GERD

1. GASTROESOPHAGEAL
REFLUX DISEASE

2. • Definition
• Pathophysiology
• Clinical Presentation
• Evaluation
• Management
• Endoluminal Therapies

3. Definition of GERD
Retrograde flow of gastric contents into
esophagus, leading to symptoms or
complications.

4. RISK FACTORS AND ASSOCIATED CONDITIONS
• Obesity.
• Increasing age.
• Genetics .
• Alcohol consumption.
• Tobacco use.
• Diet.

5. Pathophysiology
Failure of endogenous antireflux mechanisms
• Lower esophageal sphincter (LES) mechanism
• Spontaneous esophageal clearance
• Efficiently functioning gastric reservoir
GERD

6. 1. LES mechanism
• Made up of 4 anatomic structures
• Intrinsic musculature of distal esophagus
• Sling fibres of gastric cardia
• Diaphragmatic crura
• Intraabdominal location of GEJ

7. DETERMINANTS OF LES ANTIREFLUX
FUNCTION
• Resting pressure
• Length of LES
• Intraabdominal length of esophagus
Intragastric pressure
>
Distal esophageal pressure
=
GER
happens in cases of:
• Hypotensive LES
• Spontaneous LES relaxation
• Hiatal Hernia

8. 2. Spontaneous clearance mechanism
• to restore normal esophageal pH
• Increased swallowing frequency
• Secondary peristalsis

9. 3. Gastric Reservoir
• Gastric distension leads to unfolding of LES
• predisposes to reflux

10. CLINICAL PRESENTATION
• HEARTBURN:
• epigastric / retrosternal caustic /
stinging sensation, not associated
with pressure sensation
• REGURGITATION:
• Water Brash; movement of gastric
contents into oropharynx,
worsened by bending
TYPICAL SYMPTOMS:
Sabiston 21st edition pg, no. 1058

11. Extraesophageal symptoms of GERD
LARYNGEAL
• Hoarseness, Dysphonia
• Throat clearing, Throat pain
• Globus
• Choking
• Laryngospasm
• Contact ulcers
• Postnasal drip
• Laryngeal and tracheal stenosis
PULMONARY
• Cough
• Shortness of breath
• Wheezing
• Pulmonary disease
• Asthma
• IPF
• Chronic Bronchitis

12. Extraesophageal symptoms - mechanism
Proximal esophageal reflux
Microaspiration of gastroduodenal
contents
DIRECT CAUSTIC INJURY TO
LARYNX AND LOWER
RESPIRATORY TRACT
Reflux
Vagal nerve reflex
BRONCHOSPASM AND
COUGH

13. EVALUATION
• 1. Ambulatory pH and Impedance monitoring
• 2. Esophageal Manometry
• 3. Esophago-gastro-duodenoscopy
• 4. Barium Esophagogram

14. Evaluation
AMBULATORY pH
• Gold standard to identify distal
esophageal acid exposure
• Dual probe electrodes used
• Parameters measured:(24 hr)
• No. of reflux episodes (pH<4)
• Longest duration of reflux
• No. of episodes >5 min
• % time spent in reflux in upright
and supine
IMPEDANCE MONITORING
• Identifies episodes of non acid
reflux
• Electrodes at 1 cm interval
• Detects changes in resistance to
flow of current
• Can differentiate between
swallow and reflux

15. ESOPHAGEAL MANOMETRY
• To assess function of esophageal
body and LES
• Measures:
• LES resting pressure
• Length of LES
• HRM: High Resolution
Manometry, Colour Contour Plot
ESOPHAGOGASTRO DUODENOSCOPY
• Assessment of
• GEJ flap valve
• Barrett Esophagus
• Esophagitis - ulcers, erosions
• Strictures
• Hiatal hernia
Evaluation

16. Evaluation
BARIUM ESOPHAGOGRAM
• Can see positional reflux
• Hiatus hernia
• Diverticulae
• Tumors
• Strictures
• Dysmotility

17. Maingot’s abdominal operations pg.no. 1015

18. MANAGEMENT OF GERD
LIFESTYLE MODIFICATIONS
• Cessation of consumption of tobacco, alcohol, chocolate,fatty foods.
• Weight loss.
• Elevating the head of the bed leads to improvements in symptoms.

19. MANAGEMENT OF GERD
MEDICAL MANAGEMENT
• 8 week course of PPI therapy
• Indications:
• typical symptoms of GERD
• exclude neoplasm, non-GERD
diagnosis
• If symptoms improve: trial is
both diagnostic or therapeutic
• If symptoms persist: more
detailed evaluation
SURGICAL MANAGEMENT
• Indications:
• Objectively proven reflux disease
• Symptoms despite medical
management
• structurally abnormal LES
• severe esophagitis
• stricture
• Barretts esophagus

20. • ACG guidelines recommend PPI therapy be initiated at once a day
dosing before the first meal of the day.
• Patients with incomplete responses to twice-daily dosing (specifically
in patients with nighttime symptoms).
• As needed, bedtime administration of H2RAs is recommended for
individuals with nighttime symptoms not optimized with maximal PPI
therapy.
• The role of prokinetic agents such as metoclopramide and
domperidone in GERD is limited due to lack of data and also due to
their profound adverse effects on the central nervous system and
cardiovascular system. NLM Citation
Antunes C, Aleem A, Curtis SA.
Gastroesophageal Reflux Disease.
[Updated 2022 Jul 4]. In: StatPearls
[Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-.

21. SURGICAL MANAGEMENT - Principles
• Creation of new antireflux valve at GEJ
• Preserve ability to swallow normally
• Preserve both vagi
• Maintain intraabdominal length of esophagus
• Fundoplication should not exceed peristaltic power of esophagus

22. Fundoplication - Key steps
1. Hiatal dissection and preservation of both vagi
2. Circumferential esophageal mobilisation, fundal mobilisation
3. Hiatal closure
4. Creation of short and floppy fundoplication over esophageal dilator

23. Types of Fundoplication
COMPLETE (360o)
• NISSEN’S Fundoplication
• Total posterior-360o
• ROSETTI-HALL Fundoplication
• Total Anterior-360o
PARTIAL
• POSTERIOR
• TOUPET Fundoplication
• 270o
• ANTEROLATERAL
• WATSON’S Fundoplication
• 120o
• ANTERIOR
• 90o
• 120o DOR’S Fundoplication
• 180o

25. Fundoplication
Operative Complications
• Pneumothorax
• Gastric and esophageal injuries
• Splenic and liver injuries
• Bleeding
Outcomes
• >90% ---> improvement
• Temporary dysphagia
• Temporary inability to belch
• Gas Bloat Syndrome
• Failure of surgery

26. ENDOLUMINAL THERAPY
1. Radiofrequency energy ---> tissue reaction ---> Augmentation
2. Injection of biopolymers.
3. Endoluminal Gastroplication:
• ESOPHYX - TRANSORAL INCISIONLESS FUNDOPLICATION
4. Implantation of Magnetic Sphincter Augmentation Device (MSAD)
• LINX:
• magnetic beads around LES, increases LES resting pressure, magnetic beads move apart
when peristaltic wave pushes bolus across LES .

27. MAINGOT’S ABDOMINAL SURGERY pg.no 1044