Gastroesophageal Reflux Disease Treatments Notes

Gastro-Oesophageal Reflux Disease

Loss of competence of LOS leads to gastro-oesophageal reflux disease (GORD). The competence of LOS can be affected by obesity, smoking, excessive eating, etc. Sliding hernia is associated with GORD. As a result of reflux of gastric acid, extensive inflammation of the lower oesophagus occurs which results in various forms of oesophagitis.

Gastro-Oesophageal Reflux Disease Types

1. Acute: Following alcohol, burns, stress.
2. Chronic: It is associated with hiatus hernia or following oesophagojejunostomy.

Read And Learn More: Gastrointestinal Surgery Notes

Aetiopathogenesis

1. Structurally defective LOS secondary to inflammatory injury.
2. Inadequate abdominal length (short length) of oesophagus—precipitates a reflux when gastric distension occurs.
3. Ineffective oesophageal pump affecting clearance of food into stomach. This is influenced by following factors:
   • Gravity
   • Oesophageal motility
   • Salivation—saliva neutralises the minute amount of acid that is left following a peristaltic wave.
   • When salivary flow is decreased (following radiotherapy), the reflux can get exaggerated.
4. Increased gastric pressure: Can occur due to pyloric stenosis and diabetic gastroparesis. Following vagotomy, loss of receptive relaxation occurs resulting in increased intragastric pressure.
   • Acid refluxes into the lower oesophagus and produces diffuse inflammation with multiple ulcers.
   • The symptoms are worse when the patient lies down.
   • Due to vagal hyperactivity, inflammation and ulcers develop which produce severe longitudinal muscle spasm. Consequently, the cardia is drawn up into the thorax, leading to an increase in the oesophagocardiac angle. This increases the reflux.
   • Later, fibrosis causes shortening of the oesophagus.
   • Thus, it becomes a vicious circle of oesophagitis— longitudinal muscle spasm—displacement of oesophagus—increased regurgitation.

Gastro-Oesophageal Reflux Disease Clinical Features: Most common presentation of GORD is the history of heart¬burn and regurgitation. Heartburn is confined to the epigastrium and retrosternal areas, does not radiate to the back.

Clinical presentation of the GORD can be classified as follows: Atypical symptoms can be so many and can thus confuse the picture.

1. Oesophageal: Dysphagia, regurgitation, heartburn
2. Gastric: Early satiety, belching, bloating, nausea
3. Pulmonary: Asthma, wheezing, aspiration, cough, dyspnoea, bronchitis, hoarseness of voice due to damage to vocal cords, etc.
4. Ear, nose, throat: Waterbrash, globus, hoarseness
5. Cardiac: Chest pain

What is Globus? Sensation of a substernal lump (globus). When this occurs during fasting, it is termed ‘globus hystericus’.

It is a neurotic symptom in patients with emotional instability.

• Retrosternal pain: It is burning in nature and becomes worse on lying down. The pain reduces in the sitting position. The pain is described as heartburn and can be confused for angina pectoris. It is relieved on taking antacids.
• Heartburn is otherwise called pyrosis.
• Occult blood in stools and streaks of blood in the vomitus are common.
• Anaemia and weakness are uncommon features.
• Dysphagia: Transient difficulty in swallowing results from spasm due to inflammation of the lower end of oesophagus. Late dysphagia is due to stenosis or stricture of the oesophagus. Belching is not un-common.

Gastro-Oesophageal Reflux Disease Complications

• Benign: Oesophageal ulcers, bleeding and peptic strictures. Peptic strictures are not common nowadays due to the treatment of aid peptic disease with proton pump inhibitors.
• Barrett’s oesophagus and adenocarcinoma: Chronic reflux will bring metaplasia in the lower and mid-oesophagus resulting in Barrett’s oesophagus which progresses to adenocarcinoma oesophagus.

Scoring Systems or Classification

• Johnson-DeMeester Scoring System: Three important symptoms are taken into consideration.
• Modified Savary-Miller Classification of Reflux Oesophagitis
  • Grade 1: Single or isolated erosion at or above GE junction
  • Grade 2: Multiple non-circumferential erosions above GE junction
  • Grade 3: Circumferential erosions above GE junction
  • Grade 4: Chronic lesion—stricture, ulceration/short oesophagus
  • Grade 5: Columnar epithelium in continuity with Z line (Barrett’s oesophagus)

Gastro-Oesophageal Reflux Disease Investigations

• Barium swallow in the Trendelenburg’s position (head down position) can demonstrate the reverse flow of barium into the lower end of the oesophagus (from the stomach).
• Oesophagoscopy may reveal red, angry looking mucosa in the lower end of the oesophagus.
• Oesophageal manometry to detect motility dis-orders. A thin catheter is passed through the nose which contains pressure sensors.
• 24-hour pH monitoring is the gold standard.

Gastro-Oesophageal Oesophageal Manometry

• Information about LOS
  • Resting pressure
  • Length
  • Relaxation
• Quality of oesophageal peristalsis
• Manometry is essential. To place the pH probe 5 cm above upper border of LOS for ambulatory pH monitoring.

Gastro-Oesophageal 24-hour pH Monitoring is the Gold Standard

• Indications: When symptoms are certain but endo-scopy is normal, atypical symptoms o It involves the transnasal placement of a pH measuring electrode in the lower oesophagus. The pH electrode monitors the changes in intra-oesophageal pH over 24-hour
• A 24-hour pH profile is thus obtained that provides information on frequency, duration and pattern of reflux
• A reflux episode is defined as a pH drop to below pH 4
• Thus, identification, type and duration of reflux is noted

Summary of the investigations and the utility of these have been summarized in Table.

Gastro-Oesophageal Treatment: It can be classified as medical, endotherapy and surgical line of management. Conservative treatment or medical line of treatment should be attempted in all these patients. Majority of the patients respond to conservative line of treatment.

1. Medical Management: Treatment of uncomplicated GORD can be discussed under the following headings:

1. Lifestyle modification
   • Stop smoking
   • Stop alcohol
   • Control obesity
   • Small meals
   • Avoid coffee, chocolate and coke
   • Head up—propped-up position
   • Avoid stooping
   • Avoid tight garments
2. Drugs: Antacids with alginate—antireflux floating alginate.
   • Proton pump inhibitors: Pantoprazole 40 mg, esomeprazole till 20 mg may have to be given for one or two months or full symptoms are controlled. These are antisecretory drugs.
   • Prokinetics: Itopride 50 mg can be given 2-3 times a day for 8 weeks on empty stomach. Prokinetics enhance motility. Cisapride and mosapride are not favoured because they can cause cardiac arrhythmias.
3. Mucosa protective agents
   • Sucralfate colloidal bismuth—cytoprotective agent.
   • It is a sucrose sulphate-aluminium complex which binds to the mucosa. Thus, it protects the mucosa of GI tract against hydrochloric acid.
   • Colloidal bismuth compounds.

2. Endoscopic Management

1. Endoscopic plication/suturing or enteryx injection
   • Plexiglass microspheres (PMMA): Through an endo¬scopic needle, microspheres suspended in gelatin are injected. Gelatin is absorbed and spheres cause tissue bulking.
2. Endoscopic treatment of GORD: Three types:
   1. Radiofrequency energy to LES: It changes sphincter compliance.
   2. Barrier at GE junction: An ethylene vinyl alcohol copolymer is injected into submucosa 1-2 mm caudal to Z line.
   3. Direct endoscopic suturing and tightening of LES: To summarise, quit smoking, decrease alcohol intake, avoid overweight and start walking. Do not drink coke and do not eat chocolates, take mucosa protective agents.

Medical Management of GORD

• Alcohol to be minimised o Lose weight
• Coffee/tea to be minimised
• Oesophageal mucosa protectors—antacids, H2 receptor blockers
• Head—up tilt
• Oily and spicy food must be avoided
• Large meal to be avoided at night times Remember as ALCOHOL

3. Surgery: Indications

• Intractable pain—heartburn and dysphagia
• Complications such as haemorrhage or stricture
• The results of antireflux surgery are good with a small mortality rate (0.1 to 0.5%). However, careful selection of patients depending upon their symptoms and lifestyle are important factors.

Types of Surgery

1. Nissen’s total fundoplication: The aim is to restore 2-4 cm of intra-abdominal oesophagus by reducing the hernia, followed by repair of the hiatus
   • In this operation, fundus of the stomach is mobilised by dividing short gastric arteries.
   • Fundus is brought behind the oesophagus and wrapped in front of oesophagus. It is a loose wrap (Floppy Nissen).
   • The diaphragmatic defect is repaired by using nonabsorbable sutures such as nylon or silk. This is the operation which serves all aims.
   • Mortality and morbidity should be minimised.
   • Laparoscopic fundoplication
     • Most popular today
     • Minimal morbidity and mortality
     • Early discharge, within 1-2 days
     • Early recovery
     • All operative steps that are performed in open surgery are carried out here with a ‘better vision’ in laparoscopic method.
   • Principles of fundoplication
     • 360° gastric fundoplication should be no longer than 2 cm.
     • It should be constructed over a 60°F bougie.
     • Fundoplication should be placed in the abdomen without tension.
     • Only ‘fundus’ should be used to wrap (fundus relaxes—body does not relax on swallowing).
     • Vagus should not be damaged because it may result in failure of sphincter to relax.
     • Lengthen the oesophagus with a Collis gastroplasty (in cases of short oesophagus).
     • Patients with normal peristaltic contractions do well with 360° Nissen’s fundoplication—for others, two- thirds partial fundoplication may be the procedure of choice.
   • Nissen’s total fundoplication Complications: Too tight a plication may result in dysphagia or gas bloat syndrome wherein belching is prevented.
2. Partial fundoplication (Toupet) solves the above problem wherein fundus is sutured around the back of oesophagus or Dorr’s, where fundus is sutured anterior to the oesophagus.
3. Linx device treatment
   • It is a ring of interlinked titanium beads with magnetic cores.
   • It is indicated in patients who have GORD but without hiatus hernia.
   • These are magnetic beads placed around oesophagogastric junction.
   • These beads will stretch with increased pressure in the oesophagus.
   • This is called magnetic sphincter augmentation.