GASTROESOPHAGEAL REFLUX DISEASE

American College of Gastroenterology (ACG) guidelines defines GASTROESOPHAGEAL REFLUX DISEASE (GERD) as “TROUBLESOME symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung.”

PHENOTYPIC PRESENTATIONS OF GERD Erosive esophagitis (EE), Non erosive reflux disease (NERD) and Barrett’s esophagus

GERD encompasses esophageal and extra-esophageal syndromes otitis media chronic coughing, asthma, laryngitis reflux of gastric juice into the respiratory tract syndromes with esophageal injury reflux chest pain syndrome typical reflux syndrome

Alarm features for GERD Persistent vomiting Odynophagia Unexplained weight loss New onset dyspepsia in patient ≥60 years gastrointestinal bleeding Iron deficiency anemia

DIAGNOSIS

UPPER GASTROINTESTINAL ENDOSCOPY Principal test Main use=====evaluation of treatment failures and risk management. Typical esophagitis GERD highly specific (90%–95%) for GERD, but low sensitivity

Manometry ---NOT TO CONFIRM GERD BUT RULE OUT FUNCTIONAL DYSPHAGIA Persistent reflux symptoms despite PPI therapy and====== MANOMETRY Normal findings on endoscopy ====================

24-hour pH test Acid reflux episodes === pH fall <4. Overall DeMeester score, should not exceed 14.7 in normal subjects. Both catheter and wireless pH monitoring allow quantification of esophageal acid exposure and assessment of the temporal relationship between symptoms and acid reflux events

ESOPHAGEAL IMPEDANCE-PH MONITORING ---FAILED PPI TWICE DAILY Multichannel intraluminal impedance monitoring with pH sensor Several channels, detects the direction of bolus movement ANTEROGRADE SWALLOWS RETROGRADE EVENTS

management

LIFE STYLE MODIFICATIONS MEDICAL MANAGEMENT SURGICAL MANAGEMENT

LIFE STYLE MODIFICATIONS

MEDICAL MANAGEMENT Antacids Histamine-2 (H2)-receptor antagonists, approximately 75% effective Proton pump inhibitors (PPIs) PPIs have superior healing rates and decreased relapse rates

WHY SURGERY WHEN PPI SO GOOD??? Atrophic gastritis and/or hypergastrinemia induced carcinoid tumors due to hypochlorhydria. Increased risk of Clostridium difficile colitis and bacterial gastroenteritis

Refractory Esophagitis SURGICAL REFERRAL Refractory Esophagitis Non compliance Desire to discontinue medical therapy large hiatal hernia Side effects of medical therapy

ANTIREFLUX SURGERY- NISSEN’S FUNDOPLICATION The choice to consider anti-reflux surgery must be individualized. Patients should have documented acid reflux----- p H monitoring a defective anti-reflux barrier in the absence of poor gastric emptying, normal esophagus motility …NORMAL MANOMETRY at least a partial response to acid reduction therapy EFFECTIVE for heartburn and regurgitation (75-90%) and less effective for extraesophageal symptoms (50-75%).

Tennets of Surgery reduction of the hiatal hernia, repair of the diaphragmatic hiatus, strengthening the attachment between the gastroesophageal junction and the posterior diaphragm, strengthening the anti-reflux barrier by adding a gastric wrap around the gastroesophageal junction (fundoplication)

COMPLICATIONS: After total fundic wrap several adverse consequences may occur; persistent dysphagia, inability to belch and vomit, epigastric fullness, bloating and pain postprandially, temporary swallowing discomfort, and sometimes intense flatus

PARTIAL FUNDOPLICATION Toupet fundoplication only encircles half of the esophageal circumference. The preferred and most efficient modification of the Nissen fundoplication is the short “floppy” Nissen fundoplication, which has been shown to have success rates of up to 90% with minimal morbidity and mortality.

LINX Reflux system---NEWER SURGICAL OPTION – Made of titanium beads with magnetic link – Performance of Linx resulted in consistent symptom relief and pH control with markedly fewer side effects – Not for patients with large hiatal hernia or abnormal peristalsis

Endoluminal Surgery Endoluminal gastroplication (ELGP) -----first of the proposed endoscopic treatments for GERD. EndoCinch Plicator device Enteryx Injection…polymerize into spongy material when injected submucosally

Submucosal Enteryx Injection

EsophyxXTM device A more practical technique, the novel endoluminal fundoplication (ELF) technique overcome some of the Plicator's disadvantages, inability to reduce hiatal hernia and create a robust gastroesophageal valve

Medical versus Surgical Treatment for GERD MANY TRIALS favor laparoscopic antireflux surgery compared to long-term PPI therapy RCT: from UK ------better physiological control of reflux in patients having undergone laparoscopic Nissen fundoplication than patients under PPI therapy ….follow up of 12 months A prospective study on laparoscopic Nissen fundoplication from J. Hunter's group from Atlanta with an 11-year mean follow up, significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications by 70% of patients.

CONSIDER SURGERY IN LONG TERM CAREFULLY SELECTED PATIENTS

THE TWO SIDES OF THE SAME COIN Conclusions GERD results from TLESRs and hiatal hernia. DIAGNOSIS , PPI test 24-hour pH test alone or in combination with impedance. PPIs the best therapeutic option Choosing the right candidates for surgery still remains a problem and SHOULD BE INDIVIDUALIZED Medical and surgical therapies for the GERD are not competing or they are not even complementary. THE TWO SIDES OF THE SAME COIN

IMPROPER PATIENT SELECTION FOR SURGERY MAY END UP IN DISASTER TAKE HOME MESSAGE RIGHTLY AND TIMELY REFERRAL TO SURGERY CAN PREVENT MISERY OF THE PATIENT IMPROPER PATIENT SELECTION FOR SURGERY MAY END UP IN DISASTER