Esophagus: Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) Basics

General

  • Reflux of Gastric Acid into the Esophagus
  • The Most Common GI Diagnosis in the West
    • 10-20% Prevalence

Risk Factors

  • Smoking
  • Alcohol
  • Caffeine
  • Trigger Foods (Fatty/Fried)
  • Gastroparesis
  • Obesity
  • Hiatal Hernia
  • Pregnancy

Symptoms

  • Typical Symptoms:
    • Pyrosis (Heartburn)
      • 30-60 Min After Meals
      • Worse When Supine
    • Regurgitation (Perception of Refluxed Gastric Acid into the Mouth)
    • Epigastric Pain
  • Atypical Symptoms:
    • Water Brash (Increased Saliva Production Mixed with Gastric Acid in the Mouth)
    • Odynophagia (Painful Swallowing)
    • Globus Sensation (Perception of a Lump in the Throat)
    • Cough
    • Aspiration
    • Wheezing
    • Hoarse Voice

Alarm Symptoms

  • Alarm Symptoms:
    • Dysphagia
    • Weight Loss, Early Satiety or Anorexia
    • GI Bleed (Hematemesis/Melena) or Anemia
    • Persistent Vomiting
  • Need EGD to Evaluate for Cancer

GERD 1

Complications

Erosive Esophagitis

Barrett’s Esophagus

Esophageal Stricture

Extraesophageal Complications

  • Asthma
    • Mechanisms: Increased Vagal Tone, Bronchial Reactivity & Microaspiration
  • Laryngotracheal Stenosis
  • Chronic Laryngitis
  • Chronic Cough
  • Dental Erosions

Management

Immediate Relief

Initial Therapy

  • Initial Tx: PPI 3-4 Weeks & Lifestyle Modifications
  • 99% Effective
  • If Fails: Diagnostic Testing
    • Failure Defined as No Improvement After 8-12 Weeks

Diagnostic Testing

  • pH Probe
    • First Test to Diagnose (But Not Mandatory)
    • DeMeester Score
      • Components:
        • Percent Total Time pH < 4
        • Percent Upright Time pH < 4
        • Percent Supine Time pH < 4
        • Number of Reflux Episodes Total
        • Number of Reflux Episode > 5 min
        • Longest Reflux Episode
      • Score > 14.72 Indicates Reflux
  • Upper Endoscopy
    • Not Required for GERD Diagnosis
    • Evaluates Hiatal Hernia, Strictures, Esophagitis, Metaplasia & Malignancy
  • Manometry
    • To Rule Out Underlying Motility Disorder
    • Indications:
      • If Upper Endoscopy Normal
      • Required If Planning Surgery

Antireflux Surgery

  • Primary Surgery: Fundoplication
    • *See Esophagus: Fundoplication
    • Concurrent Dysmotility Requires Partial Fundoplication
    • May Consider Roux-en-Y Gastric Bypass if Morbidly Obese with Indications for Bariatric Surgery – Small Pouch is Created with Minimal Acid Production
  • Indications:
    • Failed Medical Management
    • GERD Complications (Esophagitis or Stricture)
    • PPI Side Effects (Headache, Nausea, Vomiting or Diarrhea)
    • Patient Preference
    • Poor Compliance
  • Contraindications:
    • Unable to Tolerate Surgery
    • High-Grade Dysplasia or Carcinoma
    • Morbid Obesity – Relative Contraindication
      • Consider Gastric Bypass
  • Best Predictors of Success:
    • Typical Symptoms
      • Typical Symptoms Resolve in 90% of Patients
      • Atypical Symptoms Resolve in 60-70% of Patients
    • Symptoms Improved on PPI
    • High Esophageal pH

Other Modern Antireflux Procedures

  • Magnetic Sphincter Augmentation (LINX Device)
    • Ring Made of Magnets Placed Around the LES
      • Increases LES Pressure while Closed
      • Can Open with Pressure while Swallowing to Permit Food Passage
    • Exact Indications Poorly Defined
    • Benefits Over Fundoplication:
      • Shorter Surgery & Faster Recovery
      • Easily Reversible
      • Does Not Permanently Alter Stomach Anatomy
      • Retains Ability to Belch/Vomit
    • Potential Risk for Esophageal Erosion (0.3%)
    • Should Eat Frequent Solid Meals Postop to Prevent Scarring Capsule Formation & Resulting Dysphagia
  • Stretta Procedure
    • Endoscopic Controlled Radiofrequency Energy Applied to the LES
    • Induces Inflammation, Collagen Deposition & Muscular Thickening
  • Transoral Incisionless Fundoplication (TIF)
    • Endoscopic Full Thickness Plication
    • Partial Fundoplication (200-300-Degrees)

Nissen Fundoplication 2

LINX Device 3

LINX Procedure 3

TIF 4

References

  1. Blaus B. Wikimedia Commons. (License: CC BY-SA-4.0)
  2. Gray H. Public Domain.
  3. Sriratanaviriyakul N, Kivler C, Vidovszky TJ, Yoneda KY, Kenyon NJ, Murin S, Louie S. LINX®, a novel treatment for patients with refractory asthma complicated by gastroesophageal reflux disease: a case report. J Med Case Rep. 2016 May 24;10(1):124. (License: CC BY-4.0)
  4. Sami Trad K. Transoral incisionless fundoplication: current status. Curr Opin Gastroenterol. 2016 Jul;32(4):338-43. (License: CC BY-NC-ND-4.0)