Chapter 40: Stomach- GERD

Question 1

What is it?

Answer 1

Excessive reflux of gastric contents into the esophagus, “heartburn”

Question 2

What are the causes?

Answer 2

1. Decreased lower esophageal sphincter (LES) tone (>50% of cases)
2. Decreased esophageal motility to clear refluxed fluid
3. Gastric outlet obstruction
4. Hiatal hernia in ≈50% of patients

Question 3

What are the signs/symptoms?

Answer 3

• Heartburn
• regurgitation
• respiratory problems/pneumonia from aspiration of refluxed gastric contents
• substernal pain

Question 4

What tests are included in the workup?

Answer 4

1. EGD
2. UGI contrast study with esophagogram
3. 24-hour acid analysis (pH probe in esophagus)
   
   • gold standard
4. Manometry
5. EKG
6. CXR

Question 5

What is the medical treatment?

Answer 5

1. Small meals
2. PPIs (proton-pump inhibitors) or H2 blockers
3. Elevation of head at night
4. No meals prior to sleeping

Question 6

What are the indications for surgery?

Answer 6

1. Intractability (failure of medical treatment)
2. Respiratory problems as a result of reflux and aspiration of gastric contents (e.g.,pneumonia)
3. Severe esophageal injury (e.g., ulcers, hemorrhage, stricture, ± Barrett’sesophagus)

Question 7

What is Barrett’s esophagus?

Answer 7

Columnar metaplasia from the normal squamous epithelium as a result ofchronic irritation from reflux

Question 8

What is the major concern with Barrett’s esophagus?

Answer 8

Devleoping cancer

Question 9

What type of cancer develops in Barrett’s esophagus?

Answer 9

Adenoca

Question 10

What percentage of patients with GERD develops Barrett’sesophagus?

Answer 10

10%

Question 11

What percentage of patients with Barrett’s esophagus will developadenocarcinoma?

Answer 11

7% lifetime (5% to 10%)

Question 12

What is the treatment of Barrett’s esophagus with dysplasia?

Answer 12

Nonsurgical:

• endoscopic mucosal resection
• photodynamic therapy
• other options:
  
  • radiofrequency ablation
  • cryoablation
  • these methods are also often used for mucosal adenocarcinoma

Question 13

Surgical options for severe GERD:

Laparoscopic nissen fundoplication

Answer 13

360-degree fundoplication—2 cm long (laparoscopically)

Question 14

Surgical options for severe GERD:

Toupet

Answer 14

Incomplete (≈200 degree) posterior wrap (laparoscopic) often used withsevere decreased esophageal motility

Question 15

How does the Nissen wrap work?

Answer 15

Thought to work by improving the LES:

1. Increasing LES tone
2. Elongating LES ≈3 cm
3. Returning LES into abdominal cavity

Question 16

In what percentage of patients does Lap Nissen work?

Answer 16

85% (70% to 95%)

Question 17

What are the postoperative complications of Lap Nissen?

Answer 17

1. Gas bloat syndrome
2. Stricture
3. Dysphagia
4. Spleen injury requiring splenectomy
5. Esophageal perforation
6. Pneumothorax

Question 18

What is gas bloat syndrome?

Answer 18

Inability to burp or vomit