Gastroesophageal reflux disease (GERD) is defined as a condition where stomach contents cause troublesome symptoms or complications, with prevalence rates indicating a significant impact on lifestyle. The document covers its etiology, pathophysiology, clinical features, complications, and various diagnostic and management strategies, emphasizing the role of lifestyle modifications and medications as primary treatment options. Surgery is considered for patients with severe symptoms or complications, guided by specific diagnostic criteria including abnormal 24-hour pH monitoring.

1. GastroesophagealGastroesophageal RefluxReflux
(GERD)(GERD)
GastroesophagealGastroesophageal RefluxReflux
(GERD)(GERD)S
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AN OVERVIEWAN OVERVIEW
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2. DR.B.SELVARAJ,MS;MchDR.B.SELVARAJ,MS;Mch;;FICSFICSDR.B.SELVARAJ,MS;MchDR.B.SELVARAJ,MS;Mch;;FICSFICS
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• PEDIATRIC SURGEON
• SVMCH&RC
• PONDICHERRY-605102
• INDIA
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3. GastroesophagealGastroesophageal RefluxReflux
(GERD)(GERD)
GastroesophagealGastroesophageal RefluxReflux
(GERD)(GERD)
•Definition
•Etiology
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•Pathophysiology
•Clinical Features
•Complications
•Investigations
•Management
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Definition of GERDDefinition of GERD
•Montreal consensus panel (44 experts):
“a condition which develops when the reflux of
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“a condition which develops when the reflux of
stomach contents causes troublesome symptoms
and/or complications”
•Troublesome—patient has to decide when reflux
interferes with lifestyle

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Why do we care about reflux?Why do we care about reflux?
• Patients experience reflux symptoms
• 44% monthly
• 20% weekly
• 4-7% dailyV
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• 4-7% daily
• Most common gastrointestinal diagnosis on outpatient
physician visits
• Frequency and severity does not predict esophagitis,
stricture, or cancer development

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GE JunctionGE Junction
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Anti Reflux MechanismsAnti Reflux Mechanisms
•Esophageal Sphincter Tone and Length.
•Sling Fibres of the Cardia.
•
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•Esophageal Hiatus Tone.
•Positive Intra Abdominal Pressure.
•Gastroesophageal acute angle of His

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AntirefluxAntireflux BarrierBarrier
• Normally, the lower esophageal sphincter exists as a
zone of high pressure between esophagus and
stomach; when the HPZ is lost, reflux occurs
• Three components of high pressure zoneV
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• Three components of high pressure zone
•Resting pressure if <8mmHg Reflux
•Overall length if < 3cms Occurs
•Intra-abdominal length if < 1cm

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ETIOLOGYETIOLOGY
•Sliding Hiatus Hernia.
•Alteration of Phreno esophageal Ligament.
•Altered Obliquity of GE junction.V
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•Altered Obliquity of GE junction.
•Reduced pinching action of Crus of Diaphragm.
•Reduced LES Pressure.
•Altered Transient Relaxation period in LES

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ETIOLOGYETIOLOGY
•Raised Intra
Abdominal
Pressure.V
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Pressure.
•Raised Intra
Gastric Pressure.
•Gastric Acid
Hypersecretion

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PathophysiologyPathophysiology of GERDof GERD
• Fundic distention (overeating) &
delayed gastric emptying (high fat)
• Lower esophageal sphincter is pulled
distally by expanding fundus
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• Squamous epithelium exposed to
gastric juice
• Repeated exposure columnarization

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PathophysiologyPathophysiology of GERDof GERD
•Extension of inflammation into muscularis propria
causes progressive loss in length and pressure of the
LES— “esophageal shortening”
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• Loss of LES leads to regurgitation, heartburn, and
subsequent severe esophagitis

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PathophysiologyPathophysiology of GERDof GERD
•Spectrum of disease theory:
Nonerosive disease erosive disease Barrett’s
esophageal adenocarcinoma
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esophageal adenocarcinoma

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Clinical presentationClinical presentation
•Heartburn- Pyrosis
•1-2 hours after eating, often at night, antacid relief
•Regurgitation (Waterbrash)V
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•Regurgitation (Waterbrash)
•Spontaneous return of gastric contents proximal to GE
jxn; less well relieved with antacids
•Dysphagia (40%)—difficulty with swallowing
should prompt search for pathologic condition

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Clinical presentationClinical presentation
•Hoarseness of Voice / Dysphonia
•Respiratory Symptoms
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•Cough / Expectoration
•Wheeze / Breathlessness
•Aspiration

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ComplicationsComplications
•Peptic Ulceration
•Hemetemesis
•Stricture Esophagus
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•Barrett’s esophagus
•Adeno Carcinoma esophagus
•Laryngeal Complications
•Respiratory Complications

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InvestigationsInvestigations
•Upper G.I. Endoscopy
•Upper G.I. Contrast StudiesV
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•Upper G.I. Contrast Studies
•Ambulatory pH Monitoring
•Esophageal Manometry

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Upper GI EndoscopyUpper GI Endoscopy
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Upper GI EndoscopyUpper GI Endoscopy
Grade BGrade A
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Grade C&D

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Barrett’s EsophagusBarrett’s Esophagus
•Intestinal / Gastric Columnar
Metaplasia of the Distal
esophagus.
•Diagnosed on Upper G.I.V
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•Diagnosed on Upper G.I.
Endoscopy.
•Pre Malignant condition, leads
to Adeno Carcinoma.
•Multiple Biopsies are required
to exclude Malignancy.

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HiatalHiatal HerniaHernia
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HiatalHiatal HerniaHernia
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Upper GI Contrast StudiesUpper GI Contrast Studies
•Only 40% of patients with classic
symptoms of GERD will have reflux
observed on radiography
•Assess for:V
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•Assess for:
•Esophageal shortening
•Hiatal hernia (80%)
•Paraesophageal hernia
•Stricture or obstructing lesion
•Beading or corkscrewing (motility disorders)

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Upper GI Contrast StudiesUpper GI Contrast Studies
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Ambulatory 24 Hrs pH MonitoringAmbulatory 24 Hrs pH Monitoring
• Rationale: gold standard
for diagnosis of GERD
• Quantifies actual time the
esophageal mucosa isV
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esophageal mucosa is
exposed to gastric juice
• Measures the ability of
the esophagus to clear
refluxed acid

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Ambulatory 24 Hrs pH MonitoringAmbulatory 24 Hrs pH Monitoring
•Correlates esophageal acid exposure with
patients symptoms
•Without abnormal pH study, surgery isV
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•Without abnormal pH study, surgery is
unlikely to benefit
•Gives a composite score (Johnson-
DeMeester score) highly sensitive and
specific (>96%) for diagnosing GERD

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Ambulatory 24 Hrs pH MonitoringAmbulatory 24 Hrs pH Monitoring
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Component Mean Standard
deviation
Normal
value
Total % time pH <4 1.49% 1.38 <4.2%
% time pH < 4 in upright
position
2.33% 1.98 <6.3%
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position
%time pH <4 in lying down
position
0.29% 0.47 <1.2%
Total No of episodes longer
than 5mts
0.6 1.24 </= 3
Duration of longest episode 3.87 min 2.69 <9.2 min
Total No of Episodes 20.6 14.7 <50

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EsophagealEsophageal ManometryManometry
Rules out esophageal
motility disorders
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Esophageal body
dysfunction (achalasia or
aperistalsis) should change
management.

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EsophagealEsophageal ManometryManometry
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ManagementManagement
Treatment Goals for GERDTreatment Goals for GERD
••Eliminate symptomsEliminate symptoms
••HealHeal esophagitisesophagitisV
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••HealHeal esophagitisesophagitis
••Manage or prevent complicationsManage or prevent complications
••Maintain remissionMaintain remission

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ManagementManagement
Lifestyle Modifications are Cornerstone of GERDLifestyle Modifications are Cornerstone of GERD
TherapyTherapy
•• Elevate head of bed 4Elevate head of bed 4--6 inches6 inches
•• Avoid eating within 2Avoid eating within 2--3 hours of bedtime3 hours of bedtime
•• Lose weight if overweightLose weight if overweightV
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•• 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, alcohol,Avoid fatty/fried food, peppermint, chocolate, alcohol,
carbonated beverages, coffee and teacarbonated beverages, coffee and tea
•• OTC medicationsOTC medications prnprn

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ManagementManagement-- MedicalMedical
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ManagementManagement-- SurgicalSurgical
• Need for
continuous drug
treatment or
escalating dose of
PPI
IndicationsIndications
• Factors predictive of successful
outcome following antireflux surgery
(n = 199)
• Abnormal score on 24-hour
esophageal pH monitoring (p <V
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PPI
• Relatively young
• Financial burden or
noncompliance
with PPI
• Patient choice
esophageal pH monitoring (p <
0.001)
• Presence of typical symptoms of
GERD (heartburn and
regurgitation) (p< 0.001)
• Symptomatic improvement in
response to acid suppressive
therapy (p = 0.02)

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ManagementManagement-- SurgicalSurgical
Principles of surgery
•Establish effective LES pressure
•Position the LES within the abdomen
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•Sphincter is under positive (intra-abdominal)
pressure
•Close any associated hiatal defect

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ManagementManagement-- SurgicalSurgical
Key points of surgery
• Complete dissection of esophageal hiatus and both
crura
• Mobilization of the gastric fundus
• Closure of the associated hiatal defectV
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• Closure of the associated hiatal defect
• Creation of a tensionless gastric wrap around
esophagus
• 50- to 60-French intraesophageal dilator
• Limiting the length of the wrap to 1.5 to 2.0 cm
• Stabilizing the wrap

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ManagementManagement-- SurgicalSurgical
Lap Nissen’s Fundoplication
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ManagementManagement-- SurgicalSurgical
Lap Nissen’s Fundoplication
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ManagementManagement-- SurgicalSurgical
Lap Nissen’s Fundoplication
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GERDGERD
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GERDGERD-- AlgorithmAlgorithm
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Take Home MessageTake Home Message
PPI’s work to control symptoms and esophagitis, but require life-
long treatment
Successful antireflux surgery is based on abnormal 24-hr pH
score, typical GERD symptoms, and symptomatic improvement inV
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score, typical GERD symptoms, and symptomatic improvement in
response to acid –suppression therapy
Having antireflux surgery is a patient-centered decision with a
risk:benefit ratio that can really only be weighed by the patient

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