GERD 2 and Achalasia

Gastro-Esophageal

Reflux Disease

Gastro-Esophageal Reflux Disease (GERD):

It is a chronic disorder which describes any symptomatic or histopathologic alteration resulting from episodes of gastro-esophageal reflux into the esophagus and/or adjacent organs
Definitions

ERD
Erosive
Reflux
Disease
1/3

NERD

Non
Erosive
Reflux
Disease
2/3


Definitions

Typical:

Heartburn
Acid regurgitation
> 2x/week
> 4 to 8 weeks
Symptoms

• Non-cardiac chest pain

• Non-obstructive dysphagia
• Globus hystericus
• Pulmonary:
• Asthma
• Chronic cough
• Hemoptysis
• Bronchitis
• Broncheictasis
• Recurrent pneumonia
Symptoms-Atypical


Symptoms-Atypical
• Otorhinolaryngological:
• Hoarseness
• Throat cleaving laryngitis
• Sinusitis
• Otolagia
• Oral
• Etching of dental enamel
• Halitosis

Epidemiolgy

Shubbar & Taka

Increasing Prevalence:

1976 15%
1988 44%

Transient lower esophageal sphincter (LES) relaxation

Hypotensive LES
Delayed Esophageal clearance
Delayed gastric emptying
Salivary function
Tissue resistance


Pathogenesis

Diagnosis

Age
Alarm features
Dysphagia
Odynophagia
Weight loss
GI bleeding
Nausea &/or vomiting
Family history of cancer
Nocturnal reflux

1-History

• Age over 40 years-old
• Alarm features
• Atypical symptoms
• Useful in:
• Grading
• Hiatus hernia
• Ulcer or stenosis
• Barrett’s Esophagus
Endoscopy
-ve endoscopy is seen in 2/3 of GERD


• Atypical symptoms
• NERD who do not respond to PPI
• When esophagitis is not demonstrated in the pre-operative endoscopic examination
24 hrs pH Recording

Management

Symptoms
Antacids/Alginates
Proton pump inhibitor
Full dose
Poor response
Consider pH
Monitoring
Reconsider
diagnosis
Normal
Fundoplication
Proton pump inhibitor
Maintenance dose
Good response
H2 receptor
Antagonists
Antacids


Behavioral modifications in the treatment of GERD
• Special care with at risk medications: anticholinergics, theophylline, tricyclic antidepressants, Ca channel blockers, B-Adrenergic agonists, alendronate.
• Avoidance of lying down for 2 hrs after meals
• Avoidance of large meals
• Drastic reduction in, or cessation of, smoking.
• Reduction of body weight if overweight

Surgical treatment

• No response to medical treatment including atypical symptoms.
• Continuous maintenance treatment is required especially in patients younger than 40 year old.
• Financial impediment

Complications

Barrett’s esophagus
Stenosis
Ulcer
Bleeding

Barrett's Esophagus

is the condition in which an abnormal columnar epithelium that is predisposed to malignancy replaces the stratified squamous epithelium that normally lines the distal esophagus. Barrett's esophagus is a consequence of chronic gastroesophageal reflux disease (GERD), which damages the esophageal squamous epithelium and causes it to heal through a metaplastic process in which columnar cells replace reflux-damaged squamous cells. The columnar-lined esophagus causes no symptoms, and the condition has clinical importance only because it is a risk factor for esophageal adenocarcinoma, a tumor whose frequency has increased more than six-fold over the past several decades.
Barrett's esophagus is diagnosed by endoscopic examination, and two criteria must be fulfilled. First, the endoscopist must ascertain that columnar-appearing epithelium lines the distal esophagus( Endoscopically, columnar epithelium has a reddish color and velvet-like texture that can be distinguished readily from normal esophageal squamous epithelium, which is pale and glossy). Second, biopsy specimens of that columnar-appearing epithelium must show evidence of metaplasia.


Achalasia
Achalasia is characterized by impaired LES relaxation with swallowing, and aperistalsis in the smooth muscle esophagus. The resting LES pressure is elevated in about 60% of cases. If there are nonperistaltic, spastic contractions in the esophageal body, the disease is referred to as vigorous achalasia or, more recently, spastic achalasia.
Clinical manifestations of achalasia may include dysphagia starting for fluid then solid, regurgitation, chest pain, hiccups, halitosis, weight loss, aspiration pneumonia, and heartburn. All patients have solid food dysphagia; the majority of patients also have variable degrees of liquid dysphagia. The onset of dysphagia is usually gradual, with the duration of symptoms averaging two years at presentation.
Characteristic barium swallow findings are proximal esophageal dilatation with the tapering of distal esophagus at the gastroesophageal junction.
ENDOSCOPY and Esophageal Manometry help dx,
Rx: Pharmacologic treatments, calcium channel blockers, are not very effective, making them more appropriate as temporizing maneuvers than definitive therapies. The definitive treatments of achalasia are disruption of the LES either surgically (Heller myotomy) or with a pneumatic dilator.