A range of endoscopic findings, from mild redness to severe. With bleeding, ulceration &stricture formation.
There is a poor correlation between symptoms, histological &endoscopic findings.
Significant GERD may be present despite normal endoscopy / normal oesophageal histology.
‘ Columnar lined oesophagus'-CLO, is a pre-malignant glandular intestinal metaplasia of the lower oeso, in which the normal squamous lining is replaced by columnar mucosa.
Occurs as an adaptive response to chronic GERD,found in 10% undergoing gastroscopy for reflux symptoms.
CLO is the major risk factor for oesophageal adenocarcinoma, with a lifetime cancer risk of 10%, more closely related to the severity& duration of reflux rather than the CLO per se.
The cancer incidence is estimated at 1/200 patient years (0.5% /year), being low& > 95% with CLO die of causes other than oesophageal cancer.
Prevalence is increasing, more in men (especially white) &> 50.
It is weakly associated with smoking but not alcohol.
E-cadherin polymorphisms, p53 mutations, TGF-β, EGF receptors, COX-2& TNF-α may play roles.
Requires multiple systematic biopsies to maximise the chance of detecting intestinal metaplasia /or dysplasia.
Neither PPI nor antireflux surgery will stop progression or induce regression of CLO& treatment is only indicated for symptoms of reflux or complications such as stricture.
Endoscopic ablation therapy or photodynamic therapy can induce regression but 'buried islands' of glandular mucosa may persist underneath the squamous epithelium& cancer risk is not eliminated.
At present these therapies remain experimental but show promise; they are also used in patients with high-grade dysplasia (HGD) or early malignancy who are not suitable for surgery.
Regular endoscopic surveillance can detect dysplasia& malignancy at an early stage & improve 2-year survival but, because most CLO is undetected until cancer develops, surveillance strategies are unlikely to influence the overall mortality rate of oesophageal cancer.
Surveillance is expensive &cost-effectiveness conflicting.
Surveillance is currently recommended every 2-3 years for those without dysplasia & at 6-12-monthly intervals for those with low-grade dysplasia.
Oesophagectomy is widely recommended for those with HGD as the resected specimen harbours cancer in up to 40%.
Recent data suggest that HGD often remains stable & may not progress to cancer, at least in the medium term.
Close follow-up with biopsies every 3 months is an alternative strategy for those with HGD.
Occurs as a consequence of chronic, insidious blood loss from long-standing oesophagitis.
Almost all such patients have a large hiatus hernia& bleeding can occur from subtle erosions in the neck of the sac ('Cameron lesions
Complications: 4.Benign oesophageal stricture
Develop as a consequence of long-standing oesophagitis.
Most elderly & have poor oesophageal peristaltic activity.
Present with dysphagia which is worse for solids than liquids.
Bolus obstruction following ingestion of meat causes absolute dysphagia.
A history of heartburn is common but not invariable;as in many elderly patients.
Diagnosis is made by endoscopy, with biopsies to exclude Cancer.
Endoscopic balloon dilatation or bouginage is helpful.
Subsequently, long-term therapy with a PPI at full dose should be started to reduce the risk of recurrent oesophagitis & stricture formation.
Young patients with typical symptoms, without worrying features such as dysphagia, weight loss or anaemia, can be treated empirically without investigation.
Investigation is advisable if patients present in middle or late age, if symptoms are atypical or if a complication is suspected.
Endoscopy is the investigation of choice, performed to exclude other upper GI diseases & identify complications.
A normal endoscopy in a patient with compatible symptoms should not preclude treatment for GERD.
Twenty-four-hour pH monitoring is indicated if, despite endoscopy, the diagnosis is not clear.
A pH of < 4 for > 6-7% of the study time is diagnostic of GERD.
When to Perform Diagnostic Tests
Symptoms associated with complications
Inadequate response to therapy
Prior to anti-reflux surgery
Diagnostic Tests for GERD
Ambulatory pH monitoring
Useful first diagnostic test for patients with dysphagia
Stricture (location, length)
Mass (location, length)
Hiatal hernia (size, type)
Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus
Indications for endoscopy
Empiric therapy failure
Detection of Barrett’s esophagus
Detect grade: LA grading classification system for GERD.
The LA Classification system – Grade A reflux esophagitis Stomach Grade A : One (or more) mucosal break, no longer than 5 mm, that does not extend between the tops of two mucosal folds.
The LA Classification system – Grade B reflux esophagitis Stomach Grade B : One (or more) mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds.
The LA Classification system – Grade C reflux esophagitis Stomach Grade C : One (or more) mucosal break that is continuous between the tops of two or more mucosal folds, but which involves less than 75% of the circumference.
The LA Classification system – Grade D reflux esophagitis Stomach Grade D : One (or more) mucosal break that involves at least 75% of the esophageal circumference.