1. Approach to patient with reflux symptoms

2. Clinical Case A 48-year-old man presents for evaluation of burning epigastric and substernal pain that has recurred almost daily for the past 4 months. He says that these symptoms seem to be worse when he lies down and after meals. He denies difficulty swallowing or weight loss. The patient has been taking a proton pump inhibitor (PPI) regularly over the past 12 weeks with partial resolution of his symptoms. His past medical history is significant for frequent early morning wheezing and hoarseness that have been present for the past few months. The patient has no other known medical problems, and he has had no prior surgeries. He consumes alcohol occasionally but does not use tobacco. On examination, he is moderately obese. No abnormalities are identified on the cardiopulmonary or abdominal examination.

3. Esophagus Anatomy  The adult human esophagus is an 18- to 25-cm long muscular tube that composed of striated muscle in the upper part, smooth muscle in the lower part, and a mixture of the two in the middle.  After traversing the diaphragm at the diaphragmatic hiatus (T10 vertebral level) the esophagus extends through the gastroesophageal junction to end at the orifice of the cardia of the stomach (T11 vertebral level).  A normally functioning LES prevents food and stomach acid from backing up into the esophagus and ultimately into the trachea.  LES maintains a higher pressure than that of the stomach so that food and digestive juices cannot wash back into the esophagus.

5. Histology

7. What Is GERD ? A chronic digestive disease. occurs when stomach acid or, occasionally, stomach content, flows back into your food pipe (esophagus). The backwash (reflux) irritates the lining of your esophagus and causes GERD.

8. Gastroesophageal reflux disease (GERD)  In general relieved by medications or in severe cases there is need for surgery. Epidemiology  About 30% of the general population have heartburn  About 44% of the US adult population have heartburn at least once a month  14% of Americans have symptoms weekly.  7% have symptoms daily. Can children get GERD? Yes, in case of neuro-developmental disorders (such as cerebral palsy).

9. Pathphysiology 1 -Decrease LES resting tone: A- Transient LES relaxation B- Atonic LES C- Increase Intra abdominal pressure 2 -Distruption in anatomical barrier ( hiatal hernia ) 3- Delayed gastric emptying ( Gastroparesis) 4 - Decreased esophageal mucosal resistance 5 - Decreased clearance of refluxed materials from esophagus 6 - Pyloric incompetence (Biliary Dudenogastric reflux )

11. Risk Factors

12. Lifestyle Factors Obesity Smoking strenuous activity immediately after eating Lying down, after eating Eating before bedtime wearing tight clothes

13. Visceroptosis or Glénard syndrome Zollinger-Ellison syndrome Scleroderma After treatment for Achalasia Medical Conditions Structural abnormality

14. PregnancyDiabetes Hypercalcaemia Oral contraceptiveAnticholenergics Medications Ca channel blocker

15. Food Chocolate Citrus fruitsCaffeinated product Fried food Spicy food

16. Clinical Features

17. SymptomPrevalenceSimple description Heartburn80%retrosternal burning sensation Regurgitation54%involuntary return of gastric contents into the pharynx without nausea, retching or abdominal contraction Epigastric pain29%sometimes radiating through to the back Dry Cough27% the trachea ('windpipe') and the esophagus form from a common precursor and thus are linked by a common nervous system reflex. thus, irritation in the esophagus due to acid reflux causes a neuronally mediated reflex in the trachea and the end result is a nagging, dry cough. another theory is that very small amounts of refluxed acid are aspirated from the esophagus down the trachea and the direct caustic irritation of this acid fluid causes cough Dysphagia23% usually a sign that a stricture has occurred, but may be caused by an associated motility disorder Hoarseness21%When stomach acid comes up the swallowing tube (esophagus) and irritates the vocal folds

18. When these signs and symptoms occur at least twice each week or interfere with patient daily life, they identify it as GERD SymptomPrevalenceDescription Belching15%When acid moves back up the esophagus from the stomach, as in reflux or heartburn, people often swallow frequently as a way to relieve some of the discomfort and then have to burp,the constant swallowing causes more air to enter the body, which in turn can cause more belching. Aspiration14% LPR (larngeal pharyngeal reflux) - the acid goes into the throat. Wheezing7% airway irritation due to acid reflux Globus sensation4%a subjective feeling of a lump or foreign body in the throat

19. Features of the pain The chest pain of gastroesophageal reflux disease (GERD) can be confused with chest pain from a heart problem. Reflux pain: Burning, worse on bending or lying down Seldom radiates to the arms Worse with hot drinks or alcohol Relieved by antacids Cardiac ischaemic pain: Gripping or crushing Radiates to neck or left arm Worse with exercise Accompanied by SOB

20. Complications

21. Complications of GERD Esophagiatis Barrett’s esophagus Stricture Anemia Gastric volvolus

22. Esophagitis An injury to the mucosa of the oesophagus with subsequent inflammation; which -if severe- may cause fibrosis. Endoscopic grading system for esophagitis Grade 1Reddening of the mucosa without ulceration Grade 2Linear ulcerations lined with granulation tissue that bleeds easily with touch Grade 3Wide ulcerations, with islands of epithelium Grade 4Stricture

23. Barrett’s esophagus It Is an abnormal change (metaplasia) in the cells of the lower portion of the esophygust is characterized by the replacement of the normal stratified Sequamus epithelium lining of the esophagus by simple columnar epithelium with goblet cells (which are usually found lower in the GIT). The junction between sequamous esophageal mucosa and gastric mucosa moves proximally. It increases the risk of adenocarcinoma of the oesophagus which is about 25 times that of the general population.

24.  Clinical Features Almost all have severe symptoms of GERD  Complications Carcinoma Stricture Perforation / Bleeding  TREATMENT Treatment of the underlying GERD Long term PPI alleviate the symptoms Surgery is depends on the grade of dysphasia

25. Barrett’s Esophagus

28. STRICTURE Occurs in late middle aged & elderly but may present in children Repeated injury, the esophagus narrows (stricture) and shortens Strictures are usually associated with - structurally defective sphincter - loss of esophageal motility Evaluation: Rule out malignancy Rule out drug induced strictures Benign reflux induced stricture: Immediately above esophagogastric jnunction 1-2 cm in length Smooth mucosa Absence of esophagitis above a stricture suggests a drug induced injury or a neoplasm as a cause for the stricture

29. Diagnosis  Diagnostic studies are not needed with classic history of GERD : heartburn and regurgitation >>> Start Empiric Therapy. When to Perform Diagnostic Tests ? 1.Middle or late age 2.Uncertain diagnosis 3.Atypical symptoms 4.Symptoms associated with complications 5.Inadequate response to therapy 6.Recurrent symptoms 7.Prior to anti-reflux surgery

30. Investigations Note :diagnosis is assumed rather than proven. Investigations is only required when diagnosis is doubt, when there is no respond to PPI or dysphagia is present (alarm symptoms)

31.  Radiography  Endoscopy  Endosonography (Endoscopic ultrasound)  Esophageal manometry  Ambulatory (24)hour pH recording

32. 1-Radiography  Barium Useful first diagnostic test for patients with dysphagia -stricture(location,length ) -mass - hiatal hernia (size,type) limitations detailed mucosal exam (barretts esophagus,esophagitis )

33. 2- Endoscopy Endoscopy is highly sensitive in identifying cancer, strictures, ulcers and erosions. Endoscopy can also demonstrate the presence of Barrett’s esophagus (where normal epithelium is replaced by columnar metaplasia).  Indications for endoscopy 1-Alarm symptoms: dysphagia(stricyure/ca), odynophagia,(esophagitis) gastrointestinal bleeding +anemia(ca/erosive esophagitis), weight loss, chest pain. 2- Empiric therapy failure 3- Preoperative evaluation 4- Detection of Barrett’s esophagus

34. Esophagitis, Barrett oesophagus, and Strictures.

35. 3- Endosonography (Endoscopic ultrasound)  Endoscopic ultrasonography relies on a high-frequency transducer located at the tip of the endoscope to provide highly detailed images of the layers of the esophageal wall and mediastinal structures close to the esophagus.  Uses : To obtain images of the internal organs in the chest and abdomen To check for any masses

37. 4-Manometry( detect pressure changes and to record information )  1 -Measure the length and pressure of the lower part of the esophagus,  2 -Assess motility in the body of the esophagus during swallowing  3 - Essential for proper placement of pH probe for ambulatory pH monitoring (5cm, above the upper border of the LES )  4 - Diagnose esophageal motility disorders.

38. 5- Ambulatory (24)hour pH recording The Gold standard  Ambulatory esophageal pH monitoring is reserved for the investigation of complicated GERD and provides a quantitative determination of the amount of time the esophageal pH is low, indicating persistent acid presence above the sphincter. Ambulatory pH monitoring is most useful in patients with atypical reflux symptoms establish or exclude GERD in patients with normal mucosa

39. A- Lifestyle Modifications  Lifestyle modification is a cornerstone of GERD Therapy.  Patients should eat frequent small meals during the day.  Avoid fatty food, spicy food, chocolate, alcohol, carbonated beverages, coffee and tea.  The last meal should be at least 2 hours before going to sleep.  Increase the level of the chest and head to be higher than cardiac opening of the stomach. (Elevate head of bed)  No smoking.

40. B- Medical Therapy 1 - Antacids  Mg hydroxide. Mg(OH)2  Aluminum hydroxide. Al(OH)3  Calcium carbonate. CaCO3  Sodium bicarbonate. NaHCO3 2-PPI  Omeprazole  Lansoprazole  Rabeprazole  Esomeprazole  Pantoprazole 3-H2-Receptor Antagonists  Cimetidine  Ranitidine  Famotidine  Nizatidine

41. C- Surgical Therapy Includes: 1-Endoscopic Therapy  Endoscopic plication  Stretta procedure( minimally invasive outpatient procedure)  Enteryx 2-Laparoscopic Fundoplication  Total fundoplication (Nissen)  Partial fundoplication  Posteriorly (Toupet)  Anteriorly (Dor, Watson)

43. Hiatal Hernia

44.  The hiatus is an opening in the diaphragm (the muscular wall separating the chest cavity from the abdomen). Normally, the esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach.

45. The distal esophagus normally is held in position by the phrenoesophageal ligament or membrane, a fusion of the endothoracic and abdominal transversalis fascia at the diaphragmatic hiatus. A hiatal hernia is present when a lax or defective phrenoesophageal ligament allows protrusion of the stomach up through the esophageal hiatus of the diaphragm

47. In individuals with hiatal hernias, the opening of the esophageal hiatus (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest.

48. WHAT ARE THE TYPES OF HIATAL HERNIA? The type of hiatal hernia is defined by the location of the gastroesophageal (GE) junction and the relationshipof the stomach to the distal esophagus.

49. There are four types of hiatal hernia: 1- Type I (sliding or axial hernia). 2- Type II (rolling or paraesophageal hernia). 3- Type III (combined or mixed hernia). 4- Type IV (abdominal organs with or without stomach herniate through hiatus).

50. TYPE I (SLIDING OR AXIAL HERNIA)  most common type and is usually asymptomatic (95% of cases).  Characterized by an upward dislocation of the cardia in the posterior mediastinum.  It is protrusion of the stomach above the diaphragm creates a bell-shaped dilation, bounded below by the diaphragmatic narrowing.

51. TYPE II (ROLLING OR PARAESOPHAGEAL HERNIA)  less common (5%)  Characterized by an upward dislocation of the gastric fundus alongside a normally positioned cardia.  It separates portion of the stomach, usually along the greater curvature, enters the thorax through the widened foramen.

53. TYPE III (COMBINED OR MIXED HERNIA)  Characterized by an upward dislocation of both the cardia and the gastric fundus.  Sometimes the whole stomach migrates up to the chest (intrathoracic stomach).

54. TYPE IV (ABDOMINAL ORGANS WITH OR WITHOUT STOMACH HERNIATE THROUGH HIATUS )  Very large hernia  Contain colon or spleen in addition to the stomach within the chest.

55. Clinical Features  Most patients with sliding hernia are asymptomatic and are diagnosed incidentally, but it can cause:  Reflux; or worsen an existing reflux.  Dysphagia(from inflammatory edema).  Esophagitis.  Pulmonary edema secondary to aspiration.

56.  Sliding hernia may worsen symptoms for several reasons: 1) the hernia acts as a "Fluid trap" for gastric reflux and increases the acid contact time in the esophagus. 2) Longer transient LES relaxation episodes particularly at night.  No relation between the size of the hernia and the severity of symptoms.

57. Predisposing Factors  Obesity  Pregnancy  Ascites  Age >50  Constipation (increased incidence in western countries)  Esophagitis

58. Complications By far, the majority of cases are asymptomatic but in rare cases it may cause:  Esophagitis  Esophageal ulcer  Esophageal stricture  Barrett's esophagus  Esophageal cancer

59. Investigation 1- Chest x-ray 2- Endoscopy 3- Esophageal manometry

60. 1- Chest x-ray  The hernia maybe visible on the a plan of radiograph of the chest as a gas bubble often with fluid level behind the heart ( in posterior mediastinum ).  Deferential Diagnosis : 1- Mediastinal cyst 2- Abscess 3- Dilated obtructed esophagus (achalasia)

61. Barium meal  The best method for diagnosis.  Confirm the diagnosis and defines any coexisting esophageal abnormalities, including strictures or ulcers.  It is a procedure in which radiograph of the esophagus, stomach and duodenum are taken after barium sulfate is ingested by a patient.  The gastrointestinal tract, like other soft-tissue structures, does not show clearly enough for diagnostic purposes on plain radiographs Barium salts are radioopaque: they show clearly on a radiograph.  If barium is swallowed before radiographs are taken, the barium within the esophagus, stomach or duodenum shows the shape of the lumina of these organs.

62. Sliding hernia

63. CT scan  Computed temography (CT) scan may be useful in an urgent situation for patients with suspected complication of volvulized paraesophageal hernia

64. 2-Esophago-gastro- duodenoscopy (EGD)  Barium study obtained prior to EGD is helpful to direct attention to locations of subtle change and alerting to such potential danger spots as esophageal diverticulum, deeply penetrating ulcer and carcinoma.  It is indicated in patients with symptoms of reflux or dysphagia to determine the degree of esophagitis and whether a stricture, Barrett esophagus, or any abnormality.

65. Continue  EGD also establishes the location of the GE junction in relation to the hiatus.  Hiatal hernia is endoscopically confirmed by finding a pouch lined gastric rugal folds lying 2 cm or more above the margins of diaphragmatic crura identified by having the patient sniff.  Paraesophageal hernia is identified on retroversion of the scope by noting a separate orifice adjacent to GE junction.  A sliding hiatal hernia is present when greater than 2 cm of gastric mucosa is present between the diaphragmatic hiatus and the mucosal squamocolumnar junction.

67. 3-Esophageal manometry  To evaluate esophageal motility is warranted in patients who are being considered for operative repair.  Done by placing a catheter into the nose and guiding it into the stomach. Once placed, the catheter is slowly withdrawn, allowing it to detect pressure changes and to record data for later review.

68. Management  Asymptomatic sliding hernia requir no treatment ( 1% risk).  Symptomatic sliding hernia nearly always require surgical repair as they are potentially dangerous.  Patients who present as an emergency with acute chest pain maybe treated by NG tube to relieve the distention that cause the pain, followed by operative repair.

69.  If the pain is not relieved or perforation is suspected immediate operation is mandatory.  All patients who are found to have a type II, III, or IV hiatal hernia and who are operative candidates should be considered for repair.  The management of asymptomatic paraesophageal hernias is a controversial issue. > Some surgeons believe that all paraesophageal hernias should be corrected electively, irrespective of symptoms, to prevent the development of complications. However, recent data suggest that observation of the asymptomatic patient, especially for those older than 65 years, may be the safest course.

70.  Modification of life style : 1- Lose weight 2- Avoid anything that causes pressure on your stomach 3- Stop smoking and cut down on alcohol  Elective surgery involve : 1- Reduction of the hernia 2- Excision of the sac 3- Reduction of the crural defect and some form of retention the stomach in the abdomen 4- Perform fundoplication

71. Fundoplication  The gastric fundus is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter.  The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.

72. Thank you