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Surgery.(GIT 1).Esophagus > 1.GERD > Flashcards

1.GERD Flashcards

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1
Q

The cardio-oesophageal sphincter

A

is a functional intrinsic physiological sphincter-like mechanism at the cardia which normally prevents regurgitation from the stomach

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2
Q

The cardio-esophageal sphincter normally prevents regurgitation from the stomach by :

A
  1. The oblique angle of insertion of the esophagus into the stomach (angle of His).
  2. Pinchcock action of the right crus of the diaphragm.
  3. The “rosette-like” arrangement of the cardiac gastric mucosa.
  4. Lower 4 cm of the oesophagus are intra-abdominal
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3
Q

angle of His

A

The oblique angle of insertion of the oesophagus into the stomach

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4
Q

Pressure in the lower esophageal sphincter is

A

10-25 mm Hg

35- 45 cm H2O

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5
Q

ETIOLOGY of GERD

A

(1) 1ry : Incompetence of cardio-esophageal junction

(2) 2ry: Delayed emptying of stomach

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6
Q

1ry : Incompetence of cardio-esophageal junction in ETIOLOGY of GERD

A

Factors

pathogenesis

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7
Q

Factors of 1ry : Incompetence of cardio-esophageal junction in ETIOLOGY of GERD

A

Sliding hiatus hernia.

Obesity.
Fatty meal
Chocolate

Smoking.
Caffeine consumption
Alcohol consumption.

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8
Q

Pathogenesis of 1ry : Incompetence of cardio-esophageal junction in ETIOLOGY of GERD

A

All these factors act by increasing the number of Transient lower esophageal sphincter relaxations (TLOSRs) which occur normally and are quite separate from swallow-induced relaxations

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9
Q

Pathogenesis of 2ry: Delayed emptying of stomach in ETIOLOGY of GERD

A

Pyloric stenosis

Pylorospasm due to :-D.U. & gall stones

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10
Q

PATHOLOGY of GERD

A

1- Starting of the condition

2- Progression of the condition

3- Vicious circle

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11
Q

Starting of the condition in PATHOLOGY of GERD

A
  • Starts by mild inflammation & hyperemia

* Followed by superficial ulcerations of the esophageal mucosa.

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12
Q

Progression of the condition in PATHOLOGY of GERD

A

With progression of the condition,

  • The musculosa is affected especially the longitudinal muscle layer
  • When it spasms, it draws the cardia more & more up into the thorax resulting in increased acid reflux.
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13
Q

Vicious circle in PATHOLOGY of GERD

A

A vicious circle goes on leading to esophageal fibrosis which may end by narrowing & shortening of the esophagus.

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14
Q

CLINICAL PICTURE of GERD

A

A) Classic presentation

B) Extra-esophageal reflux disease symtoms (EERD)

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15
Q

Classic presentation in CLINICAL PICTURE of GERD

A
  1. Heart burn & retrosternal discomfort
  2. Regurgitation & water brash .
  3. Dysphagia :
  4. Odynophagia
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16
Q

Pathogenesis of Heart burn & retrosternal discomfort in Classic presentation in CLINICAL PICTURE of GERD

A
  • It is the presenting symptom.

* brought about by bending over or lying flat in bed at night

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17
Q

meaning of water brash

A

Maya betrod fe zoroh

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18
Q

Pathogenesis of Dysphagia in Classic presentation in CLINICAL PICTURE of GERD

A
  • At 1st, it is due to esophageal spasm & edema.

* Later, it is due to fibrosis & stricture formation

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19
Q

Pathogenesis of Odynophagia in Classic presentation in CLINICAL PICTURE of GERD

A

Painful dysphagia with severe esophagitis.

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20
Q

Extra-esophageal reflux disease symtoms (EERD) in CLINICAL PICTURE of GERD

A

1- Coughing or wheezing

2- Non-cardiac chest pain.

3- Hoarseness of voice

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21
Q

Pathogenesis of Coughing or wheezing in EERD in CLINICAL PICTURE of GERD

A

as a result of aspiration of gastric contents into the tracheo-bronchial tree.

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22
Q

Pathogenesis of Non-cardiac chest pain in EERD in CLINICAL PICTURE of GERD

A

Reflux is the most common cause of Non-cardiac chest pain

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23
Q

Pathogenesis of Hoarseness of voice in EERD in CLINICAL PICTURE of GERD

A

irritation of the vocal cords by gastric refluxate.

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24
Q

EERD stands for

A

Extra-esophageal reflux disease

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25
Q

Complications of GERD

A

1) Esophageal stricture & Schatzki ring.
2) Short esophagus.
3) Barrett’s esophagus
4) Malignancy
5) 2ry anemia
6) Inhalation pneumonia

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26
Q

Pathogenesis of Esophageal stricture & Schatzki ring in Complications of GERD

A

Fibrosis in inner circular muscle layer

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27
Q

Pathogenesis of Short esophagus in Complications of GERD

A

Fibrosis in outer longitudinal muscle layer

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28
Q

Pathogenesis of Barrett’s esophagus in Complications of GERD

A

Columnar metaplasia of the squamous lining in the lower esophagus which is pre cancerous to adenocarcinoma

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29
Q

Pathogenesis of Malignancy in Complications of GERD

A

Adenocarcinoma of the lower esophagus

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30
Q

Pathogenesis of 2ry anemia in Complications of GERD

A

minor occult bleeding from esophagitis

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31
Q

Pathogenesis of Inhalation pneumonia in Complications of GERD

A

recurring reflux.

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32
Q

INVESTIGATIONS of GERD

A
  1. Barium meal in Trendelenburg’s & anti Trendelenburg’s position.
  2. Upper GIT endoscopy :
  3. 24 hours pH monitoring
  4. Esophageal manometry
  5. Investigations for Saint’s triad
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33
Q

the reason why Barium meal is done in Trendelenburg’s & anti Trendelenburg’s position in INVESTIGATIONS of GERD

A

To detect degree of severity by reversibility of reflux

34
Q

Upper GIT endoscopy in INVESTIGATIONS of GERD

A
  • Normal finding
  • Abnormal finding
  • Belsey grading for GERD by upper GIT endoscopy
35
Q

Normal finding in Upper GIT endoscopy in INVESTIGATIONS of GERD

A

Normally the cardia closes on inspiration due to its presence normally intra-abdominal and its pressure increase during inspiration closing the cardia

36
Q

Pathogenesis of closed cardia on inspiration in Upper GIT endoscopy in INVESTIGATIONS of GERD

A

due to its presence normally intra-abdominal and its pressure increase during inspiration closing the cardia

37
Q

Abnormal finding in Upper GIT endoscopy in INVESTIGATIONS of GERD

A
  • The cardia opens in cases of hiatus hernia on inspiration
  • May reveal reflux of gastric juice through the cardia.
  • Also complications will be apparent
38
Q

Pathogenesis of abnormally opened cardia on inspiration in Upper GIT endoscopy in INVESTIGATIONS of GERD

A

The cardia opens in cases of hiatus hernia on inspiration due to its presence abnormally intra-thoracic and its pressure decrease during inspiration opening the cardia

39
Q

Belsey grading for GERD by upper GIT endoscopy in INVESTIGATIONS of GERD

A

Grade I : esophageal hyperemia.

Grade II : esophageal erosions.

Grade III : esophageal ulcerations.

Grade IV : Stricture formation, Schatzki ring or Barrett’s oesophagus

40
Q

24 hours PH monitoring in INVESTIGATIONS of GERD

A

Reliability

Procedures

Results

41
Q

Reliability of 24 hours pH monitoring in INVESTIGATIONS of GERD

A

The most important reliable test to diagnose the presence of reflux.

42
Q

Procedures of 24 hours pH monitoring in INVESTIGATIONS of GERD

A
  1. A special pH electrode is introduced in the lower esophagus
  2. A 24 hour study of the pH of the esophagus is recorded
  3. The patient is asked to record the periods when he gets the symptoms of reflux esophagitis
43
Q

Results of 24 hours pH monitoring in INVESTIGATIONS of GERD

A

If the timing of these periods coincides with a low pH recording, this signifies that these symptoms are actually due to reflux esophagitis

44
Q

Esophageal manometry in INVESTIGATIONS of GERD

A

It reveals:

  • Low pressure at LOS e.g: 7 8 9 mm Hg
  • The peristalsis power
45
Q

Benefits of revealing the peristalsis power in Esophageal manometry in INVESTIGATIONS of GERD

A

Helps to choose the proper surgical procedure

Weak peristalsis )> Partial wrap.
Good peristalsis )> Complete wrap

46
Q

Investigations for Saint’s triad in INVESTIGATIONS of GERD

A

Abdominal U.S.

47
Q

Saint’s triad

A

A Triad of :

Gall stones, Hiatus hernia & Diverticulosis coli.

48
Q

TREATMENT of GERD

A

(A) Conservative treatment

(B) Surgical Treatment

(C) MANAGEMENT OF COMPLICATIONS

49
Q

Conservative treatment of GERD

A

The majority of cases can be controlled by Conservative treatment

  1. Waiting 3 hours after a meal before lying down.
  2. Elevating the head of the bed during sleep.
  3. Reduction of weight is very important.
  4. Frequent small, non-irritant meals.
  5. Stop smoking and alcohol consumption.
  6. Drugs
50
Q

The reason why we should wait 3 hours after a meal before lying down in Conservative treatment of GERD

A

To ensure gastric emptying

51
Q

Drugs in Conservative treatment of GERD

A
  • Proton pump inhibitors ( PPIs )
  • H2 receptors blockers
  • Prokinetics
  • Anti-cholinergic drugs are contraindicated
52
Q

Proton pump inhibitors ( PPIs ) in Conservative treatment of GERD

A

as Omeprazole

The most effective drugs.

53
Q

H2 receptors blockers in Conservative treatment of GERD

A

as Famotidine are also effective

54
Q

Prokinetics in Conservative treatment of GERD

A

as Metoclopramide and Domperidone

produce brief improvement of the symptoms but with no healing of esophagitis

55
Q

The reason why Anti-cholinergic drugs are contraindicated in Conservative treatment of GERD

A

as they cause gastric stasis, increasing esophageal reflux

56
Q

Surgical Treatment of GERD

A
  • Indications
  • Surgical modalities
  • Recent surgical modalities
57
Q

Indications of Surgical Treatment of GERD

A
  1. Failure of medical treatment.
  2. Reflux in both Trendelenburg’s & anti -Trendelenburg’s position.
  3. Complicated cases as ulcer, stricture or Barrett’s esophagus.
58
Q

Surgical modalities in Surgical Treatment of GERD

A

1 - Nissen’s fundoplication

2- Floppy Nissen’s fundoplication :

3- Toupet partial fundoplication :

4 - Belsey Mark IV Cardioplasty :

5- Hill’s gastropexy :

6- The Angelchik prosthesis

59
Q

Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A

Approach

Principle

Advantages

Disadvantages

60
Q

Approach of Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A
  • Trans-abdominal.

* Trans-thoracic approach

61
Q

indication of Trans-abdominal approach of Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A

in the uncomplicated cases

62
Q

indication of Trans-thoracic approach of Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A

useful in patients with peri-oesophagitis

63
Q

Principle of Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A

The fundus of the stomach is wrapped
completely 360 degree around the lower 5 cm of
the esophagus.

64
Q

Advantages of Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A

Recurrence is rare.

65
Q

Disadvantages of Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A
  • Gas-bloat syndrome

* Dysphagia.

66
Q

Pathogenesis of Gas-bloat syndrome in Disadvantages of Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A

considerable amount of abdominal gaseous distension due to inability to eructate.

67
Q

Principle of Floppy Nissen’s fundoplication in Surgical modalities in Surgical Treatment of GERD

A
  • The fundus of the stomach is wrapped completely 360 degree around the lower 5 cm of the oesophagus
  • but this is done while insertion of a Iarge 54-60 F.bougie in the oesophagus
68
Q

Meaning of 54-60 F.bougie

A

F. is french

bougie means candle in French

Act like stent Then remove it

69
Q

Principle of Toupet partial fundoplication in Surgical modalities in Surgical Treatment of GERD

A
  • The fundus of the stomach is wrapped 270 degree
    around the lower 5 cm of the oesophagus
  • leaving a part of the esophagus exposed
    anteriorly.
70
Q

Belsey Mark IV Cardioplasty in Surgical modalities in Surgical Treatment of GERD

A

Approach

Principle

71
Q

Approach of Belsey Mark IV Cardioplasty in Surgical modalities in Surgical Treatment of GERD

A

Only trans-thoracic

72
Q

Principle of Belsey Mark IV Cardioplasty in Surgical modalities in Surgical Treatment of GERD

A

Restoration of the cardio-esophageal angle by suturing the fundus of the stomach to the distal esophagus in a 240 degree anterior wrap.

The esophago-gastric junction is then sutured to the under surface of the diaphragm.

73
Q

Principle of Hill’s gastropexy in Surgical modalities in Surgical Treatment of GERD

A

The cardia is sutured to the median arcuate ligament of the diaphragm

74
Q

Principle of The Angelchik prosthesis in Surgical modalities in Surgical Treatment of GERD

A

It is a silastic prosthetic collar placed around the lower esophagus

It probably acts by decreasing the number TLOSRs.

75
Q

Recent surgical modalities in Surgical Treatment of GERD

A

1- Laparoscopic Nissen’s fundoplication

2- Laparoscopic Toupet fundoplication

76
Q

Management of complications in TREATMENT of GERD

A

Management of

A) Esophageal stricture :

B) Short Esophagus :

C) Adenocarcinoma

77
Q

Management of Esophageal stricture in Management of complications in TREATMENT of GERD

A

1- Endoscopic dilatation.

2- Thal’s fundic patch :

3- Antral patch :

78
Q

Principle of Thal’s fundic patch in Management of Esophageal stricture in Management of complications in TREATMENT of GERD

A

Longitudinal incision is done through the stricture which is then closed transversely by a fundic patch.

79
Q

Principle of Antral patch in Management of Esophageal stricture in Management of complications in TREATMENT of GERD

A

Longitudinal incision is done through the stricture which is then closed by an antral patch.

80
Q

Management of Short Esophagus in Management of complications in TREATMENT of GERD

A

Collis gastroplasty

81
Q

Principle of Collis gastroplasty in Management of Short Esophagus in Management of complications in TREATMENT of GERD

A
  • Lengthening of the short esophagus by dividing the fundus of the stomach as a continuation of the esophagus.
  • Nissen’s fundoplication is then performed
82
Q

Management of Adenocarcinoma in Management of complications in TREATMENT of GERD

A
  • Total esophagectomy

* Stomach follow up

Surgery.(GIT 1).Esophagus (1 decks)

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