GERD

HOW GASTRO ESOPHAGEAL REFLUX DISEASE (GERD) OCCURS

WHAT IS GASTRO ESOPHAGEAL REFLUX DISEASE?

GASTRO ESOPHAGEAL REFLUX DISEASE (GERD) refers to mucosal damage resulting from the abnormal retrograde movement of gastric contents from the stomach into the esophagus. When the esophagus is repeatedly exposed to refluxed material for prolonged periods, inflammation of the esophagus can occur and in some cases it progress to erosion of the squamous epithelium (erosive esophagitis).



 

ANATOMY: The esophagus is divided into 3 parts: cervical, thoracic, abdominal. The body of esophagus is made up of inner circular and outer longitudinal muscular layers. The proximal third of esophagus is striated muscle, which transitions to smooth muscle in distal two thirds. The proximal esophagus consists upper esophageal sphincter. The distal thoracic esophagus is located on the left side of midline. As the thoracic esophagus enters the abdomen through the esophageal hiatus in the diaphragm, it becomes the abdominal esophagus.
               A prominent fat pad located on the anterior surface of the esophagus marks the lower limit of the phrenoesophageal ligament, which corresponds to the esophagogastric junction.
 
HOW DOES HEART BURN AND GERD OCCUR?    
Acid reflux occurs when the sphincter muscle at lower end of your esophagus relaxes at the wrong time, allowing stomach acid to back up into your esophagus. This cause heartburn and other signs and symptoms. Frequent reflux can lead to gastroesophageal reflux.
EPIDEMIOLOGY:
GERD is extremely common, with a prevalence of approximately 20% of adults in western culture. Most adults with GERD have mild disease but esophageal mucosa damage (reflux esophagitis) can develop in up to a third of the patients. Symptoms occur daily in approximately 7%, weekly in 14% and monthly in 15%-40% of all patients.
         There is no difference in prevalence among males and females, but males have a high rate of complications.  GERD incidence increases with age, particularly after 40 years of age.
 

 ETIOLOGY:
  • Weakening of lower esophageal sphincter.
  • Foods like fatty meals, garlic, onion, pepper, coffee, tomato juice, orange juice.
  • Drugs like anticholinergics, nicotine, theophylline, dopamine, estrogen, aspirin, non-steroidal anti-inflammatory drugs. These irritate esophageal mucosa and decreases LES pressure.
  • Delayed gastric emptying time.
  • Reduced mucosal resistance.
CLINICAL MANIFESTATIONS:
  • Heart burn (pyrosis)
  • Water brash (hyper salivation)
  • Belching
  • Regurgitation
  • Atypical symptoms include: cough, pharyngitis, chest pain.
COMPLICATIONS:
  • Dysphagia
  • Odynophagia
  • Hemorrhage
  • Barrett’s esophagus
  • Esophageal adenocarcinoma
  • Esophageal strictures.
PATHOPHYSIOLOGY:
The distal esophagus passes through the diaphragmatic hiatus that usually formed by the right crus of the diaphragm. As result the diaphragm function as external sphincter by compressing the gastroesophageal junction, this compression increases LES pressure by 10-100mmHg.
 

DIAGNOSIS:
  • Biopsy
  • Endoscopy
  • Pill cam ESO
  • Barium radiography
  • Esophageal manometry 
GOALS:

To reduce the symptoms, to decrease the frequency of gastroesophageal reflux, promote healing of the injured mucosa and prevent the development of complications.
If the disease not cured by these drugs then surgery is recommended

Surgery for the GERD involve a procedure to reinforce the LES called Nissen fundoplication. In this procedure, surgeon wraps top of the stomach around lower esophagus. The reinforces the LES, making it less likely that acid will back up in the esophagus.
The LINX device is an expandable ring of metal beads that  keeps stomach acid from refluxing into the esophagus, but allows food to pass into the stomach.
 

 
 
NON-PHARMACOLOGICAL TREATMENT:
       Elevate the head of the bed to avoid regurgitation.
       Avoid foods that may decrease LES pressure.
       Avoid the foods that have a direct irritant effect on the esophageal mucosa.
       Include protein rich meals in diet
       Eat small meals
       Weight reduction
       Avoid smoking and alcohol
       Discontinue the drugs which promote reflux (Theophyline, NSAIDS, Beta blockers)




                                                                                                                                                                                                            Presented by:
                                                                                    M. Keerthi Kumari

                                                                                     S. Sai Sushma

 
 
 
 
 
 

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