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GASTROESOPHA GEAL

REFLUX

Prof. Dr. Turgut IPEK


GERD in t he 2 0th C ent ury
 GERD was probably not recognized before the mild
of the 1930’es. At the time Winkelstein described a
patient with an esophageal stricture and in his
paper he wondered if the stricture was caused by
acid regurgitation from the stomach into
esophagus. As radiology was the available
investigation it was discovered that a number of
patient had a hiatal hernia and GERD became
synonymous with a hiatal hernia.
 Later endoscopy became part of the diagnostic
armamentarium, and now esophagitis became the dominant
term.
 Finally pH studies were developed and focus was directed
more towards acid regurgitation into stomach.
 Initially antacids and alginates were the supplements to
general advices; but from the late 1970’es first H2-reseptor
antagonists, later PPI became available
Ethnic and geographical variation
GERD is predominant among Caucasians and occurs rarely
among blacks.
Prevalence of GERD-symptoms
A huge number of studies have focused on the prevalence of
heartburn.
Prevalence on the basis of investigations
The important investigations in GERD is endoscopy and pH-
studies. Both these investigations are available and associated
with considerable discomfort.
Sex and age distrubution
There is, however, a tendency towards a higher prevalence of
macroscopic esophagitis with increasing age. It is noteworthy that
most series on antireflux surgery includes more men than women.
Gastro özofageal Re flü H astalı ğı -
GERD

 GERD, mukozal lezyonlar olmadan (NERD) semptomatik


hastalıktan eroziv özofajitin komplikasyonlarına (özofageal
striktür,ülserasyon yada Barrett’s özofagus) kadar bir spektrum
hastalıktır.

 Oldukça yaygındır (% 15-20).


 Ciddi özofajit yaş ile artar
 60 yaş üzeri ciddi özofajit oranı %75
 Ciddi özofajit kadınlara göre erkeklerde daha sık gözlenir
 Günlük heartburn %7
 Haftalık heartburn %20
 Aylık heartburn %44

 Amerika’da gastroenteritis ve kolelitiasis takiben en sık


görülen gastrointestinal hastalıktır (19 milyon/yıl)
a- Heartburn ve regürjitasyon gibi tipik
semptomları olan ancak non-eroziv reflü
hastalığı (NERD) olarak adlandırılan reflü
özofajiti olmayan grup
b- Komplikasyon olsun yada olmasın reflü
özofajitli grup
c- Atipik semptomları olan grup
Ris k F aktörler
 Obezite
 İleri yaş
 Hiatal herni varlığı
 Semptomların ciddiyeti

Erkek hasta
Alkol kullanımı
Sigara kullanımı
1yılı aşkın GERD anamnezi
Natural history of GERD
 GERD can present in a number of different ways varying from
non-erosive GERD to complications as stenosis, Barrett and
adenocarcinoma of the esophagus .
 Symptom severity is independent of the grade of macroscopic
esophagitis
 When patients have consulted their doctor for GERD the disease
is usually chronic. Long term studies (around 10 years) have
shown that only 10% are asymptomatic without treatment.
 Non-erosive disease usually does not (<25%) progress into
esophagitis. However, only few long term studies are available.
Pathophysiology of GERD
 The disease is present when pathologic
exposure of the esophageal lumen to gastric
juice occurs and this can be a pathologic
amount of duodenal components such as bile.
The most frequent condition in
gastroesophageal reflux disease is pathologic
acid exposure and therefore this is often used
synonymously.
The antireflux barrier
 The main reason for pathologic reflux is a malfunction of the
antireflux barrier at the level of the gastroesophageal
junction.
 The intraabdominal portion of the lower esophageal
sphincter is involved in preventing reflux during the
swallowing of the patient. Both the intraabdominal sphincter
length and the pinching effect of the diaphragm helps to
close the sphincter during elevation of intraabdominal
pressure.
 The mechanical incompetence of the lower
esophageal sphincter has been described by the
De Meester, using as relevant criteria the overall
length of the sphincter which is in the physiologic
situation 3-4cm long at the distal end of the
esophagus. The resting tone of the sphincter
characterized by the lower esophageal sphincter
pressure varies in healthy volunteers in relation to
the gastric pressure between 10 and 30 mmHg.
Esophageal peristalsis
 Esophageal clearance and peristaltic function
of the esophageal body is also involved in
producing increased esophageal exposure to
gastric juice. The physiologic swallowing
function is involved in the neutralizing acid of
reflux by enabling to swallow saliva.
Mucosal resistance
 It is however an important factor in assessing the
ability of gastric juice to cause toxic effects in the
esophageal wall.
Duodeno-gastroesophageal reflux:
Gastric disorders
 The backup of gastric contents in the intraduodenal
segment due to delayed gastric emptying can
cause pathologic acid reflux into esophagus.
Ph ysiol ogy
 The antireflux mechanism consists of a
valvular cardia, the propulsive pump action of
the esophagus and a reservoir function of the
stomach. Failure of any may lead to
abdominal esophageal exposure to gastric
juice.
Pu mp
Physiology: Esophageal clearance of refluxed
material involves:
 The volumic clearance related to the esophageal
peristalsis and gravity.
 The chemical clearance related to salivation

Failure:
f) Reduction of the volumic clearance (hiatal hernia)
g) Reduction of the chemical clearance (reduction of
saliva)
Valve
Physiology: the antireflux valve includes:
b) The LOWER ESOPHAGEAL SPHINCTER (LES)
• the intrinsic esophageal sphincter (competency: pressure-overall
length-intraabdominal length)
c) Anatomical factors:
• Hiss angle
• phrenoesophageal ligament.
Failure:
e) Low LES pressure
f) Transient inappropriate LES relaxion
g) Hiatal hernia
Re serv oir
 Gastric functions abnormalities causing GERD
include increased intragastric pressure, gastric
dilatation, decreased emptying rate and
increased acid secretion
GERD ’de Ta nı Yö ntemle ri
 Anamnez
 Endoskopi
 Bernstein test
 24 saatlik ambulatuar pH
 Kısa süreli asid supresyon tedavisi
 Yeni teknikler
magnetoencephalography
PET
fonksiyonel MRI
chromoendoskopi
high resolution-magnification endoskopi
En doskopi
 Tipik reflü semptomlu hastaların %30-40’ında eroziv özofajit
saptanır
 Eroziv özofajitli hastalarda 24 saatlik pH ölçümü pozitif
 NERD olgularının %37-60’ında 24 saatlik pH ölçümü normal
 Chromoendoskopi Barrett’s tanısında etkin
sensitivite %95, spesifisite %97
Evaluation:
Evaluation of the GERD can be divided into mandatory and selective
tests. The selection of the test is based on a decisional algorithm starting
with the evaluation of the symptom of the patient.

Mandatory tests Selective tests


- endoscopy - 24 hrs pH monitoring
- esophageal monometry - 24 hrs monometry
- barium swallow - 24 hrs bilimetry
- gastric emptying
En dos copy
 inpatients with symptoms of GERD who have
undergone endoscopic examination 50-60%
have been reported to have reflux esophagitis
 the presence of esophagitis is recorded and
graded by
the Savary Miller Score,
the MUSE classification
Normal özofagus
Grade I
özofajit
Grade II
özofajit
Grade III
özofajit
Grade IV
özofajit
Grade IV
özofajit
Ülser
Grade V
özofajit
Barrett’s
Esophageal Monometry
• is the gold standard for assessment of the body of
the esophagus (pump)
• is mandatory before antireflux operations (valve)
Assesment of the LES
• resting pressure
• relaxation
• length overall-abdominal length
• transient relaxation
Barium swallow
• barium upper gastrointestinal series are routinely performed
preoperatively and postoperatively.
Parameters
• esophageal motility (5 single swallow of barium)
• Macroscopic esophageal alterations
• Hiatal hernia: size reducibility
• Rings
• Esophagitis
• Stricture
• anatomic situation of the esophagogastric junction(short
esophagus)
24 hrs PH monitoring
• may be performed selectively in patients when the diagnosis is in
doubt.
• may be omitted in symptomatic patients with documented
esophagitis and typical symptoms
• is mandatory:
 in patients with atypical symptoms
 in patients who present typical symptoms non responding to adequate
antacid medical therapy
Parameters
• quantifies the amount of reflux (De Meester Score)
• quantifies esophageal acid clearance
• allows a correlation between reflux and symptoms
De Me es ter S co re
Percent of time ph<4
Total period
Upright period
Supine period
Number of episodes:
Total
Longer than 5 minutes
Duration of longest episode
Symptom index: (numbers of reflux related symptoms episodes /
total number of symptom episodes) X 100%
24 hrs esophageal monometry
 to identify esophageal motility abnormalities as the
cause of non cardiac chest pain
 evaluation of esophageal motility in patients with
GERD
 combined with 24 hrs ph monitoring
 evaluation of esophageal clearance function
 completion of the evaluation in patients presenting
with abnormal esophageal function on standard
monometry
24 h rs B il imet ry
 allows spectrophotometric measurements of
esophageal luminal bilirubin concentration
 in patients non responding to medical therapy
and in patients with Barret’s esophagus
 may be combined with ph study.
Gastric emp tyin g s tud ies
 the radionuclide measurement of gastric
emptying is used selectively in patients who
have postprandial abdominal bloating or
fullness that suggest delayed gastric
emptying.
GER D S emp tomları
TİPİK ATİPİK ALARM
 Pirozis (Heartburn)  Farengeal ağrı • Kanama
 Epigastrik ağrı  Disfoni • Disfaji
 Geğirme  Uykuda apne • Odinofaji
 Regürjitasyon  Noktürnal astım

 Halitozis

 Hıçkırık

 Noktürnal öksürük

 Sırt ağrısı

 Nonkardiak göğüs ağrısı

 Palpitasyon
Surgery
 The goal of the antireflux operations is to increase the efficancy
of the LES and the cardia.
Techn ique s
 in corporation of a portion of the distal esophagus into the
stomach to ensure that it will be a affected by changes in
intraabdominal pressure through the into gastric pressure.
 total 360 degree fundoplication (Nissen)
 partial fundoplication (Toopet,Lind,Belsey)
 Collis-Nissen
 cardiopexy associated with some sort of wrapping of the stomach
(Hill-Watson)
Pre nsi ple r
AMAÇ

• Distal özofagusta yeterli basıncı


oluşturmak ve fonksiyonel bir açı meydana
getirmek
HIAT AL H ER NIA
Physiology
• Classification: Currently three hernias are generally
recognized: 85% of all hiatal hernias are of the sliding
kind.
Sliding Hiatal Hernia
• There is relaxation of the phrenoesophageal ligaments
and enlargement of the hiatal muscular tunnel. Thus, the
gastric cardia may be allowed to herniate upward into the
enlarged hiatus. If the hernia is large the entire fundus of
the stomach can slide into the thorax
Paraesophageal Hernia
• It represents herniation of the gastric fundus through
the esophageal hiatus along side the esophagus,
while the cardiaesophageal junction is maintained in
normal position
Mixed Hiatal Hernia
• The gastroesophageal junction slips above the
diaphragm and the localized defect permits
protrusion varying amount of stomach
 Hiatal Herni tüm popülasyonun %5’inde
GERD’li popülasyonun %50-60’ında
mevcuttur.
 HH’lerin %94’ünde reflü mevcuttur.
 Paraözofageal herniler HH’lerin %5-10’ında rastlanır.

 En sık gözlenen tip I (sliding) HH

 Hiatal Herni Nüksü % 0-42 oranında görülür.


Symptoms
• most individuals with hiatal hernia are asymptomatic
• gastroesophageal reflux is the major complication related
hiatal hernia. Ph monitoring reveals reflux in 83% of
patients with hiatal hernia versus 43% in those without;
bleeding
chest pain
dyspnea and substernal discomfort
dysphagia
Evaluation
• Barium upper GI series
• Endoscopy
• Esophageal monometry

In the herniated stomach, the pressure is negative (intrathoracic


pressure).The characteristical feature in monometric study is the
gap between the RIP and the high pressure zone of the LES.
Monometry allows also study of associated esophageal motility
disorder.
Surgery
Principles of surgical repair involves:
• placement of the hernias contents in the abdominal
cavity
• repair of the crural defect
• combined antireflux procedure (65% of
postoperative reflux if not)
DIAGNOSTIC ASS ESS ME NT OF
GAS TR OE SOPHAGE AL R EFLU X DIS EASE
COMP LIC ATIO NS OF LAPA ROSCO PIC AN TIR EFLU X
SU RGE RY

OPERATIVE COMPLICATIONS
 Perforations
 Pneumothorax
 Bleeding
 Conversion to open surgery

POSTOPERATIVE COMPLICATIONS
 Mortality
 Herniation of the wrap
 Slipped Nissen
 Disrupted Nissen
 Dysphagia
 Recurrent reflux
 Epigastric pain and gas bloat