GERD/HIATUS HERNIA

Dr.P.Viswakumar, M.SAssistant Professor of Surgery,

PSGIMSRCBE-641004

MCQ

In GERD following factors play an important role as antireflux barrier,all excepta) Cholinergic neuronsb) Lower esophageal sphincterc) Esophageal persistalsisd) LES Length

MCQ

Which one of the factor not responsible for reflux mechanism a) Swallow induced relaxation of LESb) Para esophageal herniac) Transient relaxation of LESd) Hypotensive LES

MCQ

Which one of the following is not a test for mucosal damage assessmenta) Endoscopyb) Barium esophagogramc) Ambulatory PH and impedence monitotingd) Esophageal biopsy

MCQ

Which one of the following drug used to treat to control tLESR ?a) Bethanacolb) Baclofenc) Cisaprided) Pantoprazole

MCQ

In Fundoplication which procedure involes 360 degree wrap a) Dorb) Thalc) Nissand) Toupet

• Gastroesophageal reflux (GER) is a physiologic process by which gastric contents move retrograde from the stomach to the esophagus.

• GER itself is not a disease and occurs multiple times each day without producing symptoms or mucosal damage.

Gastro Esophageal Reflux

Gastroesophageal Reflux Disease

• GERD is a spectrum of disease usually producing symptoms of heartburn and acid regurgitation.

• “GERD is a premalignant condition that results in esophageal adenocarcinoma”

• GERD is a consequence of the failure of the normal antireflux barrier to protect against frequent and abnormal amounts of refluxed material.

Pathogenesis• Its is Complex disease resulting from

imbalance between protective and defensive factors

Protective Factors:

a) Antireflux Barrierb) Esophageal Acid Clearancec) Tissue Resistance

Pathogenesis

Aggressive Factors :a) Gastric Acidityb) Volumec) Duodenal Content

Anti Reflux barrier

Factors contributing Anti reflux Barrier : a) Intrinsic LES (Lower esophageal

sphincter).b) Diaphragmatic Crurac) Intraabdominal Esophagusd) Acute Angle of His

Lower esophageal Sphincter

• LES involves the distal 3 to 4 cm of the esophagus and at rest is tonically contracted.

• Resting LES pressure ranges from 10 to 30 mm Hg.• The LES maintains a high-pressure zone by the

intrinsic tone of its muscle and by cholinergic excitatory neurons.

• It is lowest after meals and highest at night.• Also influenced by circulating peptides and

hormones, foods (particularly fat), as well as a number of drugs.

Increase LES Pressure Decrease LES Pressure

Hormones/peptides Gastrin CCK Motilin Secretin Substance P Somatostatin

Vasoactive intestinal peptide

Neural agents α-Adrenergic agonists α-Adrenergic antagonists β-Adrenergic antagonists β-Adrenergic agonists Cholinergic agonists Cholinergic antagonists

Foods and nutrients Protein Chocolate

Fat Peppermint

Other factors Antacids Barbiturates Baclofen Calcium channel blockers Cisapride Diazepam Domperidone Dopamine Histamine Meperidine Metoclopramide Morphine Prostaglandin F 2α Prostaglandins E 2 and I 2

Serotonin Theophylline

Mechanism of Reflux

• Transient Lower Esophageal Sphincter Relaxations.

• Swallow-Induced Lower Esophageal Sphincter Relaxations.

• Hypotensive Lower Esophageal Sphincter Pressure.

• Hiatal Hernia.

tLESR Swallow induced Hypotensive StrainingLESR LES

Control GERD Mild EsophagitisSevere Esophagitis

Esophageal Acid Clearance

1) Volume Clearance 2) Acid Clearance

Volume Clearance : (Peristalsis)• Both primary (swallowing) and Secondary Persistalsis

(Esophageal Distension)• Inoperative during deep rapid-eye-movement (REM) sleep.• Peristaltic dysfunction due to severe esophagitis caused by

defective anti reflux barrier.• Gravity contributes to bolus clearance when reflux occurs in

the upright position.

Acid Clearance

Salivary and Esophageal Gland Secretionsa) The stimulus for salivation appears

to be the presence of acid in the proximal esophagus (20 cm above LES).

b) The aqueous bicarbonate-rich secretions of the esophageal submucosal glands dilute and neutralize residual esophageal acid.

Tissue Resistance

• Tissue resistance can be subdivided into i)preepithelial

ii)Epithelial and iii)Postepithelial • Luminal acid attacks the epithelial defenses by

damaging the intercellular junctions, allowing hydrogen ions to enter and acidify the intercellular space.

Other Aggressive Factors

• Gastric Acid Secretion - Acid and pepsin are the key ingredients of the gastric refluxate producing esophagitis.

• Acid combined with even small amounts of pepsin disrupts the mucosal barrier.

• Duodenogastric Reflux - Along with acid and pepsin, duodenal contents may be injurious to the esophageal mucosa.

• Delayed Gastric Emptying- Gastric Distension

Symptoms Esophageal :• Heart burn- rising from the stomach or lower chest and

radiating toward the neck, throat, and occasionally the back

• Post prandial – After spicy,fatty foods.• Other common symptoms of GERD are acid regurgitation

and dysphagia. • Less common symptoms associated with GERD include

water brash, odynophagia, burping, hiccups, nausea, and vomiting.

Symptoms

Extra-esophageal :• Chest pain - mimic angina pectoris typically worse after

meals and emotional stress.• Asthma – 34-89% Asthmatics has GERD as underlying

cause.• Other Pulmonary Disorders - aspiration pneumonia,

interstitial pulmonary fibrosis, chronic bronchitis, and bronchiectasis.

• Ear, Nose, and Throat Diseases- Laryngitis, recurrent pharyngitis and leading cause of chronic cough secondly to asthma and sinusitis.

• Sleep Disorders

Diagnosis

Diagnosis• Vast no of tests are available but many times

these tests are unnecessary.• Classic symptoms of heartburn and acid

regurgitation are sufficiently specific to identify reflux disease and begin medical treatment.

• However, this is not always the case, and clinicians must decide which tests to choose so as to make a diagnosis in a reliable, timely, and cost-effective manner depending on the information desired

Tests based on NecessityTests for Reflux • Intraesophageal pH monitoring (catheter or

catheter-free system) • Ambulatory impedance and pH monitoring

(nonacid reflux) • Barium esophagogram

Tests to Assess Symptoms • Empirical trial of acid suppression • Intraesophageal pH monitoring with symptom

analysis

Barium Esophagogram

Barium Esophagogram

Tests to Assess Esophageal Damage • Endoscopy • Capsule endoscopy • Esophageal biopsy • Barium esophagogram Tests to Assess Esophageal Function • Esophageal manometry • Esophageal impedance

Clinical Course

Non- Erosive disease- Suspected in the patient with typical reflux symptoms and a normal endoscopy and confirmed by the patient’s response to antisecretory therapy.

Female, younger, thin & without hiatal herniaErosive Disease- male, older, and overweight

and are more likely to have hiatal hernias.Barret esophagus.

ComplicationsHemorrhage.Ulcers.Perforation.Peptic Esophageal Strictures.Esophageal Shortening.Barret’s Esophagus.Esophageal Adenocarcinoma.

Treatment

Treatment of Uncomplicated Disease

• Non prescriptional therapies• Life style modification

Prescription Medication

• Prokinetic Drugs- bethanechol, a cholinergic agonist; metoclopramide, a dopamine antagonist; and cisapride a serotonin (5-HT4) receptor agonist.

• Transient Lower Esophageal Sphincter Relaxation Inhibitors - the only medication available that decreases tLESRs is baclofen.

• H2RAs- (cimetidine, ranitidine, famotidine, and nizatidine) are more effective in controlling nocturnal than meal-stimulated acid secretion.

• PPIs PPIs inhibit meal-stimulated and nocturnal acid

secretion to a significantly greater degree than H2RAs232 but rarely render patients achlorhydric.

PPIs do not “cure” reflux disease, rather they treat GERD in an indirect way by decreasing the number of acid reflux episodes.

PPIs (omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole) have superior efficacy compared with H2RAs

SURGICAL THERAPY

SURGICAL THERAPYWhy we need surgery when medical therapy able to treat GERD effectively???

Symptomatic relief and effective resolution of esophageal inflammation, which may help ameliorate some of the long-term sequelae of GERD, but medical therapy must be continued indefinitely and does not prevent bile reflux.

• Successful surgery needs proper patient selection.

Primary Indications for Antireflux Surgery • Patients with esophageal and/or extraesophageal GERD

symptoms that are responsive but not completely eliminated by PPIs

• Patients with heartburn eliminated by PPIs but continued nonacid reflux

• Patients with well-documented reflux events preceding symptoms such as chest pain, cough, or wheezing

• Patients with GERD complications such as peptic stricture, Barrett esophagus, or vocal cord injury while taking PPIs twice a day

• Patients with well-documented GERD who desire to stop chronic PPI use despite excellent symptom control for any reason (e.g., side effects, lifestyle, expense)

Other Indications

• Low LES Pressure• Short length LES

Surgical ProcedureThe 2 most popular procedures, performed laparoscopically through the abdomen, are the

• Nissen 360-degree fundoplication • Toupet partial fundoplication

Nissan’s fundoplication

Nissan’s Fundoplication Dor’s Fundoplication

Toupet’s Fundoplication

Hiatal Hernia

Treatment of Complication

Peptic Stricture :• Dysphagia is by far the most common

complaint of patients with a peptic stricture.• Workup of a patient with an esophageal

stricture could begin with a contrast esophagogram.

• Treated with endoscopic ballon dilatation after ruling out malignancy.

• Acid suppression therapy• Intra lesional corticosteroids• Esophageal stents• Surgical option can be considered in non

dilatable stricturea) Esophagectomyb) Esophagectomy with Roux-en-y

Reconstruction (Esophago-jejunostomy)

Short Esophagus

Risk Factors for a Short Esophagus :• Peptic stricture • Hiatal hernia ≥5 cm • Short esophageal length (determined

manometrically or endoscopically) • Barrett esophagus

Short Esophagus

Open Technique :a)Colle’s Gastroplasty

Short Esophagus

• Laproscopic Approach:

Take Home Message

• GER itself is not a disease its called “GERD” if it is associated with mucosal damage.

• GERD results from imbalance between protective and aggressive factors

• Gastric distension found to be earliest and one of the predisposing factors in GERD

• Most GERD are diagnosed with clinical symptoms of heart burn.

• Special test such as esophageal PH monitoring ,endoscopy and manometry warranted in patients with suspected complication and non responders to medical therapy

• GERD is more of surgical disease than a medical one as previously thought.

• Medical therapy aims only controlling the symptoms and progression of complication to some extent but not cures reflux per say.

• Surgical therapy proves a definitive role in curing the reflux and development of complications.

• Complications such as peptic stricture and short segment esophagus to be addressed specifically

MCQ

In GERD following factors play an important role as antireflux barrier,all excepta) Cholinergic neuronsb) Lower esophageal sphincterc) Esophageal persistalsisd) LES Length

MCQ

Which one of the factor not responsible for reflux mechanism a) Swallow induced relaxation of LESb) Para esophageal herniac) Transient relaxation of LESd) Hypotensive LES

MCQ

Which one of the following is not a test for mucosal damage assessmenta) Endoscopyb) Barium esophagogramc) Ambulatory PH and impedence monitotingd) Esophageal biopsy

MCQ

Which one of the following drug used to treat to control tLESR ?a) Bethanacolb) Baclofenc) Cisaprided) Pantoprazole

MCQ

In Fundoplication which procedure involes 360 degree wrap a) Dorb) Thalc) Nissand) Toupet

MCQ

In above slides Wasim Akram is compared with which one of the following a) Gastic volumeb) Gastric Acidityc) Tissue resistanced) Duodenal contents

THANK YOU