1. Gastro Oesophageo Reflux Disease (GORD) JMJ1

2. Contents Pathophysiology Oesophageo mucosal defense mechanisms Clinical features Diagnosis and investigations Treatment Complications JMJ2

3. Pathophysiology Between swallows, Muscles of oesophagus are relaxed, Except for those of sphincters. LOS remains closed usually Muscles of LOS get relaxed when swallowing is initiated Transient lower oesophageal sphincter relaxations (TLESRs) Part of normal physiology But occurs more frequently in GORD patients Little amount of reflux is normal Sphincter pressure also increases in response to Rises in intra abdominal and intragastric pressures. JMJ3

4. The main anti reflux mechanisms JMJ4

5. Other anti reflux mechanisms Intra abdominal segment of oesophagus Acts as a flap valve Mucosal rosette formed by folds of gastric mucosa & the contraction of the crural diaphragm at the LOS Acting like a pinchcock, Prevents acid reflux Large hiatus hernia can impair this mechanism Oesophagus is rapidly cleared normally or refluxate By secondary peristalsis By gravity By salivary bicarbonate JMJ5

6. Factors associated with gastro oesophageal reflux Pregnancy and obesity Fat, chocolate, coffee or alcohol ingestion Large meals Cigarette smoking Drugs Antimuscuranics Calcium- channel blokers Nitrates Systemic sclerosis After treatment of achalasia Hiatus hernia JMJ6

7. Factors associated with gastro oesophageal reflux Pregnancy and obesity Fat, chocolate, coffee or alcohol ingestion Large meals Cigarette smoking Drugs Antimuscuranics Calcium- channel blokers Nitrates Systemic sclerosis After treatment of achalasia Hiatus hernia JMJ7

8. Osophageal mucosal defense mechanisms Surface Mucus and the unstirred water layer trap bicarbonate This is a weak buffering mechanism, compared to that in the stomach and duodenum Epithelium Apical cell membrane and junctional complexes between cells act to limit diffusion of H + into the cells. In oesophagitis – junctional complexes are damaged. JMJ8

9. Osophageal mucosal defense mechanisms Postepithelium Bicarbonate normally buffers acid, in the cells and intracellular spaces Hydrogen ions impair the growth and replication of damaged cells Sensory Mechanisms Acid stimulates primary sensory neurons in the oesophagus by activating the VANILOID RECEPTOR 1 (VR1) This can initiate inflammation and release pro-inflammatory substances from the tissue to produce pain Pain can also be due to - contraction of longitudinal oesophageal muscle JMJ9

10. Clinical fetures Clinical Features HeartburnRegurgitation JMJ10

11. Heartburn Is the major feature Aggravated by Bending Stooping Lying down Relieved by Oral antacids Patient complains pain on drinking Hot liquids Alcohol JMJ11 Which promotes acid exposure

12. Heartburn Correlation between heartburn and esophagitis is poor Differentiation of cardiac and oesophageal pain can be difficult In addition to the clinical features, a trial of PPI is always worthwhile and if symptoms persist, ambulatory pH and impedance monitoring should be performed JMJ12

13. Regurgitation of food and acid Particularly on bending or lying flat Aspiration pneumonia is unusual without an accompanying stricture But cough and asthma can occur & respond slowly (1-4 months to a PPI JMJ13

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15. Hiatus Hernia Sliding Hiatus Hernia Rolling or para- oesophageal hernia JMJ15

16. Sliding hiatus hernia JMJ16 Oesophageal-gastro junction and part of stomach ‘slides’ through the hiatus That it lies above the diaphragm Present in 30% of people over 50 years Produces no symptoms Any symptoms are due to reflux

17. Rolling or para-oesophageal hernia JMJ17 Part of the fundus of the stomach, Prolapses through the hiatus, Alongside the oesophagus LOS remains below the diaphragm & remains competent Occasionally severe pain occurs due to volvulus or strangulation

18. Rolling or para-oesophageal hernia JMJ18

19. Features of pain in GORD and Cardiac ischemia GORD Burning, worse on bending, stooping or lying down Seldom radiates to the arms Worse with hot drinks or alcohol Relieved by antacids Cardiac ischemia Gripping or crushing Radiates to neck or left arm Worse with exercise Accompanied by dyspnea JMJ19

20. Diagnosis and Investigations JMJ20 Clinical diagnosis can be made Unless there are alarm signs, (esp.dysphagia), Patients under 45 years, Can safely be treated initially without investigations Investigations Assess oesophagitis & hiatus hernia by endoscopy Document reflux by intraluminal monitoring

21. Intraluminal Monitoring JMJ21 24 hour luminal Ph monitoring or, Impedance combined with manometry is helpful if there is no response to PPI & should always be performed to confirm reflux before surgery Excessive reflux pH 4% of the time

22. Treatment JMJ22 Loss of weight Raising head end of the bed at night Precipitating factors should be avoided, With dietary measures Reduction in alcohol and caffeine consumption & Cessation of smoking

23. Treatment JMJ23 Treatment Life style modifications Drugs Endolunimal gastroplication Surgery

24. Treatment JMJ24 Drugs Alginate- containing antacids Dopamine antagonist prokinetic agents H2- receptor antagonists Proton pump inhibitors

25. Alginate-containing antacids JMJ25 10 ml tds ‘over the counter’ agents for GORD They form a gel or ‘foam raft’ with gastric contents to reduce reflux Magnesium containing antacids Tends to cause diarrhea Aluminum containing compounds Cause constipation

26. Dopamine antagonist prokinetic agents JMJ26 Metoclopramide and domepridone Enhances peristalsis & Speed gastric emptying

27. H 2 - receptor antagonists JMJ27 Cimetidine Ranitidine Famotidine Nizatidine Acid suppressors If antacids fail They can be often obtained over the counter

28. Proton Pump Inhibitors JMJ28 Omeprazole Rabeprazole Lansoprazole Pantoprazole Esomeprazole Inhibit gastric hydrogen/potassium- APTase Reduce gastric acid secretion by 90% DOC for all mild cases Most respond well 20-30% will persist with heartburns Severe symptoms – bd dosing & prolonged Tx

29. Endo luminal gastroplication JMJ29 In this endoscopic procedure, multiple plications or pleates are made below the gastro-oesophageal junction.

30. Surgery JMJ30 Never be performed to hiatus hernia alone Best predictor Typical reflux symptoms with documented acid reflux Current surgical techniques – Return the oesophageal junction to the abdominal cavity Mobilize the gastric fundus Close the diaphragmatic crura snugly Involve a short tension-free fundoplication

31. Surgery JMJ31 Indications for operation Not clear Intolerance to medication Desire for freedom from medications Expense of therapy Concern of long-term side effects Patients with oesophageal dysmotility unrelated to acid reflux, patients with no response to PPIs and those with undelying functional bowel disease should NOT have surgery

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33. JMJ33 Complications Peptic stricture Barrett’s oesophagus

34. JMJ34 Peptic Stricture Due to usage of PPI – strictures are uncommon in this era Usually occurs in – patients over the age of 60 Present with intermittent dysphagia for solids which worsens gradually over a long period Mild cases May respond to PPI alone Severe cases Need endoscopic dilatation Long term PPI therapy

35. JMJ35 Barrett’s Oesophagus Part of normal oesophageal squamous epithelium is replaced by metaplastic coloumnar mucosa to form a segment of ‘columnar-lined oesophagus’ (CLO) There is almost always a hiatus hernia Diagnosis is made by Endocopy showing proximal displacement of squamo coloumnar mucosal junction Biopsies demonstrating coloumnar lining above the proximal gastric folds Interstinal metaplasia is no longer a requirement – (British Society of Gastroenterology guidelines)

36. JMJ36 Barrett’s Oesophagus

37. JMJ37 Barrett’s Oesophagus

38. JMJ38 Barrett’s Oesophagus

39. JMJ39 Barrett’s Oesophagus Barret’s oesophagus may be seen as Continual circumferential sheet Finger like projections extending upwards from the squamo- coloumnar junction Islands of coloumnar mucosa interspersed in areas of residual squamous mucosa Central obesity increases risk of Barrett’s by 4.3 times Commonest in middle aged obese men 0.12-0.5% - develop oesophageal adenocarcinoma

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