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CasLroesophageal 8eflux ulsease

W GLkD ls one of Lhe mosL
prevalenL gasLrolnLesLlnal
dlsorders opulaLlonbased
sLudles show LhaL up Lo
13 of lndlvlduals have
hearLburn and/or
regurglLaLlon aL leasL once a
week and 7 have
sympLoms dally
W 8ackground
CasLroesophageal reflux ls
a normal physlologlcal
phenomenon experlenced
lnLermlLLenLly by mosL
people parLlcularly afLer a
GLkD Introduct|on
W Gastroesophagea| ref|ux d|sease (GLkD) occurs when
Lhe amounL of gasLrlc [ulce LhaL refluxes lnLo Lhe
esophagus exceeds Lhe normal llmlL causlng sympLoms
wlLh or wlLhouL assoclaLed esophageal mucosal ln[ury
(le esophaglLls)
W 1he cumulaLlve effecLs of CL8 depend on Lhe amounL of
refluxed maLerlal per eplsode Lhe frequency of reflux
eplsodes Lhe raLe of clearance of Lhe esophagus by
gravlLy and perlsLalLlc conLracLlon and Lhe raLe of
neuLrallzaLlon of gasLrlc acld by sallvary secreLlon
GLkD athophys|o|ogy
1he physlologlcal and anaLomlcal facLors LhaL prevenL Lhe reflux of
gasLrlc [ulce from Lhe sLomach lnLo Lhe esophagus lnclude Lhe
W 1he lower esophageal sphlncLer (LLS) musL have a normal lengLh and
pressure and a normal number of eplsodes of LranslenL relaxaLlon
(relaxaLlon ln Lhe absence of swallowlng)
W 1he gasLroesophageal [uncLlon musL be locaLed ln Lhe abdomen so
LhaL Lhe dlaphragmaLlc crura can asslsL Lhe acLlon of Lhe LLS Lhus
funcLlonlng as an exLrlnslc sphlncLer 1he presence of a hlaLal hernla
dlsrupLs Lhls synerglsLlc acLlon and can promoLe reflux
W Lsophageal clearance musL be able Lo neuLrallze Lhe acld refluxed
Lhrough Lhe LLS (Mechanlcal clearance ls achleved wlLh esophageal
perlsLalsls Chemlcal clearance ls achleved wlLh sallva)
W 1he sLomach musL empLy properly
actors assoc|ated w|th the deve|opment
of GLkD
GLkD athophys|o|ogy
Abnorma| gastroesophagea| ref|ux |s caused by the
abnorma||t|es of one or more of the fo||ow|ng
protect|ve mechan|sms
W funcLlonal (frequenL LranslenL LLS relaxaLlon) or
mechanlcal (hypoLenslve LLS) problem of Lhe LLS
ls Lhe mosL common cause of CL8u (surglcal
damage Lo Lhe LLS and esophaglLls scleroderma
llke dlseases myopaLhy assoclaLed wlLh chronlc
lnLesLlnal pseudoobsLrucLlon lncompeLence of
Lhe dlaphragmaLlc crural muscle)
GLkD athophys|o|ogy
W CerLaln foods (eg coffee alcohol) medlcaLlons (eg
calclum channel blockers nlLraLes beLablockers
slldenafll) or hormones (eg progesLerone) can decrease
Lhe pressure of Lhe LLS
W CbeslLy ls a conLrlbuLlng facLor ln CL8u probably
because of Lhe lncreased lnLraabdomlnal pressure
Some sLudles have shown LhaL CL8u ls hlghly prevalenL
ln paLlenLs who are morbldly obese and LhaL a hlgh body
mass lndex (8Ml) ls a rlsk facLor for Lhe developmenL of
CL8u lncreased lnLragasLrlc pressure and
gasLroesophageal pressure gradlenL lncompeLence of
Lhe LLS and lncreased frequency of LranslenL LLS
relaxaLlons may all play a role ln Lhe paLhophyslology of
Lhe dlsease ln paLlenLs who are morbldly obese
GLkD Cccurrence
W kace
JhlLe males are aL a greaLer rlsk for 8arreLL
esophagus and adenocarclnoma Lhan oLher
W ex
-o sexual predllecLlon exlsLs CL8u ls as common ln
men as ln women
1he maleLofemale raLlo for esophaglLls ls 2131
1he maleLofemale raLlo for 8arreLL esophagus ls
W Age
CL8u occurs ln all age groups
1he prevalence of CL8u lncreases ln people older
Lhan 40 years
Typical Typical
(esophageal) (esophageal)
symptoms symptoms
Atypical Atypical
(extraesophageal) (extraesophageal)
symptoms symptoms
Complica Complica- -
tions tions
Differentia Differentia- -
tions tions
eartburn eartburn
Regurgita Regurgita- -
tion tion
Dysphagia Dysphagia
Bleeding Bleeding
Asympto Asympto- -
matic matic
Coughing, Coughing,
wheezing wheezing
oarseness oarseness
Noncardiac chest Noncardiac chest
pain pain
Otitis/Sinusitis Otitis/Sinusitis
Obstructive Lung Obstructive Lung
Disease Disease
Interstitial Lung Interstitial Lung
Disease Disease
Obstructive sleep Obstructive sleep
apnea apnea
Reflux Reflux
esophagitis esophagitis
Erosive Erosive
esophagitis esophagitis
Peptic Peptic
stricture stricture
Barrett's Barrett's
esophagus esophagus
Esophageal Esophageal
cancer cancer
Adenocarci Adenocarci- -
noma noma
Achalasia Achalasia
Cholelithiasis Cholelithiasis
Coronary Artery Coronary Artery
Atherosclerosis Atherosclerosis
Esophageal Esophageal
Cancer Cancer
Esophageal Esophageal
Spasm Spasm
Gastritis, Gastritis,
Chronic Chronic
Irritable Bowel Irritable Bowel
Syndrome Syndrome
Peptic Ulcer Peptic Ulcer
Disease Disease
W |story
W CL8u can cause Lyplcal (esophageal) sympLoms or aLyplcal
(exLraesophageal) sympLoms Powever a dlagnosls of
CL8u based on Lhe presence of Lyplcal sympLoms ls correcL
ln only 70 of paLlenLs
W 1yp|ca| (esophagea|) symptoms lnclude Lhe followlng
eartburn ls Lhe mosL common Lyplcal sympLom of CL8u
PearLburn ls felL as a reLrosLernal sensaLlon of burnlng or
dlscomforL LhaL usually occurs afLer eaLlng or when lylng down or
bendlng over
kegurg|tat|on ls an efforLless reLurn of gasLrlc and/or esophageal
conLenLs lnLo Lhe pharynx 8egurglLaLlon can lnduce resplraLory
compllcaLlons lf gasLrlc conLenLs splll lnLo Lhe Lracheobronchlal
eartburn eartburn
kegurg|tat|on kegurg|tat|on
1yp|ca| (esophagea|) symptoms (conLlnuaLlon)
Dysphag|a occurs ln approxlmaLely one Lhlrd of paLlenLs because
of a mechanlcal sLrlcLure or a funcLlonal problem (eg
nonobsLrucLlve dysphagla secondary Lo abnormal esophageal
perlsLalsls) aLlenLs wlLh dysphagla experlence a sensaLlon LhaL
food ls sLuck parLlcularly ln Lhe reLrosLernal area erslsLenL
dysphagla suggesLs developmenL of a pepLlc sLrlcLure MosL
paLlenLs wlLh pepLlc sLrlcLure have a hlsLory of several years of
hearLburn precedlng dysphagla Powever ln oneLhlrd of paLlenLs
dysphagla ls Lhe presenLlng sympLom 8apldly progresslve
dysphagla and welghL loss may lndlcaLe Lhe developmenL of
adenocarclnoma ln 8arreLLs esophagus
8|eed|ng occurs due Lo mucosal eroslons or 8arreLLs ulcer
Many paLlenLs wlLh CL8u remaln asymptomat|c or se|ftreated
and do noL seek aLLenLlon unLll severe compllcaLlons occur
GLkD upraesophagea| man|festat|ons
GLkD upraesophagea| man|festat|ons
W Atyp|ca| (extraesophagea|) symptoms lnclude Lhe
Cough|ng and]or wheez|ng are resp|ratory symptoms (chronlc
cough bronchoconsLrlcLlon pharynglLls larynglLls bronchlLls or
pneumonla pulmonary flbrosls chronlc asLhma) resulLlng from
Lhe asplraLlon of gasLrlc conLenLs lnLo Lhe Lracheobronchlal Lree or
from Lhe vagal reflex arc produclng bronchoconsLrlcLlon
pproxlmaLely 30 of paLlenLs who have CL8ulnduced asLhma
do noL experlence hearLburn
oarseness resulLs from lrrlLaLlon of Lhe vocal cords by gasLrlc
refluxaLe Poarseness ls ofLen experlenced by paLlenLs ln Lhe
8eflux ls Lhe mosL common cause of noncard|ac chest pa|n
accounLlng for approxlmaLely 30 of cases aLlenLs can presenL
Lo Lhe emergency deparLmenL wlLh paln resembllng a myocardlal
GLkD Comp||cat|ons
pproxlmaLely 30 of paLlenLs wlLh gasLrlc reflux develop
esophaglLls LsophaglLls ls classlfled lnLo Lhe followlng 4
grades based on lLs severlLy
Crade l LryLhema
Crade ll Llnear nonconfluenL eroslons
Crade lll Clrcular confluenL eroslons
Crade lv SLrlcLure or 8arreLL esophagus (8arreLL
esophagus ls LhoughL Lo be caused by Lhe chronlc reflux of
gasLrlc [ulce lnLo Lhe esophagus 8arreLL esophagus occurs
when Lhe squamous eplLhellum of Lhe esophagus ls
replaced by Lhe lnLesLlnal columnar eplLhellum 8arreLL
esophagus ls presenL ln 813 of paLlenLs wlLh CL8u and
may progress Lo adenocarclnoma
W Acha|as|a chalasla ls a prlmary esophageal moLlllLy
dlsorder characLerlzed by fallure of a hyperLenslve LLS Lo relax and
Lhe absence of esophageal perlsLalsls 1hese abnormallLles cause a
funcLlonal obsLrucLlon aL Lhe gasLroesophageal [uncLlon
W Cho|e||th|as|s 8ecause Lhey are common gallsLones ofLen coexlsL
wlLh oLher gasLrolnLesLlnal condlLlons LlLLle evldence suggesLs LhaL
gallsLones cause chronlc abdomlnal paln hearLburn posLprandlal
dlsLress bloaLlng flaLulence consLlpaLlon or dlarrhea
W Coronary Artery Atherosc|eros|s 8eflux ls Lhe mosL common cause
of noncardlac chesL paln accounLlng for approxlmaLely 30 of cases
aLlenLs can presenL Lo Lhe emergency deparLmenL wlLh paln
resembllng a myocardlal lnfarcLlon 8eflux should be ruled ouL (uslng
esophageal manomeLry and 24h pP LesLlng lf necessary) once a
cardlac cause for Lhe chesL paln has been excluded lLernaLlvely a
LherapeuLlc Lrlal of a hlghdose proLon pump lnhlblLor (l) can be
W Lsophagea| pasm LLlology of esophageal spasm ls
unknown 1heorles lnclude gasLrlc reflux or a prlmary nerve
or moLor dlsorder 8ecause of Lhe slmllarlLy of sympLoms of
reflux dlsease and esophageal spasm many paLlenLs may
be mlsdlagnosed wlLh reflux lurLhermore reflux and
spasm can occur concomlLanLly
W Irr|tab|e 8owe| yndrome lrrlLable bowel syndrome (l8S) ls
a funcLlonal Cl dlsorder characLerlzed by abdomlnal paln
and alLered bowel hablLs ln Lhe absence of speclflc and
unlque organlc paLhology
W Chron|c Gastr|t|s ept|c U|cer D|sease should be
dlfferenLlaLed by upper endoscopy and P pylorl LesLs
W Lsophagea| Cancer
CL8u ls Lhe mosL common predlsposlng facLor for adenocarclnoma of
Lhe esophagus denocarclnoma beglns from CL8u and progresses Lo
(8arreLL) meLaplasla lowgrade and hlghgrade dysplasla 1he rlsk of
adenocarclnoma among paLlenLs wlLh 8arreLL meLaplasla has been
esLlmaLed Lo be 3060 Llmes LhaL of Lhe general populaLlon
uysphagla ls Lhe mosL common presenLlng sympLom uysphagla ls
lnlLlally experlenced for sollds buL evenLually lL progresses Lo lnclude
JelghL loss ls Lhe second mosL common sympLom and occurs ln more
Lhan 30 of people wlLh esophageal carclnoma
aln can be felL ln Lhe eplgasLrlc or reLrosLernal area lL can also be felL
over bony sLrucLures represenLlng a slgn of meLasLaLlc dlsease
Poarseness caused by lnvaslon of Lhe recurrenL laryngeal nerve ls a
slgn of unresecLablllLy
8esplraLory sympLoms can be caused by asplraLlon of undlgesLed food
or by dlrecL lnvaslon of Lhe Lracheobronchlal Lree by Lhe Lumor
I Lab tud|es
LaboraLory LesLs are seldom useful ln esLabllshlng a dlagnosls of CL8u
II Imag|ng tud|es
W 8ar|um esophagogram
8arlum esophagogram ls parLlcularly lmporLanL for paLlenLs who
experlence dysphagla
8arlum esophagogram can show Lhe presence and locaLlon of a
sLrlcLure and Lhe presence and shape of a hlaLal hernla
W Lsophagogastroduodenoscopy (Upper endoscopy)
LsophagogasLroduodenoscopy (LCu) ldenLlfles Lhe presence and
severlLy of esophaglLls and Lhe posslble presence of 8arreLL
LCu also excludes Lhe presence of oLher dlseases (eg pepLlc
ulcer) LhaL can presenL slmllarly Lo CL8u
LCu ls frequenLly performed Lo help dlagnose CL8u LsophaglLls ls
presenL ln only 30 of paLlenLs wlLh CL8u
kef|ux esophag|t|s
Lndoscop|c c|ass|f|cat|ons of Lsophag|t|s
W avaryM|||er
Crade l one or more
supravesLlbular non
confluenL reddlsh spoLs wlLh
or wlLhouL exudaLe
Crade ll eroslve and exudaLlve
leslons ln Lhe dlsLal esophagus
whlch may be confluenL
Crade lll clrcumferenLlal
eroslons ln Lhe dlsLal
esophagus covered by
hemorrhaglc and
Crade lv presence of chronlc
compllcaLlons such as deep
ulcers sLenosls or scarrlng
wlLh 8arreLLs meLaplasla
W Los Ange|es C|ass|f|cat|on
-oL presenL -o breaks (eroslons) ln Lhe
esophageal mucosa (edema eryLhema or
frlablllLy may be presenL)
Crade Cne or more mucosal breaks conflned
Lo Lhe mucosal folds each noL more Lhan 3
mm ln maxlmum lengLh
Crade 8 Cne or more mucosal breaks more
Lhan 3 mm ln maxlmum lengLh buL noL
conLlnuous beLween Lhe Lops of Lwo
mucosal folds
Crade C Mucosal breaks LhaL are conLlnuous
beLween Lhe Lops of Low or more mucosal
folds buL whlch lnvolve less LhaL 73 of Lhe
esophageal clrcumference
Crade u Mucosal breaks whlch lnvolve aL leasL
73 of Lhe esophageal clrcumference
1he presence or absence of sLrlcLures ulcers
and/or 8arreLLs esophagus much be noLed
separaLely eg Crade 8 wlLh sLrlcLure
8arrett`s esophagus
III Cther tests
W 1 Lsophagea| manometry
Lsophageal manomeLry deflnes Lhe funcLlon of Lhe LLS and
Lhe esophageal body (perlsLalsls)
Lsophageal manomeLry ls essenLlal for correcLly poslLlonlng
Lhe probe for Lhe 24hour pP monlLorlng
W kad|onuc||de measurement of gastr|c empty|ng
W lLhough delayed gasLrlc empLylng ls presenL ln as many
as 60 of paLlenLs wlLh CL8u Lhls empLylng ls usually a
mlnor facLor ln Lhe paLhogenesls of Lhe dlsease ln mosL
paLlenLs (excepL ln paLlenLs wlLh advanced dlabeLes
melllLus or connecLlve Llssue dlsorders)
W aLlenLs wlLh delayed gasLrlc empLylng Lyplcally
experlence posLprandlal bloaLlng and fullness ln addlLlon
Lo oLher sympLoms
W Ambu|atory 4hour p mon|tor|ng
mbulaLory 24hour pP monlLorlng ls Lhe crlLerlon sLandard ln
esLabllshlng a dlagnosls of CL8u wlLh a senslLlvlLy of 96 and a
speclflclLy of 93
mbulaLory 24hour pP monlLorlng quanLlfles Lhe
gasLroesophageal reflux and allows a correlaLlon beLween Lhe
sympLoms of reflux and Lhe eplsodes of reflux
aLlenLs wlLh endoscoplcally conflrmed esophaglLls do noL need
pP monlLorlng Lo esLabllsh a dlagnosls of CL8u
Ind|cat|ons for esophagea| manometry and p mon|tor|ng
erslsLence of sympLoms whlle Laklng adequaLe anLlsecreLory
Lherapy such as l Lherapy
8ecurrence of sympLoms afLer dlsconLlnuaLlon of acldreduclng
lnvesLlgaLlon of aLyplcal sympLoms such as chesL paln or asLhma ln
paLlenLs wlLhouL esophaglLls
ConflrmaLlon of Lhe dlagnosls ln preparaLlon for anLlreflux surgery
Med|ca| Care
W 1reaLmenL ls a sLepwlse approach
W 1he goals are Lo conLrol sympLoms Lo heal
esophaglLls and Lo prevenL recurrenL esophaglLls or
oLher compllcaLlons
1he treatment |s based on ||festy|e mod|f|cat|on
and contro| of gastr|c ac|d secret|on
L|festy|e mod|f|cat|ons lnclude Lhe followlng
Loslng welghL (lf overwelghL)
voldlng alcohol chocolaLe clLrus [ulce and LomaLobased
voldlng large meals
JalLlng 3 hours afLer a meal before lylng down
LlevaLlng Lhe head of Lhe bed 20 cm
W harmaco|og|c therapy
Antac|ds were Lhe sLandard LreaLmenL ln Lhe 1970s and are sLlll
effecLlve ln conLrolllng mlld sympLoms of CL8u nLaclds should
be Laken afLer each meal and aL bedLlme
|stam|ne receptor antagon|sts are Lhe flrsL llne agenLs
for paLlenLs wlLh mlldLomoderaLe sympLoms and grades lll
esophaglLls PlsLamlne P2 recepLor anLagonlsLs are effecLlve for
heallng only mlld esophaglLls ln 7080 of paLlenLs wlLh CL8u and
for provldlng malnLenance Lherapy Lo prevenL relapse
(c|met|d|ne mg ran|t|d|ne 1S mg b|d famot|d|ne mg
b|d n|zat|d|ne 1S mg b|d)
ddlLlonal P2 blocker Lherapy has been reporLed Lo be useful ln
paLlenLs wlLh severe dlsease (parLlcularly Lhose wlLh 8arreLL
esophagus) who have nocLurnal acld producLlon
|stam|ne receptor antagon|sts
roton pump |nh|b|tors (Is) are Lhe mosL powerful
medlcaLlons avallable 1hey should be used only when CL8u has
been ob[ecLlvely documenLed ls work by blocklng Lhe flnal sLep
ln Lhe P+ lon secreLlon by Lhe parleLal cell Cmeprazo|e (
mg]d) |ansoprazo|e ( mg]d) pantoprazo|e (4 mg]d)
esomeprazo|e (4 mg]d) or rabeprazo|e ( mg]d) for 8 weeks
can heal eroslve esophaglLls ln up Lo 90 of paLlenLs 1he drug ls
Laken 13 Lo 30 mln before breakfasL and can be malnLalned
lndeflnlLely 8efracLory paLlenLs can double Lhe dose and
admlnlsLer lL Lwlce a day before meals
W 1hey have few adverse effecLs and are well LoleraLed for
longLerm use Powever recenL daLa have shown LhaL ls
can lnLerfere wlLh calclum homeosLasls and aggravaLe
cardlac conducLlon defecLs 1hey have also been
responslble for hlp fracLure ln posLmenopausal women
roton pump |nh|b|tors (Is)
rok|net|c agents lmprove Lhe moLlllLy of Lhe esophagus and
sLomach 1he proklneLlc drugs lnclude bethanecho|
metoc|opram|de and domper|done (moLlllum)
8ethanecho| ls a chollnerglc anLagonlsL LhaL causes lncreased
LLS pressure perlsLalsls and sallvary flow Powever Lhls
agenL ls conLralndlcaLed ln paLlenLs wlLh asLhma
Metoc|opram|de ls a dopamlne anLagonlsL LhaL may lmprove
gasLrlc empLylng buL ls assoclaLed wlLh exLrapyramldal slde
1hese agenLs are somewhaL effecLlve buL only ln paLlenLs
wlLh mlld sympLoms oLher paLlenLs usually requlre
addlLlonal acldsuppresslng medlcaLlons such as ls Long
Lerm use of proklneLlc agenLs may have serlous even
poLenLlally faLal compllcaLlons and should be dlscouraged
rok|net|c agents
GLkD 1kLA1MLN1 urg|ca| Care
lor paLlenLs who develop compllcaLlons surglcal LreaLmenL should be
consldered aL an earller sLage Lo avold Lhe serlous consequences
1he ma|n surg|ca| method |s Laparoscop|c fundop||cat|on
Ind|cat|ons for fundop||cat|on |nc|ude the fo||ow|ng
aLlenLs wlLh sympLoms LhaL are noL compleLely conLrolled by l
aLlenLs wlLh wellconLrolled dlsease who deslre deflnlLlve one
Llme LreaLmenL
1he presence of 8arreLL esophagus
1he presence of exLraesophageal manlfesLaLlons of CL8u
?oung paLlenLs
oor paLlenL compllance Lo medlcaLlons
osLmenopausal women wlLh osLeoporosls
aLlenLs wlLh cardlac conducLlon defecLs
CosL of medlcal Lherapy
GLkD 1kLA1MLN1 urg|ca| Care
W Laparoscoplc fundopllcaLlon ls performed under
general endoLracheal anesLhesla 1he fundus of
Lhe sLomach ls wrapped around Lhe esophagus Lo
creaLe a new valve aL Lhe level of Lhe
gasLroesophageal [uncLlon
W pproxlmaLely 92 of paLlenLs obLaln resoluLlon of
sympLoms afLer undergolng laparoscoplc
Laparoscoplc fundopllcaLlon
1hank 1hank ou ou for attent|on for attent|on