? Defined as troublesome symptoms or complications that result from
the reflux of gastric contents into the esophagus or beyond into the
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oral cavity or lung.
? Troublesome is defined by consensus as
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? mild symptoms that occur at least 2 times per week or? moderate to severe symptoms at least once per week.
? The pathogenesis is multifactorial.
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GERD...? Caused by abnormal function of the lower esophageal sphincter .
? The most frequent abnormality is
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? an increase in transient lower esophageal sphincter relaxations (TLESR),
without an antecedent swallow that results in reflux of gastric contents into
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the esophagus.? The LES can be identified with esophageal manometry.
LES - made up of four anatomic structures:
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1. The intrinsic musculature of the distal esophagus
? Is in a state of tonic contraction.
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? Within 500 milliseconds of the initiation of a swallow, these muscle fibersrelax to allow passage of liquid or food into the stomach, and then they
return to a state of tonic contraction.
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LES...2. Sling fibers of the gastric
cardia
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? are oriented diagonally from the
cardia-fundus junction to the
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lesser curve of the stomach.? the sling fibers contribute
significantly to the high-pressure
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zone of the LES.
LES....
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3. The crura of the diaphragm? surround the esophagus as it passes through the esophageal hiatus.
? During inspiration, when intrathoracic pressure decreases relative to intra-
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abdominal pressure,
? the anteroposterior diameter of the crural opening is decreased,
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? compressing the esophagus and increasing the measured pressure at the LES.LES...
4. Gastroesophageal junction
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? is firmly anchored in the abdominal cavity,? increased intra-abdominal pressure is transmitted to the GEJ, which increases
the pressure on the distal esophagus
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? prevents spontaneous reflux of gastric contents.
? Gastroesophageal reflux (GER) occurs when intra-gastric pressure is
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greater than the high-pressure zone of the distal esophagus.? Conditions:
1. LES resting pressure is too low (i.e., hypotensive LES)
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2. LES relaxes in the absence of peristaltic contraction of the esophagus (i.e.,
spontaneous LES relaxation).
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? Hypotensive LES is frequently associated with hiatal hernia because ofdisplacement of the GEJ into the posterior mediastinum.
Hiatal hernias ?
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Four types (I to IV).1. Type I hiatal hernia-
? also called a sliding hiatal hernia,
? most common type.
? GEJ migrates cephalad into the
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posterior mediastinum.
? This occurs because of laxity of
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thephreno-esophageal
membrane.
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Hiatal hernia...
? Type II is known as a rolling hernia.
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? A type I hernia occurs when the GEJis anchored in the abdomen, and the
gastric fundus migrates into the
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mediastinum through the hiatal defect.
? Hiatal hernia types I to IV, also
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referred to as PEH,? are frequently associated with
gastroesophageal
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obstructive
symptoms
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? (e.g., dysphagia, early satiety, andepigastric pain).
Hiatal hernia...
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? Type I I is referred to as a mixedhernia.
? Characterized by both the GEJ
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and fundus located in the
mediastinum.
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type IV hiatal hernia? occurs when any visceral structure (e.g., colon, spleen, pancreas, or
small bowel) migrates cephalad to the esophageal hiatus and is
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located in the mediastinum.
Symptoms ..
Mechanism of extra-esophageal symptoms of
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GERD1. Proximal esophageal reflux and micro-aspiration of gastroduodenal
contents cause direct caustic injury to the larynx and lower
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respiratory tract; this is the most common mechanism.2. Distal esophageal acid exposure triggers a vagal nerve reflex that
results in bronchospasm and cough. This mechanism is due to the
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common vagal innervation of the trachea and esophagus.
Preoperative diagnostic evaluation
? Four diagnostic tests are useful to establish the diagnosis of GERD and
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to identify abnormalities in gastroesophageal anatomy and function.
1. Ambulatory pH and Impedance Monitoring
2. Esophageal Manometry
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3. Esophagogastroduodenoscopy4. Barium Esophagram
1. Ambulatory pH and Impedance Monitoring
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? Ambulatory pH monitoring quantifies distal esophageal acidexposure and is the "gold standard" test to diagnose GERD.
? A 24-hour pH monitoring is conducted with a thin catheter that is
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passed into the esophagus .
? Catheter has a dual-probe pH catheter, which contains two solid-state
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electrodes that are spaced 10 cm apart and detect fluctuations in pHbetween 2 and 7.
? distal electrode must be placed 5 cm proximal to the LES;
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? the location of the LES is identified on esophageal manometryImpedance Monitoring....
? Esophageal impedance monitoring identifies episodes of nonacid reflux.
? Similar to 24-hour pH monitoring, esophageal impedance is performed
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with a thin, flexible catheter placed into the esophagus.
? Impedance catheters use electrodes placed at 1-cm intervals to detect
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changes in the resistance to flow of an electrical current (i.e., impedance).? Impedance increases in the presence of air and decreases in the presence
of a liquid bolus.
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? Therefore, this technology can detect both gas and liquid movement in the
esophagus.
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? Combined impedance-pH monitoring has beenshown to identify reflux episodes with greater
sensitivity than pH testing alone
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2. Esophageal Manometry? Esophageal manometry is the most effective way to assess function
of the esophageal body and the LES.
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? High-resolution esophageal manometry gathers data using a 32-
channel flexible catheter with pressure sensing devices arranged at 1-
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cm intervals.? Study is conducted in approximately 15 minutes, during which time
the patient performs 10 swallows.
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? Esophageal manometry can exclude achalasia and identify patients
with ineffective esophageal body peristalsis.
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time is on the x-axis,esophageal length is on the y-axis,
and pressure is represented by a color scale
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? Esophageal manometry also measures the? LES resting pressure and
? assesses the LES for appropriate relaxation with deglutition.
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? Because the LES is the major barrier to GER, a defective LES is
common in patients with GERD.
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3. Esophagogastroduodenoscopy? The esophagus should be examined for evidence of mucosal injury
due to GER, including
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? ulcerations, peptic strictures, and Barrett esophagus.
? Both peptic strictures and esophagitis can be considered
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pathognomonic for GERD.4. Barium Esophagram
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? Provides a detailed anatomicevaluation of the esophagus and
stomach that is useful during
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preoperative evaluation of patients
with GERD.
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? The presence, size, and anatomiccharacteristics of a hiatal hernia or
PEH can be evaluated.
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? Other condition that can be
identified- esophageal diverticula,
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tumors,peptic
strictures,
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achalasia,
dysmotility,
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andgastroparesis.
Additional preoperative evaluation
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1. Dysphagia
? In patients with GERD, the most common cause of dysphagia is a
reflux-associated inflammatory process of the esophageal wall.
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? This inflammation can be manifested as a Schatzki ring, a diffuse
distal esophageal inflammation, or a peptic stricture.
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? peptic strictures are pathognomonic for long-standing reflux anddevelop from the chronic mucosal inflammation that occurs with
GERD.
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? When strictures result in significant dysphagia, patients can
experience weight loss and protein-calorie malnutrition.
Obesity
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? is a significant risk factor for the development of GERD.
? Compared with patients of normal weight, obese patients have
? increased intra-abdominal pressure,
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? decreased LES pressure, and
? more frequent transient LES relaxations.
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Barrett Esophagus? Based on endoscopic measurements, it can be classified into
1. long segment (3 cm) and
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2. short segment (<3 cm).
? If Barrett esophagus is suspected on the basis of endoscopic
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appearance of the esophageal mucosa, multiple biopsy specimensshould be taken to histologically establish the diagnosis and to
determine the presence of dysplasia.
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? When dysplasia is present, there is an increased risk for development
of adenocarcinoma.
Treatment of Gastroesophageal Reflux Disease
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? Medical Management :
? For patients who present with typical symptoms of GERD, an 8-week
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course of PPI therapy is recommendedSurgical Management
? For patients who exhibit
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? elevated distal esophageal acid exposure and
? persistent typical GERD symptoms despite maximal medical therapy,
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? antireflux surgery should be strongly considered.? Antireflux operations include
? partial posterior (180- and 270-degree)- Toupet fundoplication
? partial anterior (90- and 180-degree)- Dor fundoplication
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? 360-degree esophagogastric fundoplications- Nissen fundoplication.Failed Antireflux Surgery
? The most common symptoms of failed LARS are
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? typical symptoms of GERD (i.e., heartburn, regurgitation, and water brashsensation) and dysphagia.
? All patients who present with recurrent or persistent symptoms of
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GERD should be evaluated with esophageal manometry and
ambulatory pH study.
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? If the pH study demonstrates elevated distal esophageal acidexposure,
? an esophagram and
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? upper endoscopy should be performed.
Failed Antireflux Surgery....
? Once the diagnosis of persistent or recurrent GERD is made, PPI
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therapy should be instituted.
? Most of these patients experience resolution of their symptoms with
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resumption of PPI therapy.? If failure of medical therapy,
? reoperation should be performed.
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