GASTRO-OESOPHAGEAL REFLUX DISEASE
Aetiology Normal competence of the gastro-oesophageal junction is maintained by the lower oesophageal sphincter ( LOS) .In normal circumstances, the LOS transiently relaxes as a coordinated part of swallowing, as a means of allowing vomiting to occur and in response to stretching of the gastric fundus, particularly after a meal to allow swallowed air to be vented. Most episodes of physiological reflux occur during postprandial transient lower oesophageal sphincter relaxations (TLOSRs). In the early stages of GORD, most pathological reflux occurs as a result of an increased number of TLOSRs rather than a persistent fall in overall sphincter pressure. In more severe GORD, LOS pressure tends to be generally low, and this loss of sphincter function made worse if there is loss of an adequate length of intra-abdominal oesophagus.
The absence of an intra-abdominal length of oesophagus results in a sliding hiatus hernia.
Sliding hiatus hernia is associated with GORD and may make it worse but, as long as the LOS remains competent, pathological GORD does not occur. Many GORD sufferers do not have a hernia, and many of those with a hernia do not have GORD. It should be noted that rolling or paraoesophageal hiatus hernia is a quite different and potentially dangerous condition . A proportion of patients have a rolling hernia and symptomatic GORD or a mixed hernia with both sliding and rolling components. Reflux oesophagitis that is visible endoscopically .
The strong association between GORD, obesity and the parallel rise in the incidence of adenocarcinoma of the oesophagus represents a major health challenge for most western countries.
Clinical features
The classical triad of symptoms is retrosternal burning pain (heartburn), epigastric pain (sometimes radiating through to the back) and regurgitation. Most patients do not experience all three. Symptoms are often provoked by food, particularly those that delay gastric emptying (e.g. fats, spicy foods). As the condition becomes more severe, gastric juice may reflux to the mouth and produce an unpleasant taste often described as ‘acid’ or
‘bitter’. Heartburn and regurgitation can be brought on by stooping or exercise. A proportion of patients have odynophagia with hot beverages, citrus drinks or alcohol. Patients with nocturnal reflux and those who reflux food to the mouth nearly always have severe GORD. Some patients present with less typical symptoms
such as angina-like chest pain, pulmonary or laryngeal symptoms. Dysphagia is usually a sign that a stricture has occurred, but may be caused by an associated motility disorder. Diagnosis
In most cases, the diagnosis is assumed rather than proven, and treatment is empirical. Investigation is only required when the diagnosis is in doubt, when the patient does not respond to a proton pump inhibitor (PPI) or if dysphagia is present. The most appropriate examination is endoscopy with biopsy. If the typical appearance of reflux oesophagitis, peptic stricture or Barrett’s oesophagus is seen, the diagnosis is clinched, but visible oesophagitis is not always present, even in patients selected as above. In patients with atypical or persistent symptoms despite therapy, oesophageal manometry and 24-hour oesophageal Ph recording may be justified to establish the diagnosis and guide management. Manometry and pH recording are also essential in patients being considered for anti-reflux surgery. While the main purpose of the test is objectively to quantify the extent of reflux disease, it is also used to rule out a diagnosis of achalasia. In the early stages of achalasia, chest pain can dominate the clinical picture and, when associated with intermittent swallowing problems and nonspecific symptoms, it is easy to see how a clinical diagnosis of GORD might be made . Management of uncomplicated GORD
Medical management
Most patients use simple antacids, antacid–alginate preparations and H2-receptor antagonists. advice about weight loss, smoking, excessive consumption of alcohol, tea or coffee, the avoidance of large meals late at night and a modest degree of head-up tilt of the bed. Tilting the bed has been shown to have an effect that is similar to taking an H2- receptor antagonist.
Diagnostic measurement in GORD
- 24-hour pH recording is the ‘gold standard’ for diagnosis of GORD - TLOSRs are the most important manometric findings in GORD - The length and pressure of the LOS are also important
patients have a rapid improvement in symptoms (within a few days), and more than 90% can expect full mucosal healing at the end of this time
Surgery
Strictly speaking, the need for surgery should have been reduced as medication has improved so much while minimal access surgery, which has improved the acceptability of procedures.
Endoscopic treatments of GORD
A number of endoscopic treatments ;endoscopic suturing devices that plicate gastric mucosa just below the cardia to accentuate the angle of His, radiofrequency ablation applied to the level of the sphincter and the injection of submucosal
polymers into the lower oesophagus.
There are many operations for GORD, but they are virtually all based on the creation of an intra-abdominal segment of esophagus,crural repair,some form of wrap of upper stomach (fundoplication) around the intra-abdominal oesophagus.
Operations. Total or partial fundoplication
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .