Treatment for GERD / Reflux / Hiatal hernia
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This document discusses gastroesophageal reflux disease (GERD). It defines GERD as any symptoms or esophageal damage from gastric acid reflux. Classic GERD symptoms include heartburn and regurgitation. The document outlines treatment options for GERD ranging from lifestyle modifications to medication and surgery. It also discusses complications of untreated GERD such as esophagitis, strictures, and Barrett's esophagus which can progress to cancer. Surgical fundoplication is described as a treatment for refractory GERD.
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Treatment for GERD / Reflux / Hiatal hernia
- 2. Dr Nitin Jha (MBBS,MS,FIAGES) Consultant Laparoscopic,MIS and Bariatric surgeon FORTIS Hospital, Noida. INDIA drnitinjha@yahoo.com drnitinjha@yahoo.com
- 3. Any symptoms or esophageal mucosal damage that results from reflux of gastric acid into the esophagus Classic GERD symptoms ◦ Heartburn (pyrosis): substernal burning discomfort ◦ Regurgitation: bitter, acidic fluid in the mouth when lying down or bending over drnitinjha@yahoo.com
- 5. Type II & Type III are referred to as “paraesophageal hernias”. Type II (rolling) ◦ The esophagogastric junction is in its normal intraabdominal location ◦ The hernia sac (containing portions of the gastric fundus and body) develops alongside the esophagus Type III ◦ The esophagogastric junction is displaced into the thorax and like a Type II, the hernia sac contains portions of the gastric fundus or body. drnitinjha@yahoo.com
- 6. Lower esophageal sphincter ◦ Intrinsic muscle of distal esophagus ◦ Sling fibers of cardia ◦ Diaphragm ◦ Transmitted pressure of abdominal cavity drnitinjha@yahoo.com
- 8. Symptom Predominance (%) Heartburn 80 Regurgitation 54 Abdominal Pain 29 Cough 27 Dysphagia for solids 23 Hoarseness 21 Belching 15 Aspiration 14 Wheezing 7 Globus 4 drnitinjha@yahoo.com
- 9. Pulmonary Asthma Aspiration pneumonia Chronic bronchitis Pulmonary fibrosis Other Chest pain Dental erosion ENT Hoarseness Laryngitis Pharyngitis Chronic cough Globus sensation Dysphonia Sinusitis Subglottic stenosis Laryngeal cancer drnitinjha@yahoo.com
- 10. Typical symptoms Suspicious CXR Chest C.T. Upper GI Series In urgent situations: ◦ Placement of NG tube & subsequent coiling Often difficult to assess the location of the actual junction… drnitinjha@yahoo.com
- 11. Endoscopy Empirical Therapy Barium swallow Ambulatory pH monitoring Esophageal manometry drnitinjha@yahoo.com
- 12. Treatment Response Lifestyle modifications/antacids 20 % H2-receptor antagonists 50 % Single-dose PPI 80 % Increased-dose PPI up to 100 % drnitinjha@yahoo.com
- 13. Elevation of the head of the bed, Decreased fat intake, Cessation of smoking, Avoiding recumbency for 3h postprandial, Avoidance of certain foods (chocolate, EtOH, peppermint) Small frequent meals No data reflecting the efficacy of these maneuvers drnitinjha@yahoo.com
- 14. Erosive/ulcerative esophagitis Esophageal (peptic) stricture Barrett’s esophagus Adenocarcinoma drnitinjha@yahoo.com
- 15. Antacids H2 receptor antagonists If symptoms persist, continuous therapy is required, or alarm symptoms/signs develop – pt should have additional evaluation and treatment drnitinjha@yahoo.com
- 16. Intractable GERD – rare ◦ Difficult to manage strictures ◦ Severe bleeding from esophagitis ( grade III-IV) ◦ Non-healing ulcers GERD requiring long-term PPI-BID in a healthy young patient Large hiatal hernia Persistent regurgitation/aspiration symptoms Not Barrett’s esophagus alone Noncompliance Patient’s preference ( cost, life style…) drnitinjha@yahoo.com
- 17. Creation of a floppy valve by maintaining close apposition b/w the abdominal esophagus and the gastric fundus Exaggeration of the flap valve at the angle of His Increase in the basal pressure generated by the lower esophageal sphincter Reduction in the triggering of LES relaxations Reduction in the capacity of the gastric fundus speeding prox. and a total gastric emptying Prevention of effacement of the lower esophagus drnitinjha@yahoo.com
- 18. Liver Retractor Suction Harmonic ScalpelGrasping Forceps Flexible Dissector Penrose Drain French Bougie Needle Holder Scissors drnitinjha@yahoo.com
- 19. Patient’s position: ◦ Supine with legs apart ◦ 30° Reverse Trendelenburg General anesthesia Endotracheal intubation Surgeon in between patient’s legs ◦ Assistant to surgeon’s left ◦ Scrub nurse to surgeon’s right drnitinjha@yahoo.com
- 21. Main Complications: ◦ Bleeding ◦ Perforation of esophagus ◦ Perforation of stomach ◦ Splenic injury. drnitinjha@yahoo.com
- 23. Ant. partial fundoplication Thal/Dor procedure Post. partial fundoplication Toupet procedure drnitinjha@yahoo.com
- 24. VIDEO… LAP HIATAL HERNIA REPAIR AND FUNDOPLICATION. drnitinjha@yahoo.com