Esophageal Reflux Flashcards
Prevelance of GERD in Western world
14-20% of population
2 primary pathophysiolic MOA of GERD
- Inability of esophagus to clear refluxate due to altered esophageal motility
- Loss of reflux barriers due to anatomic changes:
- hiatal hernia
- intrinsic LES hypotension
- increased intragastric pressure (obesity or delayed gastric emptying or outlet obstruction)
Results of pathologic reflux
- esophagitis
- ulceration
- peptic strictures
- Barrett’s esophagus
Risk associated with Barrett’s esophagus
Histologic changes (metaplasia) represent premalignant lesion with development of dysplasia and esophageal adenocarcinoma
Risk of esophageal adenocarcinoma associated with Barrett’s esophagus
40-fold increased risk
Sx associated with GERD
- Heartburn
- Dysphagia
- Odynophagia
- Hypersalivation
- Astham
- Laryngitis
- Persistent cough
- Globus sensation
- Non-cardiac chest pain
- Nausea
- Assymptomatic
Diagnostic eval of GERD
- Initial diagnosis based history
- Typical sx of heartburn or regurgitation responsive to PPI
- Further testsing if PPI therapy fails
- Typical sx of heartburn or regurgitation responsive to PPI
- Endoscopy with biopsy
- UGI swallow
- Manometry
- pH testing
Biopsy and survillence approach for Barrett’s Esophagus
- Biopsies: four quadrants of esophagus
- every 2 cm for no dysplasia or low-grade dysplasia
- every 1 cm for high-grade dysplasia
- Surveillance: depends on grade of dysplasia
- No dysplasia on 2 separate occassions: 3-5 years
- Low-grade dysplasia: annual
- High-grade dysplasia:
- esophagectomy
- local endoscopic therapy (EMR, PDT) with q3 month EGD
Mainstay of GERD treatment
Medical managment
- H2 blocker or PPI
- PPI better efficacy in resolution of heartburn/healing esophagitis
- Diet counseling:
- avoid fatty food and EtOH
- avoid acidit/irritating foods (citrus and carbonated beverages)
- Lifesyle modification
- smoking cessation
- weight reduction (BMI 20-25)
- avoidance of meals witin 3 hrs of bedtime
2 conditions that must be satisfied before surgical treatmet of GERD
- Failure of medical managment
- persistence of sx
- documented presence of mucosal injury
- Preop studies demonstrate loss of barrier function that may improve with surgery
Goals of surgery for GERD
- Ensure intra-abdomina location of GE junction
- Reconstruct extrinsic sphincter (reduce esophageal hiatus to more physiologic size
- Reinforce intrinsic LES with fundoplication
T/F
Barrett’s esophagus alone is an indication for surgery
False
Potential complication of long-standing GERD
Esophagel shortening due to chronic scarring
- GE junction often in thorax
- Requires esophageal lengthing procedure
- Collis gastroplasty
Description of Collis gastroplasty
- 3-6 cm, selectively vagotimized, proximal stomach is tubularized to create a neo-esophagus
- Re-approximation of crura
- Fundoplication
MC perfomed fundoplications for GERD
- Nissen (360 degree): no esophageal dysmotility
- Toupet (270 degreee: presence of quesion of esophageal dysmotility
Desired length of tension free intra-abdominal esophagus prior to fundoplication
2.5 - 3.0 cm
Surgical principles of fundoplication
- Fundus completely mobilized with division of short gastric vessels
- Vagus nerves preserved
- Diphragmatic crural defects closed (deep, non-absorbable suture)
- Floppy, tension free fundoplication
Overall success of surgical therapy for GERD
80-90% success in symptom relief (heartburn and regurgitation)
- Rate of success for healing esophagis equivalent between surgery and medical therapy
- Thus, surgery best for patients who have failed medical therapy
Potential complications of surgery for GERD
- Persistent bloating
- Inabiltity to belch
- Severe dysphagia (fundoplication too narrow)
- Need for reoperation
T/F
Definitive evidence exists demonstrating that surgical correction for GERD reduces or reverses Barrett’s esophagus
False
- Managment of GERD should primarily involve medical managment with selective use of surgical therapy
