GASTROESOPHAGEAL REFLUX DISEASE�(GERD)�

Issah J. kiswagala

(M.B.B.S)

INTRODUCTION

• Gastroesophageal reflux disease occurs when the amount of gastric juice refluxes into the esophagus due to loss of competence of lower oesophageal sphincter (LOS), causing symptoms with or without associated esophageal mucosal injury i.e. esophagitis.

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• As a result of reflux of gastric acid, extensive inflammation of the lower oesophagus occurs which results in various forms of oesophagitis
• The competence of LOS can be affected by obesity, smoking, excessive eating, etc. and Sliding hernia
• Alternative Names
• Peptic esophagitis; Reflux esophagitis; GERD; Heartburn - chronic; Dyspepsia - GERD

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SURGICAL ANATOMY

• The lower oesophageal sphincter (LOS) is a bundle of muscles at the low end of the esophagus, where it meets the stomach. When the LOS is closed, it prevents acid and stomach contents from traveling backwards from the stomach.
• The same zone also permits retrograde passage of air and gastric contents into esophagus during belching and vomiting.
• This zone keeps the junction between esophagus and stomach continuously closed, but is still able to relax briefly via input from inhibitory neurons that are responsible for its innervation.
• The LOS muscles are not under voluntary control.

EPIDEMIOLOGY

• Copying Western dietary habits have made GERD a common disease in developing countries.
• In America 25%-40% of Americans experience symptomatic GERD at some point. And approximately 7%-10% of Americans experience symptoms of GERD on a daily basis.
• No sexual predilection exists: GERD is as common in men as in women.
• GERD occurs in all age groups. The prevalence of GERD increases in people older than 40 years.

RISK FACTORS

• Pregnancy (Reflux is quite common in pregnancy)
• Obesity (transient increase of intra-abdominal pressure that overcomes the LOS pressure)
• Use of alcohol (possibly)
• Hiatal hernia (a condition in which part of the stomach moves above the diaphragm, which is the muscle that separates the chest and abdominal cavities)
• Smoking (Nicotine tends to relax smooth muscles inside the body so to as LOS)
• High carbohydrate diet (induce more acid reflux in low oesophagus and more reflux symptoms in patients with GERD) due to long stay in stomach
• Reclining within 3 hours after eating

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• Symptoms can also be caused by certain medicines, such as:
• Anticholinergics e.g. sea sickness medicine, atropine, hyoscine, tropicamide
• Bronchodilators for asthma e.g. albuterol, terbutaline, ipratropium,
• Calcium channel blockers for high BP e.g. amlodipine, nifedipine, verapamil
• Dopamine-active drugs for Parkinson disease e.g. ropinirole, pramipexole
• Progestin for abnormal menstrual bleeding or birth control
• Sedatives for insomnia or anxiety e.g. diazepam
• Tricyclic antidepressants e.g. amitriptyline,

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AETIOPATHOGENESIS

• Acid refluxes into the lower oesophagus and produces diffuse inflammation with multiple ulcers.
• The symptoms are worse when the patient lies down.
• Due to vagal hyperactivity, inflammation and ulcers develop which produce severe longitudinal muscle spasm. Consequently, the cardia is drawn up into the thorax, leading to an increase in the oesophago-cardiac angle. This increases the reflux. Later, fibrosis causes shortening of the oesophagus.
• Thus, it becomes a vicious circle of oesophagitis-longitudinal muscle spasm- displacement of oesophagus increased regurgitation.

TYPES

• There are two types of GERD
• Acute: Following alcohol, burns, stress, trauma, peptic ulcer, infection
• Chronic: It is associated with hiatus hernia or after gastric surgery (oesophagojejunostomy).

CLINICAL FEATURES

• Typical esophageal and common symptoms include the following:
• Heartburn (Pyrosis) a burning pain in the chest
• Regurgitation (Bringing food back up)
• Dysphagia (Difficulty swallowing)
• Nausea after eating
• Feeling that food is stuck behind the breastbone (Globus)
• Symptoms may get worse when you bend over or lie down, or after you eat.

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• Abnormal reflux can cause atypical (extraesophageal) symptoms which are less common, such as the following:
• Coughing and/or wheezing
• Hoarseness, sore throat
• Noncardiac chest pain
• Enamel erosion or other dental manifestations
• Hiccups

DIFFERENTIAL DIAGNOSES�

• Achalasia
• Oesophagitis
• Oesophageal Cancer
• Oesophageal Spasm
• Hiatal Hernia
• Peptic Ulcer Disease
• Gastritis

INVESTIGATIONS

• You may not need any tests if the symptoms are mild.
• If symptoms are severe or they come back after treatment then do,
• Baseline investigations such as CBC
• A stool occult blood test may diagnose bleeding that is coming from the irritation in the esophagus, stomach, or intestines.
• Barium swallow in the Trendelenburg's position (head down position) can demonstrate the reverse flow of barium into the lower end of the oesophagus (from the stomach).
• An upper endoscopy (OGD) to examine the lining of the esophagus, stomach, and first part of the small intestine.
• Oesophageal manometry to measure the pressure inside the lower part of the esophagus

TREATMENT

• Conservative treatment
• Surgical treatment

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CONSERVATIVE TREATMENT�

1. Lifestyle modification
• Stop smoking
• Stop alcohol
• Control obesity
• Avoid coffee, chocolate and coke
• Head up-propped-up position by 8 inches
• Avoid stooping
• Avoid tight garments
• Avoiding large meals
• Waiting 3 hours after a meal before lying down

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MEDICAL MANAGEMENT�

1. Antacids:
• Magnesium tricilicate (250mg/120mg) 2-4 tabs PO 6 hourly PRN, Relcer gel (Al-Mg based 100ml or 180ml) given 10ml (PO) after each meal or at bedtime
2. Proton pump inhibitors:
• Omeprazole (PO) 20mg Od for 8 weeks or Esomeprazole (PO) 20mg for 8 weeks. These are antisecretory drugs.
3. Prokinetics: enhance motility by increasing the frequency or strength of contractions without disrupting the rhythm.
• ltopride 50 mg can be given 2-3 times a day for 8 weeks on empty stomach. Others drugs are Metoclopramide and Domperidone. Cisapride and mosapride are not favoured because they can cause cardiac arrhythmias.
4. Mucosa protective agents
• Sucralfate colloidal bismuth - cytoprotective agent. It is a sucrose sulfate-aluminium complex which binds to the mucosa. Thus it protects mucosa of GI tract against hydrochloric acid.
• Colloidal bismuth compounds.

SURGICAL TREATMENT �

• Endotherapy
• Endoscopic plication/suturing
• Enteryx injection
• Plexiglass microspheres (PMMA)
• Open Surgery
• Nissen's total fundoplication
• Partial fundoplication (Toupet)
• Belsey Mark IV operation

PROGNOSIS�

• Most patients with GERD do well with medications, although a relapse after cessation of medical therapy is common and indicates the need for long-term maintenance therapy.

COMPLICATIONS�

• Esophagitis (esophageal mucosal damage) is the most common complication of GERD, occurring in approximately 50% of patients
• Oesophageal Strictures which are advanced forms of esophagitis. Strictures can result in dysphagia and a short esophagus
• Barrett esophagus (metaplastic conversion of the normal distal squamous esophageal epithelium to columnar epithelium). is thought to be caused by the chronic reflux of gastric juice into the esophagus.
• Adenocarcinoma (increasing the risk of about 30-40 times in GERD)