Gastro-Esophageal Reflux Disease (GERD)

>>Gastro-Esophageal Reflux Disease (GERD)
Gastro-Esophageal Reflux Disease (GERD) 2017-04-30T22:14:42-07:00

According to the definition, it is a reflux of gastric contents (mainly acid) through the lax lower oesophagal sphincter.
GERD, also known as heartburn or pyrosis, is a disease affecting lower one-third of the oesophagus and upper part of the stomach. The condition happens as a result of two phenomena appearing simultaneously; aggravated intragastric pressure and diminished lower esophageal tone. Both of these factors contribute to the reflux of acidic stomach secretions into the oesophagus and ultimately result in the indications of GERD.
Unfortunately, the aftermath of GERD results in the inflammation of oesophagus and Barrett’s oesophagus which later on develops into a localised adenocarcinoma.
Barrett’s oesophagus is the intestinal metaplasia of lower third of the oesophagus with stratified squamous epithelium being replaced with columnar epithelium brought up by refluxing contents.

Risk factors of Developing GERD

  • Morbid obesity
  • Genetic predisposition or strong family history
  • Smoking
  • Alcoholism
  • Pregnancy
  • Dry mouth or persistent dysphagia
  • Hiatal Hernia
  • Asthma
  • Diabetes
  • Connective tissue disorders
  • Nitroamines
  • Use of spicy and oil-rich food
  • Tea
  • Caucasians
  • TP53 mutations
  • RB gene mutations
  • Lifestyle choices: Tight clothes which increased intra-abdominal pressure

Your physician can perform the clinical diagnosis of GERD by a lower oesophagal biopsy taken by endoscopy. Microscopic examination will show an abundance of neutrophils and hyperemia in the oesophagal mucosa.

Signs and Symptoms of GERD

  • Chest paincentred to the middle of the sternum. Pain may be colicky and radiating to the entire chest wall. Most patients complain of a prickly pain in the epigastria region. A burning sensation might also be experienced, which is often cured by antacids.
  • Sour taste in mouth
  • Dysphagia
  • Dry cough
  • Hoarseness
  • Vomiting
  • Sensation of lump or food bolus in the throat

Extra Oesophagal Cccurrences of GERD

  • It is safe to consider GERD as a possible risk factor in patients suffering from an array of diseases including a chronic cough and asthma. Therefore, a thorough and targeted medical assessment for a wide range of non-GERD reasons should be performed on the suspected individual.
  • For all patients suffering from the mainstream features of GERD, physicians are quite likely to prescribe PPI trial in order to detect any extra oesophagal occurrence.
  • If a patient is showing (some) extra oesophagal symptoms but is totally barred from the hardcore traits of GERD, PPI trial should follow reflux monitoring.
  • Patients suffering from recurring extra oesophagal indications of GERD, despite having PPI therapy and thorough testing for other causes should undergo detailed auxiliary evaluation by allergy, pulmonary and ENT specialist.

Treatment and Preventive Measures

The goal of treatment revolves around the patient seeking long-term relief and prevention of complications.
Preventative measures are aimed at reducing the occurrence of GERD which include counselling of the patient to avoid meals right before bedtime. Usually, patients are advised not to ingest any solids (especially spicy or sour food items) at least 3 hours before bed. They are also encouraged to sleep in the left lateral position which brings the oesophagus above stomach and aids relief from reflux.
Many home remedies are used for GERD, including the (stomach and milk) acid neutralizer, formally called the soda bicarbonate solution.
¬Medical treatment is the mainstay in curing GERD. Antacids can be used in cases of emergency; these are available in the form of dissolvable tablets as well as powders. H2 receptor antagonists are drugs of choice for GERD. They act slowly over time, but provide extended relief and block the release of stomach acid. Proton pump inhibitorscan be used as well, but are rarely used now.

GERD Refractory

  • The foremost step to supervise refractory GERD is to aggravate the dosage of PPI therapy
  • For patients showing typical or dyspeptic symptoms, upper endoscopy could be performed to rule out any probability of non-GERD causes

Surgical treatment can either be performed by laparoscopy or open surgery. The aim of this treatment is to create an intra-abdominal oesophagus, aural repair and some form of wrapping of the stomach around the oesophagusto overcome reflux (fundoplication).

Fundoplication:

This surgery targets on constriction of the lower oesophagal sphincter for preventing reflux by covering the ‘head’ of the stomach around the exterior of the lower oesophagus. This procedure is described as 360-degree fundoplication under the oesophagus for a distance of 4-5cm (as shown on the picture on next page). Although it offers a pretty reasonable control over reflux, it is linked with an over-competent cardiac portion. Hence, leading to dysphagia and gas bloat syndrome.

Partial Fundoplication

Partial fundoplication is performed to avoid over-competency of the cardiac part,performed which requires a 270-degree gastric fundoplication around the distal 4cm of the oesophagus. Partial fundoplication can be performed posteriorly (Toupet) or anteriorly (Watson).
It offers significantly fewer side effects than total fundoplication, but the success rate is quite low. Laparoscopic partial fundoplication is being used in the industry quite excessively with 80-90% success rate to relieve reflux symptoms.
Linx:It is a loop of small magnetic titanium beads binding with the intersection of stomach and oesophagus. The magnetic pull between the beads is solid and keeps the sphincter closed, but allows food to pass through. It can be fixed using laparoscope. New studies show improvements in this procedure.

Complications of GERD

  • Stricture
  • Oesophageal shortening
  • Barrett’s oesophagus
  • Oesophageal carcinoma

Stricture

Reflux-induced stricture usually occurs in the late middle-aged men and senior peoples. It usually occurs just above the gastro-esophageal junction. Mainly the peptic strictures respond to endoscopic dilatation and PPIs.

Oesophageal shortening

Oesophagal shortening can occur due to fibrosis and sliding hiatal hernia. If a good segment of the oesophagus cannot be obtained without tension; a Collis gastroplasty should be performed. In Collis gastroplasty, the new oesophagus is created by using the fundus of the stomach.

Schatizki’s Ring

It is a circular ring at the distal end of the oesophagus, usually at squamocolumnar junction. It may be a sequel of GERD or Barrett’s oesophagus. Usually, single balloon dilation is curative.