Gastroesophageal Reflux Disease
43 GASTROESOPHAGEAL REFLUX DISEASE
Michael E. Fenoglio M.D., Lawrence W. Norton M.D.
1. What symptoms suggest gastroesophageal reflux disease (GERD)?
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Substernal burning after meals or at night, associated occasionally with regurgitation of gastric juices, is one symptom. Discomfort is relieved by standing or sitting. Dysphagia, a late complication of GERD, is caused by mucosal edema or stricture of the distal esophagus. However, no symptom is specific for GERD, and therapeutic decisions should not be made on symptoms alone.
2. What is the difference between heartburn and GERD?
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Heartburn is a lay term for mild, intermittent reflux of gastric content into the esophagus without tissue injury. It is relatively common among adults. GERD implies esophagitis with varying degrees of erythema, edema, and friability of the distal esophageal mucosa. It occurs in 10% of the population.
3. What causes GERD?
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The underlying abnormality of GERD is functional incompetence of the lower esophageal sphincter (LES), which allows gastric acid, bile, and digestive enzymes to damage the unprotected esophageal mucosa. Achalasia, scleroderma, and other esophageal motility disorders are sometimes associated with GERD.
4. Is hiatal hernia an essential defect in patients with GERD?
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No. Not all patients with GERD have a hiatal hernia, and not all patients with a hiatal hernia have GERD. A total of 50% of patients with GERD have an associated hiatal hernia.
5. What studies are useful to diagnose GERD?
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Endoscopy with biopsy is essential in diagnosing GERD. Barium swallow with or without fluoroscopy can diagnose reflux but cannot identify esophagitis. Twenty-four-hour esophageal pH testing associates reflux with symptoms and is useful in some patients. Gastric secretory or gastric emptying tests are occasionally helpful. Manometry of the esophagus and LES is required whenever an esophageal motility disorder is suspected and before any surgical intervention.
6. What is the initial management of a patient suspected of having GERD?
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* Change diet to avoid foods known to induce reflux (e.g., chocolate, alcohol, and coffee).
* Avoid large meals before bedtime.
* Stop smoking.
* Do not wear tight, binding clothes.
* Elevate the head of the bed 4-5 inches.
* Take antacids when symptomatic.
* Weight loss can be very effective in reducing GERD symptoms.
7. If initial treatment fails, what should be recommended?
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About 50% of patients show significant healing with H2 blockers, but only 10% of these patients remain healed 1 year later. Metoclopramide promotes gastric emptying but rarely relieves symptoms consistently in the absence of acid reduction.
KEY POINTS: DIAGNOSTIC WORK-UP OF GERD
1. Underlying anatomic abnormality may cause functional incompetence of the lower esophageal sphincter (LES).
2. Endoscopy and biopsy are paramount in diagnosis.
3. Swallow studies delineate possible anatomic causes.
4. 24-hour pH monitoring can link reflux to patient’s symptoms.
5. Manometry of the LES is required if esophageal motility disorder is suspected.
8. What is the role of proton pump inhibitor (PPI) in GERD?
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PPIs (omeprazole and others) irreversibly inhibit the parietal cell hydrogen ion pump and are > 80% successful in healing severe erosive esophagitis. Two thirds of patients who continue the medication remain healed. A concern in prolonged PPI therapy is hypergastrinemia secondary to alkalinization of the antrum. Gastrin is trophic to gastrointestinal mucosa, but the initial fear of induced neoplasia has not been borne out by follow-up studies.
9. When should operation for GERD be recommended?
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Failure of nonoperative (medical) therapy is the primary indication for surgery. Noncompliance with prescribed treatment is a frequent cause of failure and even stricture unresponsive to dilation. With PPIs, most patients’ symptoms can be controlled for long periods of time. Current recommendations for surgical intervention include: (1) failed medical therapy (e.g., intractable disease, intolerance or allergy to medications, noncompliance, and recurrence of symptoms while on medical therapy), (2) complications (e.g., stricture, respiratory symptoms, medicosocial changes, and premalignant mucosal changes), (3) patient preference (e.g., cost-long-term medical prescriptions can be expensive-or lifestyle issues).
10. What is the goal of surgical treatment?
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Operations for GERD attempt to prevent reflux by mechanically increasing LES pressure and, in most procedures, to restore a sufficient length of distal esophagus to the high-pressure zone of the abdomen. Hiatal hernia, when present, is reduced simultaneously.
11. What procedures can accomplish this goal and how do they do it?
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1. In the Nissen fundoplication, which is used in > 95% of patients, the fundus of the stomach is mobilized, wrapped around the distal esophagus posteriorly, and secured to itself anteriorly (i.e., 360-degree wrap). The procedure alters the angle of the gastroesophageal junction and maintains the distal esophagus within the abdomen to prevent reflux. The operation is performed transabdominally by either laparotomy or laparoscopy. (See Figure 43-1.)
2. The Belsey Mark IV operation accomplishes the same anatomic changes but is done via a thoracotomy. (See Figure 43-2.)
3. The Hill gastropexy restores the esophagus to the abdominal cavity by securing the gastric cardia to the preaortic fascia. (See Figure 43-3.)
4. The Toupet (partial) fundoplication is used in patients who have associated motility disorders. Because the wrap is not circumferential, the incidence of postoperative dysphagia is significantly reduced with this partial wrap compared with a full 360-degree wrap (Nissen fundoplication). However, long-term durability may not be as good as with a Nissen fundoplication. This operation can be done transabdominally by either laparotomy or laparoscopy. (See Figure 43-4.)
Figure 43-1 In the Nissen fundoplication, which is used in > 95% of patients, the fundus of the stomach is mobilized, wrapped around the distal esophagus posteriorly, and secured to itself anteriorly (i.e., 360° wrap). The procedure alters the angle of the GE junction and maintains the distal esophagus within the abdomen to prevent reflux. The operation is performed transabdominally by either laparotomy or laparoscopy.
Figure 43-2 The Belsey Mark IV operation accomplishes the same anatomic changes as the Nissen fundoplication but is done via a thoracotomy.
Figure 43-3 The Hill gastropexy restores the esophagus to the abdominal cavity by securing the gastric cardia to the preaortic fascia.
Figure 43-4 The Toupet (partial) fundoplication is used in patients who have associated motility disorders. Because the wrap is not circumferential, the incidence of postoperative dysphagia is significantly reduced with this partial wrap compared with a full 360° wrap (Nissen fundoplication). However, long-term durability may not be as good as with a Nissen fundoplication. This operation can be done transabdominally by either laparotomy or laparoscopy.
12. What are the success rates for such procedures?
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All of the procedures described in question 11 eliminate GERD in almost 90% of patients who are followed for
10 years. But the Nissen fundoplication wins in comparison studies. Recurrent symptoms should be thoroughly worked up because they are frequently associated with other disorders and not recurrent GERD.
13. What are the long-term complications of such procedures?
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The repair may fail, with recurrence of reflux, after any of these operations. Incorrect placement or slippage of the stomach wrap can complicate Nissen fundoplication and the Belsey Mark IV procedure. Dysphagia and the inability to belch (i.e., gas-bloat syndrome) result from too tight a wrap.
14. How can stricture from GERD be managed?
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Pliable (unfixed) strictures can be dilated. Fixed strictures require surgical repair. A Thal patch expands the stricture by interposing a piece of stomach.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
