Gastroesophageal Reflux Disease
Prof. Faisal Ghani Siddiqui
FCPS; PGDip-bioethics; MCPS-HPE
faisal@lumhs.edu.pk
www.lumhs.edu.pk/faculties/surgery/gsurgery/faculty
PREAMBLE
• What is GERD?
• LES?
• What causes GERD?
• How does GERD present?
• What are its complications?
INTRODUCTION
What is
GERD?
Condition characterized by
heartburn and regurgitation
due to the
loss of the HPZ
GERD
• Common; Accounts for majority of
esophageal pathologies
• Chronic disease; needs life-long
medical treatment
• Surgery is effective; provides longterm relief
PATHOPHYSIOLOGY
of
gastroesophageal Reflux Disease
•
HPZ located at the EG junction
• No distinct anatomical sphincter
• 3-4 cms long
• 10-25 mmHg
• Relaxes during swallowing / belching
Resting LES
pressure
Overall length
of the sphincter
Intraabdominal
length of the
sphincter
Resting LES
pressure
Overall length
of the sphincter
Intraabdominal
length of the
sphincter
LARGE MEALS
REPEATED STOMACH DISTENSION
SHORTENING OF LES
INCOMPETENT SPHINCTER
REFLUX
Resting LES
pressure
Overall length
of the sphincter
Intraabdominal
length of the
sphincter
Permanently
Defective LES
• Mean resting pressure < 6mm
• Overall length < 2cm
• Intra-abdominal length < 1 cm
ACID / PEPSIN
/DUODENAL CONTENTS
EXPOSURE
ESOPHAGITIS
BE
STRICTURE
SYMPTOMS
of
Gastroesophageal Reflux Disease
• Heartburn
• Regurgitation
• Dysphagia
• Chest pain
COMPLICATIONS
of
Gastroesophageal Reflux Disease
REPEATITIVE
ESOPHAGEAL
INJURY
MUCOSAL &
INTRAMURAL
FIBROSIS
STRICTURE
REPLACEMENT OF
SQ. EPITHELIUM
WITH COLUMNER
EPITHELIUM
BARRETT’S
ESOPHAGUS
Squamous
epithelium
replaced by
columnar
epithelium
Norman Barrett 1950
Barrett’s
Esophagus
Endoscopically identified columnar
mucosa, which on biopsy shows intestinal
mucosa with goblet cells
COMPLICATIONS OF
BARRETT’S
ESOPHAGUS
ULCERATION
STRICTURE
CARCINOMA
DYSPLASIA
METAPLASIA
DYSPLASIA
ADENOCARCINOMA
MANAGEMENT
of
Gastroesophageal Reflux Disease
Management of GERD
CONSERVATIVE
TREATMENT
INVESTIGATIONS
SURGERY
Management of GERD
CONSERVATIVE
TREATMENT
INVESTIGATIONS
SURGERY
CONSERVATIVE
TREATMENT
• Antacids
• Alginic acid
• Metoclopromide / domperidone
• Proton pump inhibitors
• Change in life style
Change in Life-style
• Elevate head of the bed
• Avoid tight fitting clothes
• Eat small, frequent meals
• Avoid eating before bedtime
• Dietary changes
PPI’s
suppress acidity
& relieve symptoms
but do not control reflux
Control of reflux
better than
control of symptoms!
Antireflux surgery
eliminates reflux!
Management of GERD
CONSERVATIVE
TREATMENT
INVESTIGATIONS
SURGERY
INVESTIGATE IF
SYMPTOMS…
• Persist or progress
• Recur
INVESTIGATIONS
• Endoscopy
• 24-hour pH monitoring
• Manometry
Management of GERD
CONSERVATIVE
TREATMENT
INVESTIGATIONS
SURGERY
WHEN TO
OPERATE?
• Persistent or progressive disease
• Young patients with documented reflux
• Stricture
• Barrett’s esophagitis
GOAL OF SURGERY
to
restore normal
structure/pressure of the
LES
while preserving patient’s
ability to swallow, and
to belch
PRINCIPLES
• Restore pressure
(>12 mmHg)
• Restore length
(at least 3 cm)
• Place adequate length in abdomen
(1.5 – 2 cm)
ANTIREFLUX
PROCEDURES
• Nissen fundoplication
• Toupet partial fundoplication
• Belsey Mark IV partial fundoplication
COMPLICATIONS
• Temporary dysphagia
• Inability to vomit
• Increased flatulence