Gastro-esophageal reflux means reflux of gastric contents into the lower esophagus. It is a normal physiological phenomenon and when it causes symptoms, it is called gastro-esophageal reflux disease (GERD).it is one of the major health problem and may affect upto 20-40% of the population
What prevents GERD?
Lower esophageal sphincter is formed by distal 4cm of esophageal smooth muscles and this lower esophageal sphincter prevents gastric and duodenal contents from reflux into the lower esophagus. The normal LOS is 3-4cm long and has a pressure of 10-25 mm Hg.
Lower end of the esophagus/ lies intra- abdominally which acts as a valve and prevents the movement of gastric contents into the esophagus when intra-gastric and intra- abdominal pressure rises.
Normal peristalsis allows the rapid clearance of esophagus into the stomach.
There is angulation between the esophagus and stomach which prevents reflux.
What causes reflux?
Some degree of reflux is a normal phenomenon. The lower esophageal sphincter relaxes transiently in response to food intake to vent the swallowed air. But when there is increase in transient lower esophageal sphincter relaxations (TLOSRS), the sphincter becomes incompetent and allows abnormal exposure of esophagus to
acidic-contents. In 60% of the patients, mechanically defective lower esophageal sphincter is responsible for GERD.
Other factors which are associated with reflux are given as:
Pregnancy and obesity.
Fat, Alcohol, Large meals.
Spicy diet.
Smoking.
Hiatal hernia,
Clinical feature:
Typical symptoms includes:
heartburn,
regurgitation and dysphagia
Heartburn: retrosternal burning sensation
Regurgitation: effortless reflux of sour or bitter gastric contents into throat, mouth or even onto the lungs
Atypical/extra esophageal symptoms;
these occur because reflux of gastric contents into the larynx and trachea and these symptoms include
asthma,
chronic_cough,
laryngitis,
sore
throat and non-cardiac chest pain
Diagnosis:
Patients with typical symptoms of heart burn and regurgitation should be treated empirically with once or twice daily proton pump inhibitors (PPIS) without any investigations
Endoscopy
Endoscopy should be carried out in patients with alarm features:
(troublesome dysphagia,
odynophagia,
weight loss,
iron deficiency anemia) and in
patients where troublesome symptoms persists despite empiric PPIs therapy.
Upper GI endoscopy is excellent for documenting the type and extent of tissue damage and also to detect complications associated with GERD like Barrett's esophagus, stricture and esophageal adenocarcinoma.
Esophageal pH recording and impedance tests: it is unnecessary in most of the patients with GERD but may be indicated in patients who have extra-esophageal symptoms or those who are considered for anti-reflux surgery. Combined impedance-pH monitoring is indicated in patients with persistent symptoms despite PPI therapy to determine whether symptoms are caused by acid or non acid reflux (40%) or are unrelated to the reflux and indicative of functional disorder
How 24 hours pH is recorded and what is impedance pH recording:
A pH probe is placed 5cm above the lower esophageal sphincter and a continuous recording of esophageal pH is stored in a small recorder attached to the patient's belt. Over a 24 hours period whenever there will be reflux the pH decreases and pH
of less than 4 in 24 hour's period does not exceed 4% in a healthy patient. The patient is asked to register any symptoms at meal time and encouraged to live normal life.
Analysis of the record provides total acid exposure, frequency of reflux and time of reflux. It should be remembered that PPI (proton pump Inhibitor) must be stopped week before esophageal pH recording because they inhibit acid production and the reading may be misleading. Esophageal pH monitoring devices provide information about the amount esophageal acid reflux but not non acid reflux, impedance allow assessment of gas and non acid Techniques using multichannel intraluminal reflux. They may be useful in evaluation of patients with atypical symptoms or persistent symptoms despite PPI therapy to diagnose hypersensitivity, functional symptoms and symptoms caused by non-acid reflux.
Contrast radiography: Barium meal demonstrates reflux only in 40% of patients with GERD. However it can demonstrate presence of hiatal hernia, stricture or ulcer of lower esophagus.
Treatment guidelines for GERD
Weight reduction is recommended for GERD patients who are overweight or have had recent weight gain
Head of the bed elevation by 6 inches enhances esophageal clearance and reduces reflux and should be strongly recommended
Elimination of acidic food and fatty foods should be recommended
An 8-week course of PPIs is the therapy of choice for symptom relief and healing erosive esophagitis. There are no major differences in efficacy between the different PPIS
Traditional delayed release PPIS should be administered 30-60-minutes before meal for maximal pH control.
PPI therapy should be initiated at once a day dosing, before the first meal of the day. For patients with partial response to once daily therapy, tailored therapy with adjustment dose timing and/or twice daily dosing should be considered in patients with night-time symptoms, variable schedules, and/or sleep disturbance
Non-responders to PPI should be further evaluated by endoscopy and other investigations
In patients with partial response to PPI therapy, increasing the dose to twice daily therapy or switching to a different PPI may provide additional symptom relief.
Maintenance PPI therapy should be administered for GERD patients who continue to have symptoms after PPI is Discontinued and in patients with complications including erosive esophagitis and Barrett's esophagus. For patients who require long-term PPI therapy, it should be administered in the lowest effective dose, including on demand or intermittent therapy.
H2-receptor antagonist (H2RA) therapy can be used as a maintenance option in patients without erosive disease if patients experience heartburn relief. Bedtime H₂RA therapy can be added to daytime PPI therapy in selected patients with objective evidence of night-time reflux if needed.
There is no role for sucralfate in the non- pregnant GERD patient
PPIs are safe in pregnant patients if clinically indicated
Extra esophageal presentations of GERD:
Asthma, chronic cough, and laryngitis
GERD can be considered as a potential co- factor in patients with asthma, chronic cough, or laryngitis. Careful evaluation for non-GERD causes should be undertaken in all of these patients
PPI trial is recommended to treat extra esophageal symptoms in patients who also have typical symptoms of GERD
Reflux monitoring should be considered before a PPI trial in patients with extra esophageal symptoms who do not have typical symptoms of GERD
In patients in whom extra esophageal symptoms of GERD persist despite PPI optimization, assessment for other etiologies should be pursued through concomitant evaluation by ENT, pulmonary, and allergy specialist
GERD refractory to treatment with PPIS
The first step in management of refractory GERD is optimization of PPI therapy
Upper endoscopy should be performed in refractory patients with typical or dyspeptic symptoms principally to exclude non-GERD etiologies
In patients in whom extra esophageal symptoms of GERD persist despite PPI optimization, assessment for other etiologies should be pursued through concomitant evaluation by ENT, pulmonary, and allergy specialists
Patients with refractory GERD and negative evaluation by endoscopy (typical symptoms) or evaluation by ENT, pulmonary, and allergy specialists (extra esophageal symptoms), should undergo ambulatory reflux monitoring
Reflux monitoring off medication can be performed by any available modality (pH or impedance-pH).
Consideration for anti-reflux surgery
Indications for anti-reflux surgery
Have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression, or medication side effects)
Patient's preference: opt for surgery despite successful medical management (due to quality of life considerations, lifelong need for medication intake, expense of medications et
have complications of GERD (e.g., Barrett's esophagus with dysplasia, peptic stricture)
have extra-esophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration)
Surgical treatment can be performed either by laparoscopy or by open surgery. The aim of the surgical treatment is to create intra-abdominal esophagus, crural repair and some form of wrapping of the stomach around the esophagus to overcome the reflux (fundoplication).
Total fundoplication (NISSEN):
Nissen described the procedure as 360 degree fundoplication around the lower end of esophagus for the distance of 4-5cm (as shown on picture on next page), although it provides very good control of reflux but it is associated with over competent cardia leading to and gas bloat syndrome. ". In gas bloat syndrome the stomach fills with air as belching becomes
impossible due to over competent cardia. Patient feels very full after meal and passes excessive flatus.
Partial fundoplication:
In order to avoid over competent cardia partial fundoplication is performed which consist of 270 degree gastric fundoplication around the distal 4cm of esophagus. Partial fundoplication can be
performed either posteriorly (Toupet) or anteriorly (Dr. Watson). It has fewer side effects than total fundoplication but the failure rate was slightly higher. laproscopic partial fundoplication
is of increasingly used with 80-90% success rate to relieve reflux symptoms
In case of recurrence of the disease after surgery the best treatment is partial gastrectomy with
Roux-en-Y reconstruction.
Complications of GERD:
a. Stricture.
b. Esophageal shortening.
C. Barrett's esophagus.
d. Esophageal carcinoma.
Stricture:
Reflux induced stricture usually occurs in the late middle and elderly.
It usually occurs just above the gastro-esophageal junction.
Tx: Peptic strictures usually respond to endoscopic dilatation and PPIS.
Esophageal shortening:
Esophageal shortening can occur due to fibrosis and sliding hiatal hernia.
If a good segment of esophagus cannot be obtained without tension
Tx: A Collis gastroplasty should be performed. In Collis gastroplasty a new esophagus is created by using the fundus of the stomach.
Schatizki's Ring:
It is a circular ring at distal esophagus usually at squamocolumnar junction. It may be a sequel to GERD or Barrett's esophagus.
Tx: Usually single balloon dilation is curative.
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