP PURPOSE: 1. CONFIRM DIAGNOSIS 2. EXCLUDE OTHER PATHOLOGIES 3. DIRECT THE OPERATIVE INTERVENTION

ENDOSCOPY n n HELPS EXCLUDE OTHER PATHOLOGIES : TUMOURS , DIVERTICULA etc Most importantly used to ocument peptic esophageal injury measured by scoring systems like: SAVARY-MILLER 1 -ERYTHREMA 2 -LINEAR ULCERATION 3 -CONFLUENT ULCERATION 4 -STRICTURE EXTREME MUCOSAL INJURY : BARRET ESOPHAGUS IN WHICH CASE MULTIPLE BIOPSY SHOULD BE TAKEN TO BE TAKEN

MANOMETRY LES ANALYSED FOR MEAN RESTING PRESSURETWO WAYS: 1. STATION PULL THROUGH 2. RAPID PULL THROUGH

Usually it is the station pull through that is done In this method the pressure is measured when catheter is stagnant with radial ports in high pressure zones of LES In rapid pull through measurements are made when catheter is being pulled across the high pressure zone at 1 cm/sec MEASUREMENTS IN THIS CASE ARE USUALLY HIGHER DUE TO ARTFACTS FROM CATHETER MOVEMENTS NORMAL PRESSURE AT LES IN STATION PULL THROUGH IS 12 -30 mm OF Hg

Assessment of body of esophagus is done to determine the effectiveness of peristalsis PROCEDURE: WITH 4 CHANNELS LOCATED AT 3, 8, 13, 18 cm ABOVE LES , THE PATIENT IS A GIVEN A SERIES OF 5 ml (about 10) OF WATER TO SWALLOW. PERISTALTIC ACTIVITY IS REPORTED AS % OF INITIATED SWALLOWS THAT ARE TRANSMITTED TO EACH CHANNEL SUCCESSFULLY NORMAL – 80%

Next parameter of clinical importance measured by manometry is AMPLITUDE OF PERISTALTIC WAVES PROCEDURE : IT IS THE AVERAGE OF PRESSURES GENERATED IN THE DISTAL ESOPHAGUS DURING EFFECTIVELY TRANSMITTED PERISTALTIC WAVES INEFFECTIVE ESOPHAGEAL MOTILITY (IEM): <60% PERISTALSIS , OR DISTAL ESOPHAGEAL AMPLITUDE <30 mm of Hg-----INDICATION OF SEVERE GERD

p. H-MONITORING GOLD STNDARD FOR DIAGNOSING &QUATIFYING ACID REFLUX IS 24 hr-ph test SENSITIVITY AND SPECIFICITY 92% PRE-REQUISITES : n MEDICATION THAT AFFECT PRODUCTION OF ACID SHOULD BE STOPPED 3 DAY FOR H 2 BLOCKERS AND 14 DAYS FOR PROTON PUMP INHIBITORS n DIET & EXERCISE ARE UNRESTRICTED TO MIMIC A TYPICAL DAY IN THE PATIENTS LIFE

INDICATIONS: 1. PATIENTS NOT RESPONDING TO THERAPY 2. RELAPSE AFTER DISCONTINUATION OF MEDICINE 3. BEFORE ANTI REFLUX SURGERY 4. EVALUATING ATYPICAL SYMPTOMS LIKE COUGH , HOARSENESS

METHOD : DONE USING A THIN CATHETER CONTAINING 1 OR MORE SOLID STATE ELECTRODE IN THE ESOPHAGUS. ELECTRODES ARE PLACED 5 -10 cm APART AAND ARE CAPABLE OS SENSINHG FLUCTUATIONS IN PH 2 – 7

ELECTRODE ARE CONNECTED TO A DATA RECORDER WHICH THE PATIENT WEARS DURING PERIOD OF OBSERVATION. THERE IS A DIGITAL CLOCK DISPLAYED ON THE RECORDER. WHEN PATIENT HAS AN EVENT (CHEST PAIN OR HEART BURN)HE OR SHE IS TO RECORD THE EVENT IN THE DIARY, NOTING TIME IN THE CLOCK

INFORMATION DRAWN FROM THIS: 1. TOTAL No. OF REFLUXES(PH<4)(4. 5%) 2. NUMBER OF EPISODES LASTING MORE THAN 5 MINUTES(31/2) 3. EXTENT OF REFLUX IN UPRIGHT POSITION(8. 4%) 4. EXTENT O REFLUX IN SUPINE POSITION(3. 5%) 5. LONGEST EPISODE IN MINUTES (20)

An OVERALL SCORE IS OBTAINED BY A FORMULA THAT BIVES A WEIGHT TO EACH ITEM ACORDING TO ITS CAPACITY TO CAUSE DAMAGE TO ESOPHAGUS This value known AS THE De Meester value SHOULD BE LESS THAN 14. 7 A simpler way to determine whether reflux is occurring or not is to estimate the total % of time ph<4 in the proximal and distal channel

This is calculated by dividing the time ph was less than 4 by total time of study and Multiplying by 100. In the proximal esophagus it should be less than 1% of the time , while in the distal 4 cm above LES it should be less than 4%

ESOPHAGOGRAM n n THIS IS USED TO DETERMAINE THE EXTERNAL ANATOMY OF THE ESOPHAGUS & PROXIMAL STOMACH. ALSO THE PRESENCE & SIZE OF A HIATAL HERNIA MAY BE CHARACTERIZED USEFUL IN PLANNING THE OPERATION TUMOUR AND DIVERTICULA MAYBE DISCOVERED IN THE ESOPHAGOGRAM

OTHER TESTS n PATIENTS WITH LARYNGEAL SYMPTOMS OF GERD LARYNGOSCOPY EXAMINATION WILL HELP TO IDENTIFY INFLAMMATION OF THE LARYNGEAL MUCOSA, MUSCLE TENSION ABNORMALITIES &SEVERE SUBGLOTTIC STENOSIS

n Diverticulum in esophagogram

TREATMENT LIFE STYLE MODIFICATION: n EAT FREQUENT SMALL MEALS DURING THE DAY n CESSATION OF SMOKING n DECREAED CAFFIENE INTAKE n AVOID LARGE MEALS BEFORE LYING n ELEVATION OF HEAD END AT BED n AVOIDENCE OF CONSTRICTING CLOTHING n AVOID FATTY FOOD , CHOCOLATE, ALCOHOL, MINT , ORNAGE JUICE

MEDICAL MANAGEMENT LIFESTLYLE MODIFICATION + ANTISECRETORY DRUGS LIKE H 2 RECEPTOR BLOCKERS: RANITIDINE 150 mg bid CIMETIDINE 300 mg od PPI ARE COMPARITIVELY MORE EFFECTIVE: OMEPRAZOLE 20 mg/day LANSOPRAZOLE 30 mg/day for 8 WEEKSCAN EROSIVE ESOPHAGITIS IN 90%PEOPLE IN REFRACTORY CASES DOUBLE THE DOSE AND GIVE THE DRUG 2 TIMES A DAY n

SIDE EFFECTS OF AGGRESSIVE ACID INHIBITION IS HYPERGASTRINEMIA BUT IT IS NOT ASSOCIATED WITH INCREASED RISK OF DEVELOPING CARCINOID TUMOURS OR GASTRINOMA

SURGICAL MANAGEMENT INDICATIONS: 1. SEVERE ESOPHAGEAL INJURY LIKE ULCER, STRICTURE, BARRETT ESOPHAGUS 2. INCOMPLETE RESOLUTION OF SYMPTOMS OR RELAPSE DURING MEDICAL TREATMENT 3. IN PATIENT WITH LONG DURATION OF SYMPTOMS AND YOUNGER AGE OF ONSET SURGICAL MANAGEMENT SHOULD BE CONSIDERED INTIALLY AS IT IS MORE COST EFFECTIVE – IN PATIENTS WHO HAVE TEN YEAR LIFE EXPECTANCY AND ARE I NEED OF LIFE LONG TREATMENT SURGERY IS A CHEAPER OPTION

SURGERIES 360 DEGREES WRAP(LEFT CRUS APPROACH)NISSEN FUNDOPLICATIO N TREATMENT OF CHOICE IN MAJORITY OF PATIENTS 1.

STEPS OF SURGERY: 1. POSITION – PATIENT IN LOW LITHOTOMY POSITION SURGEON STANDS BETWEEN LEG OF THE PATIENT AND ASSISTANT ON LEFT SIDE OF PATIENT. 1. 5 TROCARS ARE PLACED SO AS TO FORM A EQUILATERAL TRIANGLE WITH A COMMON MEDIAL ANGLE. 2 MOST CEPHALAD PORTS ARE FOR THE SURGEON ASSISTANT OPERATES FROM THE CLOSEST CAUDAL PORTS RIGHT SIDED PORT IS FOR RETRACTION OF LIVER

3 RETRACT GREATER CURVATURE AND OMENTUM AND DISSECT THE LEFT CRUS AND GREATER CURVE 4. SHORT GASTRIC VESSELS ARE TAKEN EARLY TO MOBILIZE THE FUNDUS 5. 6. 7. 8. 9. FUNDUS MOBILISED THEN THE PHRENO ESOPHAGEAL MEMBRANE OVER THE LEFT CRUS MAYBE DISSECTED UNTIL CRURAL FIBRES ARE IDENTIFIED &ENTIRE LENGTH OF THE LEFT CRUS IS MOBILISED RIGHT CRURA DISSECTION IS THEN CARRIED OUT ONCE ESOPHAGUS IS MOBILISEDTHE POSTERIOR PART OF THE CRUS IS REAPPROXIMATED WITH HEAVY PERMANENT SUTURE TO ALLOW THE PASSAGE OF A 52 -FRENCH BOUGIE POST. ASPECT OF FUNDUS IS THEN PASSED BEHIND THE ESOPHAGUS FROM LEFT TO RIGHT. THE WRAP IS CREATED OVER A LENGTH OF 2 -3 CM WITH 3 OR 4 INTERRUPTED PERMANENT SUTURES BOUGIE IS REMOVED AND THE ANCHORED TO THE ESOPHAGUS &RIGHT CRUS AT THE HIATUS

WRAP IS INSPECTED – 1. SUTURE LINE SHOULD LIE JUST RIGHT OF THE MIDDLE OF ESOPHAGUS 2. POSTERIOR ASPECT OF WRAP SHOULD NOT HAVE REDUNDAD STOMACH 3. THERE SHOULD BE GENTLE SWEEPING OF WRAP TOWARD THE GREATER CURVATURE

PARTIAL FUNDOPLICATION WHEN ESOPHAGEAL MOTILITY IS POOR PARTIAL FUNDOPLICATION MAYBE CONSIDERED TO PREVENT OBSTRUCTION TO BOLUS PROPAGATION IN ESOPHAGUS IT IS THOUGHT TO BE MANDATORY IN PATIENTS WITH IEM.

PROCEDURE: • INITIAL DISSECTION IS SAME 2. ANTERIOR WRAP(THAL &DOR): CREATED WITH ANTERIOR ASPECT OF ESOPHAGUS FOLDED OVER THE ANTERIOR ASPECT OF ESOPHAGUS-DONE IN PATIENTS WITH ACHLASIA AFTER AN ANTERIOR MYOTOMY 3. POSTERIOR FLAP(TOUPET): POSTERIOR FUNDUS PASSED BEHIND ESOPHAGUS FROM LEFT TO RIGHT AND ANCHORING IT TO POST. CRURA & ESOPHAGUS CREATING A 220 -250 DEGREE WRAP

ENDOSCOPIC THERAPY n 1. 2. 3. 4. NEWER MODALITIES AUGMENTS LES SUTURING (ENDOCINCH, BARD) RADIOFREQUENCY(STRETTA, CURON MEDICAL) PLEXIGLAS INJECTION(POLYMETHYLMETHACRYLATE) BIOCOMPATIBLE POLYMER INJECTION(ENTERYX, BOSTON SCIENTIFIC)

n . The Stretta procedure is an outpatient procedure for patients who experience persistent symptoms while on medications but prefer a minimally invasive treatment. The procedure takes less than one hour under conscious sedation, not general anesthesia. Patients go home the same day and usually return to normal activities the following day. Patients experience improvement within 2 to 6 months.

n During the procedure, the Stretta catheter is placed through the patient’s mouth and into the valve between the stomach and esophagus. Radiofrequency energy is delivered to the muscle of the lower esophageal sphincter (LES) and gastric cardia to create small thermal lesions. Over time, the lesions heal and the tissue contracts. Clinical studies show improvement in GERD symptoms, acid exposure and reduction in use of heartburn medications

n ENTERYX TREATMENT

OUTCOME: RESPONSE TO OPERATIVE TREATMENT FOR GERD SEEN IN 90%-94% COMPLICATION: OPERATIVE: 1. PNEUMOTHORAX (5 -8%) 2. GASTRIC&ESOPHAGEAL INJURIES 1% 3. MAJOR LIVER INJURY RARE 4. SPLENIC INJURY 2 -3%

EARLY POST- OPERATIVE: 1. BLOATING 30% CAUSES: 1. PATIENT MAY HAVE DIFFICULTY IN BELCHING OWING TO WRAP 2. VAGAL TRAUMA MAY DECREASE GASTRIC EMPTYING. 2. POST OPERATIVE DYSPHAGIA: 20% USUALY DUE TO EDEMA , IT IS SHORT LIVED OTHER CAUSES INCLUDE TIGHT PLACING OF WRAP SUTURERESULTING IN HEMATOMA---IN SUCH CASE IT IS UNLIKELY TO RESOLVE 3. MORTALITY < 0. 5% BUT INCIDENCE INCREASES WITH AGE IN >80 YEAR OLD PATIENT -8. 3%

FAILURE: 5% ALL PATIENTS PRESENTING WITH RECURRENT SYMPTOMS SHOULD BE EVALUATED WITH MANOMETRIC&PH STUDIES ACID EXPOSURE SHOULD BE DOCUMENTED, AND ESOPHAGOGRAM SHOULD BE DONE PRESENCE OF ANATTOMIC ABNORMALITIES OF WRAP OR SIZEABLE HERNIATION-BEST TREATMENT WITH SURGERY IF THE WRAP IS IN GOOD POSITION –MEDICAL TREATMENT MAYBE TRIED n

SPECIAL CASES STRICTURES DUE TO BETTER MEDICAL THERAPY AVAILABLE THIS COMPLICATION IS QUITE RARE NOW n IF PRESENT DYSPHAGIA IS THE PRESENTING COMPLAINT. n AS THIS IS THE MANIFESTATION OF ACUTE AND CHRONIC INFLAMMATION ESOPHAGEAL SHORTENING ALSO ACCOMPANIES THIS CONDITION n EVALUATION OF THESE PATIENTS IS DIFFICULT AS STRICTURE PREVENT ACID REFLUX IN 24 HOUR PH STUDY n OTHER CAUSES OF DYSPHAGIA SHOULD BE RULED OUT n MOST EFFECTIVE TREATMENT OF STRICTURE IS ANTIREFLUX PROCEDURE

BARRET’S ESOPHAGUS PRONLONGED ACID REFLUX MAY LEAD TO CHANGES IN ESOPHAGEAL MUCOSA FRO ITS USUAL SQUAMOUS TO COLUMNAR CONFIGURATION CALLED BARRET’S ESOPHAGUS n IF THIS IS FOUND MULTIPLE BIOPSIES SHOULD BE TAKEN TO RULE ANY DYSPLASIA, MAY INDICATE A TENDENCY TO DEVELOP ADENOCARCINOMA. n ALTHOUGH INCIDENCE OF ADENOCARCINOME IN PATIENTS WITH BARRET ESOPHAGUS IS 40 TIMES MORE THAN THE COMMON POPULATION, STILL THE INCIDENCE OF CANCER IS VERY LOW IN THEM n TRATMENT WILL BE ANTI REFLUX PROCEDURE THOUGH THE RESULTS HAVE NOT BEEN PROVED TO BE VERY AS YET

SHORT ESOPHAGUS TREATMENT : OPERATION OF THESE PATIENT IS DIFFICULT STILL BY MOBILISING THE ESOPHAGUS WELL INTO THE MEDISTINUM , A 2 -3 cm SEGMENT OF ESOPHAGUS CAN BE PLACED IN THE STOMACH WITHOUT TENSION WHEN THIS IS NOT POSSIBLE COLLI’S GASTROPLASTY MAYBE PERFORMED

Short Esophagus Prior Surgery ET tube location and configuration