Investigation of Gastroesophageal Reflux LeanPeng Cheah Geelong Hospital

Gastroesophageal Reflux Disease l l Common Exact Prevalence - ? n n n Prolonged

Pathogenesis l LOS mechanism n n l Poor clearance of acid from oesophagus n

Investigations l l l Upper GI endoscopy Histology Radiology n n l l CXR

Other Investigations l l l Bilitec probe(Bile reflux) Oesopheal scintigraphy Oesophageal provocation studies n

Indications for Investigation l l No clear guidelines Often patients referred to surgical outpatient

Upper GI endoscopy l Mucosal abnormalities l Motility abnormality n n Achalasia - dilated

CXR l l Aspiration pneumonia Hiatus hernia

Barium Study l Mucosal abnormality n n l Mechanical n l Oesophagitis Stricture Web,

p. H study Indications: l Atypical symptoms l Incomplete/poor response to acid suppression l

p. H study l Measurements n n n Total acid reflux time(%) Total number

p. H Study l l Probe - 5 cm above top of LOS(LOS position

Manometry l Standard manometry: n n Mean sphincter pressure and sphincter length Motility :

Measurements of duodenogastric oesophageal reflux l p. H rises above 8 n l Aspiration

Provocation studies l l l Bernstein test Acid clearance test Standard acid reflux test(SART)

Oesophageal scintigraphy l l Solid/liquid boluses of Technitium 99 m Dynamic data with objective

Summary l Upper GI endoscopy l Radiology n n l CXR Double contrast barium

Reference l Upper Gastrointestinal Surgery - SM Griffin and SA Raimes(Eds): Chapter 9 Pathophysiology

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Investigation of Gastroesophageal Reflux Lean-Peng Cheah Geelong Hospital 23 August 2003

Gastroesophageal Reflux Disease l l Common Exact Prevalence - ? n n n Prolonged p. H monitoring - Asx subjects have GOR Many treat themselves with antacids Normal esophagus on endoscopy despite reflux symptoms : 30 -40%

Pathogenesis l LOS mechanism n n l Poor clearance of acid from oesophagus n n l l l Peristaltic dysfunction Gravity Refluxing fluid composition Oesophageal mucosal resistance factors n l Transient LOS relaxation Hiatus hernia Saliva and secretions from submucosal glands Delayed gastric emptying Gatroduodenal reflux

Investigations l l l Upper GI endoscopy Histology Radiology n n l l CXR Double contrast barium swallow + videofluoroscopy p. H study Manometry - standard and prolonged

Other Investigations l l l Bilitec probe(Bile reflux) Oesopheal scintigraphy Oesophageal provocation studies n n n Bernstein test Acid clearance test Standard acid reflux test(SART)

Indications for Investigation l l No clear guidelines Often patients referred to surgical outpatient clinics have already had endoscopy Do all cases of heartburn referred to surgeons need endoscopy? Medical legal implications

Upper GI endoscopy l Mucosal abnormalities l Motility abnormality n n Achalasia - dilated oeso, food debris and tight but passable LOS Oeso diverticulum

CXR l l Aspiration pneumonia Hiatus hernia

Barium Study l Mucosal abnormality n n l Mechanical n l Oesophagitis Stricture Web, ring, diverticulum, hiatus hernia Dynamic n n n Propagating contractions ? abnormal Achalasia VIDEOFLUOROSCOPY - solid and liquid bolus swallows(pharyngeal and upper oesohageal motility disorders)

p. H study Indications: l Atypical symptoms l Incomplete/poor response to acid suppression l Before contemplating anti-reflux surgery

p. H study l Measurements n n n Total acid reflux time(%) Total number of reflux episodes lasting more than 5 minutes

p. H Study l l Probe - 5 cm above top of LOS(LOS position determined by manometry) Reflux episode : n n l Starts when p. H drops below 4 Ends when p. H rises above 5(or 4) Diary sheet : symptoms, activities and ingested food

Manometry l Standard manometry: n n Mean sphincter pressure and sphincter length Motility : Standard 10 wet swallows – Velocity and amplitude of contractions – Abnormal contractions n LOS relaxation

Ambulatary p. H and manometry

Measurements of duodenogastric oesophageal reflux l p. H rises above 8 n l Aspiration studies n l too unreliable Uncomfortable and tedious Bilitec n Spectophotometric detection of bilirubin(indirect measure of bile salt reflux)

Provocation studies l l l Bernstein test Acid clearance test Standard acid reflux test(SART)

Oesophageal scintigraphy l l Solid/liquid boluses of Technitium 99 m Dynamic data with objective measurements of oesophageal transit

Summary l Upper GI endoscopy l Radiology n n l CXR Double contrast barium swallow + videofluoroscopy Ambulatory p. H and manometry

Reference l Upper Gastrointestinal Surgery - SM Griffin and SA Raimes(Eds): Chapter 9 Pathophysiology and investigation of GORD and motility disorders(CP Barham and D Alderson)

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