GERD

Question 1

Name 3 normal antireflux mechanisms

Answer 1

• Mechanically effective lower oesophageal sphincter LES: prevent back flow. Resting pressure, overall length, intra-abdo length
• efficient oesophageal clearance by peristalsis
• adequately functioning gastric reservoir
Kinking oesophageal R crus
Angle of his flap valve

Question 2

Which 3 characteristics of the LES must work in unison to maintain its barrier function

Answer 2

•Resting pressure (contract at rest )
• its overall length
• intra- abdominal length

Question 3

Composition of Les?

Answer 3

Collar sling musculature and clasp fibres

Question 4

Why does physiologic reflux occur? (3)

Answer 4

• Primarily transient losses of gastro oesophageal barrier, caused by relaxation LES or intragastric pressure overcome sphincter
• when upright, 12 mm Hg pressure gradient between the resting, positive intra-abdo and negative intra-thoracic pressure. this favours flow gastric juice into thorax. Supine = pressure gradient decreased
• LES pressure higher supine than upright, due to apposition hydrostatic pressure of abdomen to abdominal portion of sphincter when supine.

Question 5

Define permanently defective LES (3)

Answer 5

One or more:
•LES mean resting pressure <6 mm Hg
• overall sphincter length < 2 cm
• intra-abdo sphincter length <1 cm

Question 6

Typical symptoms GERD? (3)

Answer 6

• Heartburn: substernal. From epigastrium and radiate up. Aggravated by supine, meals, spicy or fatty food, chocolate, alcohol etc,may be relieved by antacids or anti-secretory medication
• regurgitation: effortless return acid or bitter gastric contents - worse at night, supine, bend over
. Dysphagia: most specific sign foregut path. Can be sign underlying malignancy so need to investigate

Question 7

ATypical symptoms GERD? (5)

Answer 7

• Cough
• hoarse
• chest pain
• asthma or bronchospasm
• aspiration
Dental carries

Due to aspiration and bronchoconstriction

Question 8

Classification GERD? (2)

Answer 8

• Erosive esophagitis: visible breaks distal oesoph mucosa on endoscopy with or without GERD symptoms
• non-erosive reflux disease: symptoms without mucosal injury

Question 9

GERD complications? (6)

Answer 9

• Esophagitis
• esophageal stricture
. Barrett’s oesophagus
• progressive idiopathic pulmonary fibrosis due to repetitive aspiration
• chronic laryngitis
• adult onset asthma

Question 10

Grading esophagitis?

Answer 10

Los Angeles classification
• grade a: ≥ 1 mucosal breaks (area of slough adjacent to more normal mucosa in squamous epithelium with or without overlying exudate) each ≤ 5 mm
• grade B: ≥1 mucosal break > 5 mm but not continuous between tops of adjacent mucosal folds
• grade c: ≥1 mucosal break continuous between tops of adjacent mucosal folds, but not circumferential
. Grade d: mucosal break involving at least 3/4 of luminal circumference

Question 11

Define esophageal stricture

Answer 11

Fibrotic mucosal ring (schatzki ring) at squamocolumnar junction.
Luminal stricture can develop from submucosa → intramural fibrosis

Usually develop if other complications eg esophagitis, Barret’s

Question 12

Define Barrett’s oesophagus and pathophysiology

Answer 12

• Goblet cells ( columnar epith that line intestines) found in squamous mucosa of oesophagus on biopsy = intestinal metaplasia
• eventually, normal oesophageal mucosa transform → Adencarcinoma

Question 13

Investigations for GERD? (5)

Answer 13

• Endoscopy: check anatomy, complications, malignancy , biopsy, ulcerative esophagitis to objective confirm reflux
• barium swallow: oesophageal anatomy ( narrowing, strictures, rings ), hiatal hernia anatomy . poor sensitivity for assess reflux
•24 hour ambulatory ph monitoring: must confirm reflux with this abnormal or ulcerative esophagitis
• esophageal high resolution manometry: motor function oesophagus and sphincters
• oesophageal impedance testing:electrical impedance luminal contents, evaluate GI function and reflux

Question 14

Name 3 complications Barrett’s oesophagus

Answer 14

•Adenocarcinoma (risk 40x higher)
• ulceration
• strictures at squamocolumnar junction

Question 15

Management GERD? (4)

Answer 15

Stepwise approach:
• lifestyle: elevate head of bed when sleeping, avoid tight clothes, eat small and frequent meals, avoid eating close to bedtime, avoid alcohol, coffee, chocolate, peppermint (reduce resting Les pressure)
• medical:
- mild, uncomplicated: 12 weeks of simple antacids with or without alginic acid, before beginning diagnostic testing. Some completely resolve
- persistent symptoms: lifelong PPI (symptoms recur within 6 months if stopped )
• antireflux surgery if indicated: laparoscopic Nissen’s fundoplication (360 degree wrap), or partial fundoplication

Question 16

Name 5 indications for antireflux surgery

Answer 16

• Failure medical therapy or immediate return of symptoms after stopping treatment
• Young patient unwilling to take lifelong medication
• structurally defective Les and hiatal hernias
• complications despite medical therapy: severe esophagitis , Stricture (must be dilated to >50 Fr bougie and dysphagia resolved before surgery), Barret’s
• patients with atypical symptoms should be thoroughly investigated and must have shown some response to ppl, otherwise surgery won’t help.