GERD ( GASTRO-ESOPHAGEAL RIFLUX DISEASE )
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GERD ( GASTRO-ESOPHAGEAL RIFLUX DISEASE )

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GERD is a day to day common problem, which is on the increase due to so many obvious reasons. It needs to be addressed to the public and the medical fraternity for proper management and treatment.

GERD is a day to day common problem, which is on the increase due to so many obvious reasons. It needs to be addressed to the public and the medical fraternity for proper management and treatment.

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  • --distinction between normal and GERD is blurred because some degree of reflux is physiologic is all folks Physiologic—postprandially, short lived, asymptomatic, not during sleep Pathologic—symptoms or mucosal injury and often with nocturnal symptoms
  • --At level of diaphragmatic hiatus—main deterrant to reflux --disruption due to –review slide--multifactorial
  • --Tums, rolaids, maalox --$1 billion in yearly expenditures --aluminum/calcium—constipation Mag--diarrhea
  • --otc dose uniformly half of standard lowest prescription dose --similar clinical efficacy
  • --no significant differences in symptomatic tx of GERD or healing of erosive esophagitis 1a evidence --works only on active pumps—take 30-60min prior to meals --long-term tx generally benefits outweigh risks
  • candidacy --esophagitis—by egd --need normal manometry/motility --partial response to acid suppression --reduce hh, repair diaphragm, strengthen ge jxn—antireflux barrier --75-90% effective at alleviating hrtburn/regurg --better at helping with hrtburn/regurg than atypical sx
  • Figure 11-18. Endoscopic appearance of benign strictures. Acid-septic strictures and Schatzki's rings are the most common strictures requiring dilation. Although in most instances endoscopic examination allows obvious distinction between the two, variation in air insufflation and the differences in magnification over short distances between the lower esophageal sphincter and the endoscope can make the assessment of the lower esophagus difficult in some patients. A subtle peptic stricture may be missed endoscopically, or, more precisely, may be confused with a Schatzki's ring. Contrast radiology can be a more sensitive technique for demonstrating subtle rings and strictures and for calibrating the lumen more precisely. A–C, Endoscopic photographs of several Schatzki's rings. D–G, peptic strictures. Note the esophageal pseudodiverticula proximal to the peptic stricture in panels F and G. Their presence increases the risk of unguided dilatation of the esophagus and mandates the use of a guidewire technique. H, Tight anastomotic stricture (suture at 10 o'clock) and “watermelon esophagus” viewed endoscopically. The watermelon seeds and kernel of corn provide a reference for the pinhole quality of this stricture.
  • Figure 11-21. Types of dilators: balloons. Balloon dilators are an additional option for the endoscopist approaching an esophageal stricture. They may be placed over a guidewire or through the scope (TTS). Theoretically, balloons have the advantage of being safer because of the radial application of force, and elimination of the shearing effect of rigid dilators. Moreover, dilation can be performed under direct visualization using the TTS balloon. Recent balloon innovations facilitating their use include longer balloons that avoid the tendency for slippage with inflation, and high-pressure balloons that should provide a truer diameter for the dilation of more resistant strictures. In the limited number of randomized studies comparing Savory-type dilators with balloon dilators, they appeared equally safe. Efficacy, as assessed by symptom improvement and luminal patency, has been variably reported in the literature favoring either technique [18], [19], [20]. A, Range of available balloons and an inflation gun. B–E, A peptic stricture before and after balloon dilation, thus demonstrating the direct visualization that is possible with the TTS technique. References: [18]. Saeed ZA, Winchester CB, Ferro PA, et al. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc 1995 41 189-195 [19]. Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilation of benign oesophageal stricture? An interim report of a randomized controlled trial. Gut 1988 29 1741-1747 [20]. Shemesh E, Czerniak A, Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures. World J Surg 1990 14 518-522
  • --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --ulcerations in 2-7%
  • 4-20% of patients
  • --1950—Norman Barrett --10-15% --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --RFs—male, smoker, age, obese
  • Adenoca with barretts 0.5%/yr--------without barretts 0.07%/yr

GERD ( GASTRO-ESOPHAGEAL RIFLUX DISEASE ) GERD ( GASTRO-ESOPHAGEAL RIFLUX DISEASE ) Presentation Transcript

  • GERDGERD DR SREEJOY PATNAIKDR SREEJOY PATNAIK EVENT SPONSORERSEVENT SPONSORERS ALKEM PHARMAALKEM PHARMA DT: 27/06/2012DT: 27/06/2012
  • Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease (GERD)(GERD) • Any symptoms or esophageal mucosal damageAny symptoms or esophageal mucosal damage that results from reflux of gastric acid into thethat results from reflux of gastric acid into the esophagusesophagus • Classic GERD symptomsClassic GERD symptoms – Heartburn (pyrosis): substernal burning discomfortHeartburn (pyrosis): substernal burning discomfort – Regurgitation: bitter, acidic fluid in the mouthRegurgitation: bitter, acidic fluid in the mouth when lying down or bending overwhen lying down or bending over
  • ObjectivesObjectives • Definition of GERDDefinition of GERD • Epidemiology of GERDEpidemiology of GERD • Pathophysiology of GERDPathophysiology of GERD • Clinical ManisfestationsClinical Manisfestations • Diagnostic EvaluationDiagnostic Evaluation • TreatmentTreatment • ComplicationsComplications
  • DefinitionDefinition – American College ofAmerican College of Gastroenterology (ACG)Gastroenterology (ACG) – Symptoms OR mucosal damageSymptoms OR mucosal damage produced by the abnormal reflux ofproduced by the abnormal reflux of gastric contents into the esophagusgastric contents into the esophagus – Often chronic and relapsingOften chronic and relapsing – May see complications of GERD inMay see complications of GERD in patients who lack typicalpatients who lack typical symptomssymptoms
  • Physiologic vs PathologicPhysiologic vs Pathologic • Physiologic GERDPhysiologic GERD – PostprandialPostprandial – Short livedShort lived – AsymptomaticAsymptomatic – No nocturnal sxNo nocturnal sx • Pathologic GERDPathologic GERD – SymptomsSymptoms – Mucosal injuryMucosal injury – Nocturnal sxNocturnal sx
  • Locke et al. Gastroenterology 1997;112:1148.Locke et al. Gastroenterology 1997;112:1148. High Prevalence of GastroesophagealHigh Prevalence of Gastroesophageal Reflux SymptomsReflux Symptoms 19.8% 59% 0% 10% 20% 30% 40% 50% 60% Weekly Monthly Frequency of heartburn and/or regurgitation
  • Important Reasons to Diagnose and TreatImportant Reasons to Diagnose and Treat GERDGERD • Negative impact on health-related quality of lifeNegative impact on health-related quality of life11 • Risk factor for esophageal adenocarcinomaRisk factor for esophageal adenocarcinoma22 1.1. Revicki et al. Am J Med 1998;104:252.Revicki et al. Am J Med 1998;104:252. 2.2. Lagergren et al. N Engl J Med 1999;340:825.Lagergren et al. N Engl J Med 1999;340:825.
  • PathophysiologyPathophysiology • Primary barrier toPrimary barrier to gastroesophageal reflux isgastroesophageal reflux is the lower esophagealthe lower esophageal sphinctersphincter • LES normally works inLES normally works in conjunction with theconjunction with the diaphragmdiaphragm • If barrier disrupted, acidIf barrier disrupted, acid goes from stomach togoes from stomach to esophagusesophagus
  • Clinical Presentations of GERDClinical Presentations of GERD • Classic GERDClassic GERD • Extraesophageal/Atypical GERDExtraesophageal/Atypical GERD • Complicated GERDComplicated GERD
  • Extraesophageal ManifestationsExtraesophageal Manifestations of GERDof GERD PulmonaryPulmonary AsthmaAsthma Aspiration pneumoniaAspiration pneumonia Chronic bronchitisChronic bronchitis Pulmonary fibrosisPulmonary fibrosis OtherOther Chest painChest pain Dental erosionDental erosion ENTENT HoarsenessHoarseness LaryngitisLaryngitis PharyngitisPharyngitis Chronic coughChronic cough Globus sensationGlobus sensation DysphoniaDysphonia SinusitisSinusitis Subglottic stenosisSubglottic stenosis Laryngeal cancerLaryngeal cancer
  • Potential Oral and Laryngopharyngeal SignsPotential Oral and Laryngopharyngeal Signs Associated with GERDAssociated with GERD • Edema and hyperemia ofEdema and hyperemia of larynxlarynx • Vocal cord erythema,Vocal cord erythema, polyps, granulomas,polyps, granulomas, ulcersulcers • Hyperemia and lymphoidHyperemia and lymphoid hyperplasia of posteriorhyperplasia of posterior pharynxpharynx • Interarytenyoid changesInterarytenyoid changes • Dental erosionDental erosion • Subglottic stenosisSubglottic stenosis • Laryngeal cancerLaryngeal cancer Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-
  • Pathophysiology of ExtraesophagealPathophysiology of Extraesophageal GERDGERD
  • Symptoms of Complicated GERDSymptoms of Complicated GERD • DysphagiaDysphagia – Difficulty swallowing: food sticks or hangsDifficulty swallowing: food sticks or hangs upup • OdynophagiaOdynophagia – Retrosternal pain with swallowingRetrosternal pain with swallowing • BleedingBleeding
  • When to Perform Diagnostic TestsWhen to Perform Diagnostic Tests • Uncertain diagnosisUncertain diagnosis • Atypical symptomsAtypical symptoms • Symptoms associated with complicationsSymptoms associated with complications • Inadequate response to therapyInadequate response to therapy • Recurrent symptomsRecurrent symptoms • Prior to anti-reflux surgeryPrior to anti-reflux surgery
  • Diagnostic Tests for GERDDiagnostic Tests for GERD • Barium swallowBarium swallow • EndoscopyEndoscopy • Ambulatory pH monitoringAmbulatory pH monitoring • Esophageal manometryEsophageal manometry
  • Barium SwallowBarium Swallow • Useful first diagnostic test forUseful first diagnostic test for patients with dysphagiapatients with dysphagia – Stricture (location, length)Stricture (location, length) – Mass (location, length)Mass (location, length) – Bird’s beakBird’s beak – Hiatal hernia (size, type)Hiatal hernia (size, type) • LimitationsLimitations – Detailed mucosal exam for erosiveDetailed mucosal exam for erosive esophagitis, Barrett’s esophagusesophagitis, Barrett’s esophagus
  • EndoscopyEndoscopy • Indications for endoscopyIndications for endoscopy – Alarm symptomsAlarm symptoms – Empiric therapy failureEmpiric therapy failure – Preoperative evaluationPreoperative evaluation – Detection of Barrett’sDetection of Barrett’s esophagusesophagus
  • Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring • Physiologic studyPhysiologic study • Quantify reflux inQuantify reflux in proximal/distalproximal/distal esophagusesophagus – % time pH < 4% time pH < 4 – DeMeester scoreDeMeester score • Symptom correlationSymptom correlation
  • Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring NormalNormal GERDGERD
  • Wireless, Catheter-Free Esophageal pH Monitoring • Improved patientImproved patient comfort and acceptancecomfort and acceptance • Continued normal work,Continued normal work, activities and diet studyactivities and diet study • Longer reporting periodsLonger reporting periods possible (48 hours)possible (48 hours) • Maintain constant probeMaintain constant probe position relative to SCJposition relative to SCJ Potential AdvantagesPotential Advantages
  • Esophageal ManometryEsophageal Manometry • Assess LES pressure,Assess LES pressure, location and relaxationlocation and relaxation – Assist placement of 24 hr.Assist placement of 24 hr. pH catheterpH catheter • Assess peristalsisAssess peristalsis – Prior to antireflux surgeryPrior to antireflux surgery Limited role in GERDLimited role in GERD
  • GERD vs DyspepsiaGERD vs Dyspepsia • Distinguish from DyspepsiaDistinguish from Dyspepsia – Ulcer-like symptoms-burning, epigastric painUlcer-like symptoms-burning, epigastric pain – Dysmotility like symptoms-nausea, bloating,Dysmotility like symptoms-nausea, bloating, early satiety, anorexiaearly satiety, anorexia • Distinct clinical entityDistinct clinical entity • In addition to antisecretory meds and anIn addition to antisecretory meds and an EGD need to consider an evaluation forEGD need to consider an evaluation for Helicobacter pyloriHelicobacter pylori
  • Treatment Goals for GERDTreatment Goals for GERD • Eliminate symptomsEliminate symptoms • Heal esophagitisHeal esophagitis • Manage or prevent complicationsManage or prevent complications • Maintain remissionMaintain remission
  • Lifestyle Modifications areLifestyle Modifications are Cornerstone of GERD TherapyCornerstone of GERD Therapy • Elevate head of bed 4-6 inchesElevate head of bed 4-6 inches • Avoid eating within 2-3 hours of bedtimeAvoid eating within 2-3 hours of bedtime • Lose weight if overweightLose weight if overweight • Stop smokingStop smoking • Modify dietModify diet – Eat more frequent but smaller mealsEat more frequent but smaller meals – Avoid fatty/fried food, peppermint, chocolate,Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and teaalcohol, carbonated beverages, coffee and tea • OTC medications prnOTC medications prn
  • Better LivingBetter Living • Lifestyle modificationsLifestyle modifications – Avoid large mealsAvoid large meals – Avoid acidic foods (citrus/tomato), alcohol, caffiene,Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermintchocolate, onions, garlic, peppermint – Decrease fat intakeDecrease fat intake – Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal – Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches – Avoid meds that may potentiate GERD (CCB, alphaAvoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS)agonists, theophylline, nitrates, sedatives, NSAIDS) – Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist – Lose weightLose weight – Stop smokingStop smoking
  • Acid Suppression Therapy for GERDAcid Suppression Therapy for GERD HH22-Receptor Antagonists-Receptor Antagonists (H(H22RAs)RAs) Cimetidine (TagametCimetidine (Tagamet®®)) Ranitidine (ZantacRanitidine (Zantac®®)) Famotidine (PepcidFamotidine (Pepcid®®)) NizatidineNizatidine (Axid(Axid®®)) Proton Pump InhibitorsProton Pump Inhibitors (PPIs)(PPIs) Omeprazole (PrilosecOmeprazole (Prilosec®®)) Lansoprazole (PrevacidLansoprazole (Prevacid®®)) Rabeprazole (AciphexRabeprazole (Aciphex®®)) Pantoprazole (ProtonixPantoprazole (Protonix®®)) Esomeprazole (NexiumEsomeprazole (Nexium ®®))
  • Better LivingBetter Living • Lifestyle modificationsLifestyle modifications – Avoid large mealsAvoid large meals – Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic,Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermintpeppermint – Decrease fat intakeDecrease fat intake – Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal – Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches – Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates,Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS)sedatives, NSAIDS) – Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist – Lose weightLose weight – Stop smokingStop smoking
  • TreatmentTreatment • AntacidsAntacids – Over the counter acidOver the counter acid suppressants and antacidssuppressants and antacids appropriate initial therapyappropriate initial therapy – Approx 1/3 of patients withApprox 1/3 of patients with heartburn-related symptomsheartburn-related symptoms use at least twice weeklyuse at least twice weekly – More effective than placeboMore effective than placebo in relieving GERD symptomsin relieving GERD symptoms
  • TreatmentTreatment • Histamine H2-Receptor AntagonistsHistamine H2-Receptor Antagonists – More effective than placebo and antacids forMore effective than placebo and antacids for relieving heartburn in patients with GERDrelieving heartburn in patients with GERD – Faster healing of erosive esophagitis whenFaster healing of erosive esophagitis when compared with placebocompared with placebo – Can use regularly or on-demandCan use regularly or on-demand
  • TreatmentTreatment AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGES Cimetadine 400mg twice daily 400-800mg twice dailyCimetadine 400mg twice daily 400-800mg twice daily TagametTagamet Famotidine 20mg twice daily 20-40mg twice dailyFamotidine 20mg twice daily 20-40mg twice daily PepcidPepcid Nizatidine 150mg twice daily 150mg twice dailyNizatidine 150mg twice daily 150mg twice daily AxidAxid Ranitidine 150mg twice daily 150mg twice dailyRanitidine 150mg twice daily 150mg twice daily zantaczantac
  • TreatmentTreatment • Proton Pump InhibitorsProton Pump Inhibitors – Better control of symptoms with PPIs vsBetter control of symptoms with PPIs vs H2RAs and better remission ratesH2RAs and better remission rates – Faster healing of erosive esophagitis with PPIsFaster healing of erosive esophagitis with PPIs vs H2RAsvs H2RAs
  • TreatmentTreatment AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGES Esomeprazole 40mg daily 20-40mg dailyEsomeprazole 40mg daily 20-40mg daily NexsiumNexsium Omeprazole 20mg daily 20mg dailyOmeprazole 20mg daily 20mg daily OmezOmez Lansoprazole 30mg daily 15-10mg dailyLansoprazole 30mg daily 15-10mg daily LanLan Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg daily PantocidPantocid Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg daily RazoRazo
  • TreatmentTreatment • H2RAs vs PPIsH2RAs vs PPIs – 12 week freedom from symptoms12 week freedom from symptoms • 48% vs 77%48% vs 77% – 12 week healing rate12 week healing rate • 52% vs 84%52% vs 84% – Speed of healingSpeed of healing • 6%/wk vs 12%/wk6%/wk vs 12%/wk
  • TreatmentTreatment • Antireflux surgeryAntireflux surgery – Failed medical managementFailed medical management – Patient preferencePatient preference – GERD complicationsGERD complications – Medical complications attributable to a largeMedical complications attributable to a large hiatal herniahiatal hernia – Atypical symptoms with reflux documented onAtypical symptoms with reflux documented on 24-hour pH monitoring24-hour pH monitoring
  • TreatmentTreatment • Antireflux surgery candidatesAntireflux surgery candidates – EGD proven esophagitisEGD proven esophagitis – Normal esophageal motilityNormal esophageal motility – Partial response to acid suppressionPartial response to acid suppression
  • TreatmentTreatment • Antireflux surgeryAntireflux surgery – Tenets of surgeryTenets of surgery • Reduce hiatal herniaReduce hiatal hernia • Repair diaphragmRepair diaphragm • Strengthen GE junctionStrengthen GE junction • Strengthen antireflux barrier via gastric wrapStrengthen antireflux barrier via gastric wrap • 75-90% effective at alleviating symptoms of75-90% effective at alleviating symptoms of heartburn and regurgitationheartburn and regurgitation
  • TreatmentTreatment • PostsurgeryPostsurgery – 10% have solid food dysphagia10% have solid food dysphagia – 2-3% have permanent symptoms2-3% have permanent symptoms – 7-10% have gas, bloating, diarrhea, nausea,7-10% have gas, bloating, diarrhea, nausea, early satietyearly satiety – Within 3-5 years 52% of patients back onWithin 3-5 years 52% of patients back on antireflux medicationsantireflux medications
  • TreatmentTreatment • Endoscopic treatmentEndoscopic treatment – Relatively newRelatively new – No definite indicationsNo definite indications – Select well-informed patients with well-documentedSelect well-informed patients with well-documented GERD responsive to PPI therapy may benefitGERD responsive to PPI therapy may benefit • Three categoriesThree categories – Radiofrequency application to increase LES refluxRadiofrequency application to increase LES reflux barrierbarrier – Endoscopic sewing devicesEndoscopic sewing devices – Injection of a nonresorbable polymer into LES areaInjection of a nonresorbable polymer into LES area
  • Effectiveness of Medical Therapies forEffectiveness of Medical Therapies for GERDGERD TreatmentTreatment ResponseResponse Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 % HH22-receptor antagonists-receptor antagonists 50 %50 % Single-dose PPISingle-dose PPI 80 %80 % Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %
  • Treatment Modifications forTreatment Modifications for Persistent SymptomsPersistent Symptoms • Improve complianceImprove compliance • Optimize pharmacokineticsOptimize pharmacokinetics – Adjust timing of medication to 15 – 30 minutesAdjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime)before meals (as opposed to bedtime) – Allows for high blood level to interact withAllows for high blood level to interact with parietal cell proton pump activated by the mealparietal cell proton pump activated by the meal • Consider switching to a different PPIConsider switching to a different PPI
  • GERD is a Chronic Relapsing ConditionGERD is a Chronic Relapsing Condition • Esophagitis relapses quickly after cessationEsophagitis relapses quickly after cessation of therapyof therapy – > 50 % relapse within 2 months> 50 % relapse within 2 months – > 80 % relapse within 6 months> 80 % relapse within 6 months • Effective maintenance therapy is imperativeEffective maintenance therapy is imperative
  • Complications of GERDComplications of GERD • Erosive/ulcerative esophagitisErosive/ulcerative esophagitis • Esophageal (peptic) strictureEsophageal (peptic) stricture • Barrett’s esophagusBarrett’s esophagus • AdenocarcinomaAdenocarcinoma
  • Erosive EsophagitisErosive Esophagitis
  • Peptic StricturePeptic Stricture Barium SwallowBarium Swallow EndoscopyEndoscopy
  • Esophageal Stricture: Dilating DevicesEsophageal Stricture: Dilating Devices
  • TTS Balloon Dilation of a Peptic StrictureTTS Balloon Dilation of a Peptic Stricture
  • Barrett’s EsophagusBarrett’s Esophagus
  • Esophageal CancerEsophageal Cancer Barium SwallowBarium Swallow EndoscopyEndoscopy
  • ComplicationsComplications • Erosive esophagitisErosive esophagitis – Responsible for 40-60% of GERD symptomsResponsible for 40-60% of GERD symptoms – Severity of symptoms often fail to matchSeverity of symptoms often fail to match severity of erosive esophagitisseverity of erosive esophagitis
  • ComplicationsComplications • Esophageal strictureEsophageal stricture – Result of healing ofResult of healing of erosive esophagitiserosive esophagitis – May need dilationMay need dilation
  • ComplicationsComplications • Barrett’s EsophagusBarrett’s Esophagus – Columnar metaplasia ofColumnar metaplasia of the esophagusthe esophagus – Associated with theAssociated with the development ofdevelopment of adenocarcinomaadenocarcinoma
  • ComplicationsComplications • Barrett’s EsophagusBarrett’s Esophagus – Acid damages lining ofAcid damages lining of esophagus and causesesophagus and causes chronic esophagitischronic esophagitis – Damaged area heals in aDamaged area heals in a metaplastic process andmetaplastic process and abnormal columnar cellsabnormal columnar cells replace squamous cellsreplace squamous cells – This specializedThis specialized intestinal metaplasia canintestinal metaplasia can progress to dysplasia andprogress to dysplasia and adenocarcinomaadenocarcinoma
  • When to Discuss Anti-RefluxWhen to Discuss Anti-Reflux Surgery with PatientsSurgery with Patients • Intractable GERD – rareIntractable GERD – rare – Difficult to manage stricturesDifficult to manage strictures – Severe bleeding from esophagitisSevere bleeding from esophagitis – Non-healing ulcersNon-healing ulcers • GERD requiring long-term PPI-BID in aGERD requiring long-term PPI-BID in a healthy young patienthealthy young patient • Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms • Not Barrett’s esophagus aloneNot Barrett’s esophagus alone
  • Partial fundoplication techniquesPartial fundoplication techniques • Thal 90 deg. Ant. WrapThal 90 deg. Ant. Wrap • Watson 120 deg ant-lat. wrapWatson 120 deg ant-lat. wrap • Dor 150-200 deg ant. wrapDor 150-200 deg ant. wrap • Toupet 270 deg posterior wrapToupet 270 deg posterior wrap • Belsey Mark IV 270 deg transthoracicBelsey Mark IV 270 deg transthoracic ant- lat wrap.ant- lat wrap.
  • Indications for partialIndications for partial fundoplicationfundoplication • 1.PRIMARY ESO. MOTILITY1.PRIMARY ESO. MOTILITY DISORDERSDISORDERS • Achalasia ( after myotomy)Achalasia ( after myotomy) • SclerodermaScleroderma • 2.SEC. ESOP. MOTILITY DISORDERS2.SEC. ESOP. MOTILITY DISORDERS POOR MOTILITY SEC. TO CHRONICPOOR MOTILITY SEC. TO CHRONIC /BARRETS ESOP/BARRETS ESOP
  • • 3. Inability to tolerate complete3. Inability to tolerate complete fundoplicationfundoplication • Dysphagia, gas bloatingDysphagia, gas bloating • Chronic nauseaChronic nausea • AerophagiaAerophagia • Revision of obstructing360 deg wrapsRevision of obstructing360 deg wraps
  • Scores for heartburn (a) and acid regurgitationScores for heartburn (a) and acid regurgitation (b) 12 months after an anterior or a posterior(b) 12 months after an anterior or a posterior partial fundoplicationpartial fundoplication..
  • Endoscopic GERD TherapyEndoscopic GERD Therapy • Endoscopic antireflux therapiesEndoscopic antireflux therapies – Radiofrequency energy delivered to the LESRadiofrequency energy delivered to the LES • Stretta procedureStretta procedure – Suture ligation of the cardiaSuture ligation of the cardia • Endoscopic plicationEndoscopic plication – Submucosal implantation of inert material inSubmucosal implantation of inert material in the region of the lower esophageal sphincterthe region of the lower esophageal sphincter • EnteryxEnteryx
  • Dr Craig Taylor-anteriorDr Craig Taylor-anterior fundoplicationfundoplication
  • • This is how a laparoscopic fundoplication isThis is how a laparoscopic fundoplication is performed to repair the antireflux valve inperformed to repair the antireflux valve in patients with heartburn. It was performedpatients with heartburn. It was performed by Dr Craig Taylor in Sydney. This type ofby Dr Craig Taylor in Sydney. This type of anti-reflux procedure (anterioranti-reflux procedure (anterior fundoplication) provides excellentfundoplication) provides excellent heartburn control whilst minimising the sideheartburn control whilst minimising the side effects that used to be common after theeffects that used to be common after the older Nissen fundoplication, especially gasolder Nissen fundoplication, especially gas bloating.bloating.
  • • This newer technique aims to restore theThis newer technique aims to restore the function of the valve between stomach andfunction of the valve between stomach and oesophagus in a more natural andoesophagus in a more natural and anatomical way. Patients can expect to beanatomical way. Patients can expect to be free of their heartburn and reflux and stopfree of their heartburn and reflux and stop taking antireflux medication- for manytaking antireflux medication- for many patients this can be quite life changing.Aspatients this can be quite life changing.As with all surgical procedures there are risks,with all surgical procedures there are risks, and patients need to be aware of these.and patients need to be aware of these.
  • • The procedure took approximately 1 hourThe procedure took approximately 1 hour under a general anaesthetic, and onlyunder a general anaesthetic, and only requires an overnight stay in hospital.requires an overnight stay in hospital. Patients can generally return to work withinPatients can generally return to work within a few days, and may resume all normala few days, and may resume all normal physical activity including gym and liftingphysical activity including gym and lifting within a monthwithin a month