GERD Flashcards
Etiology of GERD
Insufficient acid suppression
Reflux hypersensitivity
Functional heartburn
Ddx for GERD
Achalasia
Oesophagitis
Gastroparesis
Esophageal stricture/cancer
LA Grade A
>1 mucosal break <5mm
Does not extent between tops of two mucosal folds
LA Grade B
>= 1 mucosal break >5mm
Does not extend between the tops of two mucosal folds
LA Grade C
>1 mucosal continuous between >2 mucosal folds
<75% of circumference
LA Grade D
Mucosal break
>75% of esophageal circumference
What is HRM?
High resolution manometry
GI motility diagnostic system that measure intraluminal pressure with closely spaced sensors, analyses and displays in an esophageal pressure topography plotting
What is difference between HRM and conventional manometry?
HRM has greater number of sensors and less spacing in between
HRM: 1cm apart
Conventional: 3-8 sensors, 3-5cm apart
What is EPT
Esophageal pressure topography
- 3D plotting
- X axis: time
- Y axis: location
- Pressure: magnitude converted to color
HRM study protocol
- Insert and position the manometry catheter
- Supine
- 10 swallows of 5ml water/saline
- Change to upright position
- Min 5 liquid swallows
- Rapid drink challenge (ingestion of water, 200 mL, as quickly as possible through a straw)
HRM findings for GERD
- impaired peristalsis
- decreased peristaltic amplitude
- hypotensive LES
- excessive transient relaxations
HRM excludes esophageal motility disorder, not diagnostic for GERD
What is 24 hours ambulatory pH monitoring?
Measures reflux in oesophagus over 24 hours
Protocol for 24 hour pH monitoring
- Stop PPI 7 days before, H2RA 3 days before and antacids for 24 hours
- FAMN
- Insertion of catheter
- Normal eating habits with diary
- Remove catheter after 24 hours
What is the DeMeester score? What is the score diagnostic for GERD
Composite score calculated from 6 parameters of pH monitoring
DMS > 14.7
What are the six parameters of DeMeester score?
- Total reflux duration (<5%)
- Upright reflux time; pH<4 (<8%)
- Supine reflux time (<3%)
- Number of reflux episodes (<50)
- Number of episodes greater than 5 min in duration (<3)
- Longest reflux episode
Types of fundoplication
- Complete
- Nissen 360
- Partial
- Posterior: Toupet 270
- Anterior: Dor 180
- Hills: recreation of angle of His and posterior gastropexy
Pros and cons of complete vs partial fundoplication
- Complete
- more dysphagia, may need re-op if too tight
- more gas related symptoms
- more durable
- Partial
- allows patient to vomit
- less gas symptoms
- less durable
Anterior vs Posterior partial fundoplication
Reflux control better with posterior fundoplication
Posterior more side effects and complications (mobilisation of posterior stomach more technically demanding)
Complications of fundoplication
- Dysphagia
- Gas bloating
- Paraesophageal hernia (lap>open)
- Bilobed stomach (technical error, wrapping of too distal)
- Flatulence
- Pneumothorax, PE
- Vascular injury
- Perforation
- Recurrence (25% of patients require medication within time)
Lap vs open fundoplication
Lap: fewer complications, faster recovery
Long term outcome: lap comparable to open
Nissen procedure
- Open phrenoesophageal ligament L to R
- Dissect both crura
- Transhiatal mobilisation to allow 3 cm of intra-abdominal oesophagus
- Posterior crural closure with non-absorbable suture
- Fundus brought behind distal eso, ensure tension free by shoe-shining manoeuvre
- Create 2-3 cm wrap, distal most suture incorporating ant ms wall of eso
- Bougie placement at time of wrap construction
Indications for anti-reflux surgery
- Failed medical mx
- Patient preference
- Complications of GERD (ex. peptic stricture)
- Extraesophageal manifestations ( asthma, hoarseness, cough, aspiration)
Predictors of good outcome with ARS
- Good correlation with symptoms and reflux
- Temporary/partial PPI response
- Impaired eso fx 2nd to reflux damage
- large hiatus hernia
- pH study
Predictors of good outcome with ARS
- Good correlation with symptoms and reflux
- Temporary/partial PPI response
- Impaired eso fx 2nd to reflux damage
- large hiatus hernia
- pH study
