GASTROESOPHAGEAL REFLUX DISEASE

1. GASTROESOPHAGEAL REFLUX DISEASE

2. American College of Gastroenterology (ACG) guidelines defines GASTROESOPHAGEAL REFLUX DISEASE (GERD) as “TROUBLESOME symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung.”

3. PHENOTYPIC PRESENTATIONS OF GERD • Erosive esophagitis (EE), • Non erosive reflux disease (NERD) and • Barrett’s esophagus

5. GERD encompasses esophageal and extra-esophageal syndromes

6. Alarm features for GERD

7. DIAGNOSIS

8. UPPER GASTROINTESTINAL ENDOSCOPY • Principal test • Main use=====evaluation of treatment failures and risk management. • Typical esophagitis GERD • highly specific (90%–95%) for GERD, but low sensitivity

9. Manometry ---NOT TO CONFIRM GERD BUT RULE OUT FUNCTIONAL DYSPHAGIA • Persistent reflux symptoms despite PPI therapy and====== MANOMETRY • Normal findings on endoscopy ====================

11. 24-hour pH test • Acid reflux episodes === pH fall <4. • Overall DeMeester score, should not exceed 14.7 in normal subjects. • Both catheter and wireless pH monitoring allow • quantification of esophageal acid exposure and • assessment of the temporal relationship between symptoms and acid reflux events

14. ESOPHAGEAL IMPEDANCE-PH MONITORING ---FAILED PPI TWICE DAILY • Multichannel intraluminal impedance monitoring with pH sensor • Several channels, detects the direction of bolus movement ANTEROGRADE SWALLOWS RETROGRADE EVENTS

16. management

18. LIFE STYLE MODIFICATIONS

19. MEDICAL MANAGEMENT • Antacids • Histamine-2 (H2)-receptor antagonists, approximately 75% effective • Proton pump inhibitors (PPIs) • PPIs have superior healing rates and decreased relapse rates

20. WHY SURGERY WHEN PPI SO GOOD??? • Atrophic gastritis and/or hypergastrinemia induced carcinoid tumors due to hypochlorhydria. • Increased risk of Clostridium difficile colitis and bacterial gastroenteritis

22. ANTIREFLUX SURGERY-NISSEN’S FUNDOPLICATION • The choice to consider anti-reflux surgery must be individualized. • Patients should have • documented acid reflux----- p H monitoring • a defective anti-reflux barrier in the absence of poor gastric emptying, • normal esophagus motility …NORMAL MANOMETRY • at least a partial response to acid reduction therapy • EFFECTIVE for heartburn and regurgitation (75-90%) and less effective for extraesophageal symptoms (50-75%).

23. Tennets of Surgery • reduction of the hiatal hernia, • repair of the diaphragmatic hiatus, • strengthening the attachment between the gastroesophageal junction and the posterior diaphragm, • strengthening the anti-reflux barrier by adding a gastric wrap around the gastroesophageal junction (fundoplication)

25. COMPLICATIONS: • After total fundic wrap several adverse consequences may occur; • persistent dysphagia, • inability to belch and vomit, epigastric fullness, • bloating and pain postprandially, • temporary swallowing discomfort, and sometimes • intense flatus

26. PARTIAL FUNDOPLICATION • Toupetfundoplication only encircles half of the esophageal circumference. • The preferred and most efficient modification of the Nissen fundoplication is the short “floppy” Nissen fundoplication, which has been shown to have success rates of up to 90% with minimal morbidity and mortality.

28. LINX Reflux system---NEWER SURGICAL OPTION • – Made of titanium beads with magnetic link • – Performance of Linx resulted in consistent symptom relief and pH control with markedly fewer side effects • – Not for patients with large hiatal hernia or abnormal peristalsis

30. Endoluminal Surgery • Endoluminal gastroplication (ELGP) -----first of the proposed endoscopic treatments for GERD. • EndoCinch • Plicator device • Enteryx Injection…polymerize into spongy material when injected submucosally

31. Submucosal Enteryx Injection

33. EsophyxXTM device • A more practical technique, • the novel endoluminal fundoplication (ELF) technique • overcome some of the Plicator's disadvantages, • inability to reduce hiatal hernia and • create a robust gastroesophageal valve

36. Medical versus Surgical Treatment for GERD • MANY TRIALS favor laparoscopic antireflux surgery compared to long-term PPI therapy • RCT: from UK ------better physiological control of reflux in patients having undergone laparoscopic Nissen fundoplication than patients under PPI therapy ….follow up of 12 months • A prospective study on laparoscopic Nissen fundoplication from J. Hunter's group from Atlanta with an 11-year mean follow up, • significant symptom control, • increased patient satisfaction, and • complete withdrawal of antireflux medications by 70% of patients.

37. CONSIDER SURGERY IN LONG TERM CAREFULLY SELECTED PATIENTS

38. Conclusions • GERD results from TLESRs and hiatal hernia. • DIAGNOSIS , PPI test 24-hour pH test alone or in combination with impedance. • PPIs the best therapeutic option • Choosing the right candidates for surgery still remains a problem and SHOULD BE INDIVIDUALIZED • Medical and surgical therapies for the GERD are not competing or they are not even complementary. • THE TWO SIDES OF THE SAME COIN

39. TAKE HOME MESSAGE RIGHTLY AND TIMELY REFERRAL TO SURGERY CAN PREVENT MISERY OF THE PATIENT IMPROPER PATIENT SELECTION FOR SURGERY MAY END UP IN DISASTER