1. Gastroesophageal reflux disease A minor nuisance
Dr. Khurram Waqas Anwer
Senior Registrar, SU-II
Benazir Bhutto Hospital

2. Or is it???????????

4. Chinese water torture method
"Victims were strapped down so that they could not move, and cold or warm water was then dripped slowly on to a small area of the body; usually the forehead. The forehead was found to be the most suitable point for this form of torture because of its sensitivity: prisoners could see each drop coming, and after long durations were gradually driven frantic as a perceived hollow would form in the center of the forehead."

5. Physiological reflux vs pathological
Physiological reflux occurs during post-parandial transient lower esophageal sphincter relaxation (TLOSR)
Where as
It is deemed pathological in its severe form, where LOS pressure tends to be low, worsened if there is inadequate length of intra- abdominal esophagus.

6. Sliding hiatus hernia
Sliding hiatus hernia is associated with GERD and may make it worse,
HOWEVER
As long as LOS is functional , GERD does not occur.
So a patient with hiatus hernia may or may not have GERD, similarly a patient with GERD may or may not have a hiatus hernia.

7. How a sliding hiatus becomes the culprit
Decreased intra-abdominal esophagus length
Weak phrenoesophageal ligaments
Widening of crural opening
Sliding hiatus hernia

8. symptoms
Classical triad: retrosternal burning, epigastric pain, regurgitation. (a patient may not present with all three)
Symptoms often worsened with spicy or fatty foods.
Unpleasant taste in mouth due to acidic content refluxed in mouth.
Odynophagia and/or chest pain with hot beverages or citrus drinks.
Other like: nocturnal reflux, pulmonary symptoms, recurrent sore throat and even change in voice. etc

9. So how or when to investigate?????
Since antacids and other remedies are so commonly available, patients unlikely to present unless the symptoms are causing significant distress.
The diagnosis is mostly assumed rather than proven.
Empirical therapy is the rule…………..
unless:
1) diagnosis is in doubt. 2) failure of PPI therapy 3) atypical symptoms.

10. So when a patient comes to the OPD……..
If symptoms are typical and minor in nature:
Life style modifications like planning meal timing, cessation of foods like chocolate/ coffee/ fatty foods, sleeping at an inclined, cessation of smoking etc.
Start PPIs for a period of 8 weeks reassess if symptoms have improved  step down therapy (lower dose/ shift to H2 blocker/ complete sessation)
For those who do not respond, increase dose or add an H2 agonist, reassess. If failure investigate

11. The irony….
Since over the counter medication and PPIs are so effective, a lot of patients do not bother to make the needed life style changes.
hence they remain dependent on medication to keep their symptoms in check.

12. Investigation algorithm….
symptoms
Atypical
Investigate and manage accordingly
Typical
Empirical PPI therapy for 8 weeks
Responding
Step down therapy
Not responding
Increase dose and reassess after 8 weeks
investiga

13. If a decision to investigate is taken……
The investigations to offer are:
Endoscopy with biopsy.
24 hour pH monitoring.
Manometery.

14. Endoscopy and biopsy
This should be the first investigation performed as it gives information about the anatomy and may be indicative of an underlying malignancy.
It is pertinent to note however that there is a poor co-relation between endoscopic findings and severity of patient symptoms.
If findings are in disproportion to the severity, 24 hour ph monitoring should be offered.

15. Sliding hiatus hernia

16. 24hour pH monitoring
PPIs should be stopped at least 1 week and preferably 2 weeks prior to the date of the test.
On day of the test:
A small pH probe is passed into the distal esophagus and positioned 5cm above the upper margin of the LOS, as defined by manometery.
The probe is connected to a miniature digital recorder that is worn by the patient.
The patient marks symptomatic events like heart burn on a daily as he continues with his daily routine.
After a period of 24 hours the recorder is retrieved and the results interpreted in light of patient observations.

18. Cont…… Interpretation of results:
An esophageal pH of less than 4 at the level of the electrode is taken as the cut-off value.
Duration of pH of less than 4 in a 24-hour should not exceed 4 percent of time in a healthy adult.
The results can then be interpreted to grade the severity by various scoring systems like the “ Johnson-DeMeester” scoring system.

20. manometery
In a patient of GERD, manometery plays a role as in early cases of “cardiac achalasia” the only presenting symptoms may be retrosternal pain.
However
The pH trace of achalasia is different. pH study may be abnormal due to fermentation of food residue in the esophagus but in achalasia there are slow undulations of pH rather than rapid bursts as seen in reflux.
Complete absence of peristalsis on manometery is pathognomic of achalasia.

22. Barium swallow
Some surgeons may advocate a barium study before embarking on surgery.
It can help confirm presence of a hiatus hernia, and the type of hernia.

24. Barium studies in a patient of hiatus hernia
Sliding hiatus hernia
Para-esophageal

25. What if we don’t intervene?
If GERD is left untreated for a considerable period of time, the patient may develop:
Stricture: commonly encountered immediately above the gastroesophagel junction. Respond well to dilatation and PPIs.
Barrett’s esophagus. Runs a risk of undergoing malignant change.

26. Surgical intervention
Endoscopic interventions.
Open or MIS interventions.

27. Endoscopic interventions
A number of endoscopic interventions like endoscopic suturing to plicate the gastric mucosa, radiofrequency ablation and injection of submucosal polymers into lower esophagus have been attempted.
However
All procedures have failure rate in excess of 50% by one years time and hence are to be avoided.

28. Patient selection for surgery
The largest indication for surgical intervention in a patient of GERD is that the patient demands it.
Before commiting to surgery, a detailed discussion with the patient should be conducted and the patient counseled about the realistic outcomes expected after surgery and the possible complications that might occur.

29. Some indications for surgery
Volume reflux. (good indication)
Hermit life style. (good indication)
Intolerance to minor symptoms. (poor indication)
Poor compliance to medication. (good indication)
Misdiagnosis of GERD.

30. Few surgical risks are:
Small risk of mortality (0.1 – 0.5%)
Failed operation (5 – 10%)
Side effects like dysphagia, gas bloat or abdominal discomfort (10%)
With current operative techniques, 85-95% of patients should be satisfied with the results of surgery.

31. surgery
There are several options for surgery and virtually all procedures are based on:
Creation of an intra-abdominal segment of oesophagus.
Crural repair.
A wrap of one sort or the other, of the upper stomach around the intra-abdominal part of the esophagus.

32. The surgery entails freeing of the upper stomach from its omental attachments.
If a sliding hernia is present then it is sac is dissected out of the herniating cavity and the crura repaired with sutures.
The crural repair may be re-enforced using a mesh.

33. Crural repair
Without mesh
With mesh

34. Types of fundoplication

35. Hill procedure
Besley Mark IV