Usama M Abdelaal, MD, PhD

Assoc Prof of Gastroenterology

• 20 cm
• 1/3 striated & 2/3 non-
striated.
• Outer longitudinal , Inner
circular
• Stratified squamous /
Squamo-columnar junction
 Swallowing

1. Voluntarily movement of bolus from mouth to

pharynx.
2. UOS relaxes LOS
relaxes
3. Primary peristaltic waves
 Symptoms
• Dysphagia
• Odynophagia
• Substernal discomfort
• Heartburn
• Regurgitation
 Gastro-esophageal reflux disease
(GERD)
• Gastro-esophageal reflux: reflux of gastric contents
which can occur normally with no symptom.
• Gastro-esophageal reflux disease: patient with reflux
with persistent symptoms.
• Reflux esophagitis: inflammation of the lower
esophagus produced by persistent reflux with or
without symptoms.
Anti-reflux mechanisms

• LES
• Intra-abdominal esophagus
• Crural diaphragm and mucosal folds
Pinchcock effect
• Regular esophageal clearness : Gravity,
salivary bicarbonate, persitalisis
• Unimpeded gastric empty
Anti-reflux mechanisms
Pinchcock effect
• Transient LES relaxation. Pathogenesis
• Low resting LES tone which fail
to increase when the patient lies
down or when intra-abdominal
pressure increases.
• Increased esophageal mucosal
sensitivity to acids.
• Reduced esophageal clearance
due to poor peristalsis.
• Delayed gastric emptying.
• Sliding hiatus hernia
 Sliding hiatus hernia. What is it?
• 30% over age of
50
• No symptoms if
not associated
with GERD
• No treatment
Factors associated with increased reflux:
• Pregnancy, Obesity.
• Large meals
• Diet: fat, chocolate, coffee,
Alcohol, spicy foods.
• Cigarette smoking.
• Medications : Ca++ Channel blockers and nitrates.
• Systemic sclerosis, Hiatus hernia.
• Iatrogenic; e.g. after treatment of achalasia
 Clinical Features
• Heart burn!

Cadiac pain:
• Dyspnia, sweating
• Aggravated by exercise
• Relieved by rest or nitrate
 Clinical Features
• Reflux Pain: esophagitis
• Hematemsis, IDA

• Regurgitation of food and acid

• Aspiration into the upper airways or the lung
 Diagnosis
• The clinical diagnosis can usually be made
without investigation. Unless there are alarm signs
Alarm Features! Dysphagia, weight loss,
heamatemesis, anorexia, IDA, vomiting

Aim of investigations :
Assessing esophagitis/ hiatus hernia
 Documenting the acid reflux
 Investigations
• Endoscopy:
– Esophagitis
– Barrett's esophagus
– Non-erosive reflux disease (NERD)

• 24 hours PH monitoring: (PH<4):

 Correlation between PH and symptoms.
4% of the time

• Esophageal manometery:
To exclude associated motility disorder
Complications
• Peptic Stricture:
 Dysphasia which worse over long time
 Endoscopic dilatation,
 Occasionally surgery is required.
• Barret’s esophagus:
 Replacement of the normal squamus
epithelium in by columner epithelium
 Premalignant condition.
• Adenocarcinoma
Barrett’s esophagus
Metaplasia
Chronic irritation
Change to adenocarcinoma
Diagnosed by:
• Normal endoscopy
• Magnifying endoscopy
• Chromoendoscopy

Follow up every 2 years if

high grade
Phototherapy
Radiofrequency ablation
 Treatment

Non Pharmacological Treatment:

Control of weight
cessation of smoking,
Alcohol,
Diet: frequent small meals,
avoid fatty, spicy ,
raise head of bed
Pharmacological Treatment:
 Alginate containing antacids
Help persitalsis, gastric emptying ;
domperidone
 H2-receptor antagonists: Cimetidine,
ranitidine, .Famotidine.
 Proton pump inhibitors: inhibit gastric H +-K+
ATPase:
Omeprazole, Lansoprazole, Rabeprazole, …
 P-CABs; potassium-competitive acid blockers
Endoscopic Treatment
Stretta
TIF:
Tansoral incisonless Fundoplication
Cap – EMR
Endoscopic mucosal redection
Anti-reflux mucosectomy
 Surgical management of GERD
Indications
-Failed medical therapy , Intolerance, Side effects , Pt’s
will to get free of medications
- Severe esophageal injury
- Long duration of symptoms
- Persistent symptoms at young age
- Atypical symptoms
- Patient preference.
 ANTI-REFLUX OPERATIONS OF GERD

A) Total fundoplication procedure:

-Nissen fundoplication.

B) Partial fundoplication procedure:

-Toupet fundoplication.
• The most common method is : Nissen Fundoplication
Thanks You