DefinitionAny symptoms or esophageal mucosaldamage that results from reflux of gastricacid into the esophagus.Classic GERD symptoms Heartburn (pyrosis): substernal burning discomfort After eating (postprandial) Aggravated by change in position Prompt relief by antacids Regurgitation (water brash): bitter, acidic fluid in themouth when lying down or bending over
WARNING!Reflux symptoms are almost neverassociated with shortness of breath, difficultybreathing, feeling like you’re going to passout, or a feeling of impending doom.“Better to be in the emergency room and feelsilly than at home and feel dead”
Work UpTraditional symptoms No further work up Treat empiricallySymptoms associated with complications Barium swallow EndoscopyPrior to surgical intervention Ambulatory pH monitoring Esophageal manometryH2 BlockersPepcidZantacPPIProtonixPrevacidNexium
ENTHoarsenessLaryngitisPharyngitisChronic coughGlobus sensationDysphoniaSinusitisSubglottic stenosisLaryngeal cancerPulmonaryAsthmaAspiration pneumoniaChronic bronchitisPulmonary fibrosisOtherChest painDental erosionExtraesophagealManifestationsVaezi et al. Clin Gastro Hep 2003;1:333-344.
TreatmentLifestyle Modifications Elevate head of bed 4-6 inches Avoid eating within 2-3 hours of bedtime Lose weight if overweight Stop smoking Modify diet Eat more frequent but smaller meals Avoid fatty/fried food, peppermint, chocolate, alcohol,carbonated beverages, coffee and teaOTC medications as neededPrescription medications
Barrett’s EsophagusMetaplasia – One kind of fully differentiatedcell replaces another kind of fullydifferentiated cell Usually squamous epithelium replaces a columnarepitheliumIntestinal, columnar epithelium replaces thestratified squamous epithelium at the distalesophagus More resistant to injury More susceptible to developing carcinoma 40 Fold increase in risk
Barrett’s HistologyBenign glands inthe lower rightBarretts columnarcell metaplasia witha large goblet cellcontaining bluemucin in the lowercenterAdenocarcinomaon the left
Endoscopic Views of Barrett’sSalmon Colored Lesion
ControversyAnti-reflux Surgery in Barrett’s Proponents Regression of metaplasia in 57% of Patients Controls symptoms without medications Opponents Screening becomes more difficult 20% failure rate at 5 years in controlling symptoms
When is surgery an option?Intractable GERD Difficult to manage strictures Severe bleeding from esophagitis Non-healing ulcersGERD requiring long-term PPI (10 years) Healthy young patient “…operative therapy is considered an alternative tomedical therapy rather than a treatment of lastresort.” – Sabiston’s 18th EditionPersistent regurgitation/aspiration symptomsNot Barrett’s esophagus aloneWARNING: Bewarethe patient that does notrespond to PPItreatment!
DeMeester ScoreMeasure of lower esophageal acidity A score of >14.72 shows significant reflux.Scored in comparison to mean values Supine reflux Upright reflux Total reflux Number of episodes Number of episodes longer than 5 min Longest episodeAm J Gastroenterol. 1974 Oct;62(4):325-32.
Complications of SurgeryCollapsed lung 3%Difficulty swallowing(Dysphagia) 30% Post-op 2% after 2 monthsDeath 0.5% 8.3% for patients over age 80Failures 5%GI Motility online (May 2006) | doi:10.1038/gimo56Mechanisms of fundoplication failure.
Cancer of the EsophagusCan it lead to anything bad?
EpidemiologyAdenocarcinoma of esophagus has the fastestgrowing incidence rate of all cancers in the U.S. 17,460 new cases per year 15,070 deathsDrastic shift in epidemiology Prior to 1970 90-95% of all esophageal cancer was squamous cellcarcinoma Thoracic esophagus in African American males whosmoke & drank EtOH Currently Adenocarcinoma of the distal esophagus& GE junction accounts for nearly 70%86% mortality rateOverall 5 yearsurvival rate was16.9%
SymptomsDysphagia Solid food first 2/3 of the lumen may be obstructed beforeany symptoms are noted On average 24mm esophagus will narrow toless than 12mm before dysphagia is noticedWeight Loss
Squamous Cell Carcinoma of theEsophagusUpper and middle 2/3 of the esophagusSmoking and alcohol Both increase risk 5 fold Together the risk increases to 25 foldNitrosamines Food additive to pickled & smoked foodsLong term ingestion of hot liquids
Adenocarcinoma of the EsophagusDistal 1/3 of the esophagusGERDWestern diet Caffeine, fats, acidic, & spicy food alldecrease LES tone