Gastroesophageal Reflux Disease Pathophysiology and Treatment
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This document discusses gastroesophageal reflux disease (GERD), including its pathophysiology, symptoms, diagnosis, and treatment options. It provides details on the medical and surgical management of GERD, highlighting the importance of a thorough pre-operative workup including pH testing, manometry, and other diagnostic evaluations to determine the appropriate treatment and ensure good postoperative outcomes. Both medical therapies like proton pump inhibitors and surgical procedures like Nissen fundoplication are discussed as options for treating GERD, with surgery reserved for cases that are refractory to medical management or that involve complications.
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Gastroesophageal Reflux Disease Pathophysiology and Treatment
- 1. Gastroesophageal Reflux Disease Pathophysiology and Treatment George Ferzli, M.D., FACS Professor of Surgery, SUNY Health Science Center at Brooklyn Department of Laparoscopic Surgery, Staten Island University Hospital
- 2. 44% 13%
- 4. Incidence of presenting symptoms experienced as a percent of all patients in study (n=198) Heartburn 80% Regurgitation 68% Dysphagia 38% Resp. symptoms 27% Chest pain 10% Abdominal pain 10% Nausea or vomiting 7% Belching 6% Bleeding 5% Hinder, RA, et al: Laparoscopic Nissen Fundoplication is an effective treatment for GERD. Annals of Surgery 220, No. 4
- 5. Definition It is increased exposure of the esophagus to gastric and / or duodenal secretions
- 6. Etiology
- 9. Goals of Treatment Eliminate symptoms Heal esophagitis Manage or prevent complications Maintain remission
- 12. Lifestyle modification non-compliance Antacids poor long-term control Prokinetic agents no esophageal healing H2 Blockers short-term good results long-term 50% recur Proton pump inhibitors good healing, ?safety rapid relapse Pitfalls of Medical Management
- 14. What is the next step???
- 20. Laparoscopic Paraesophageal Hernia Repair
- 21. Paraesophageal Hernia Repair Symptomatic Outcomes Hashemi et al, J Am Coll Surg 2000;190:553-561
- 25. Laparoscopic Nissen For Barrett’s
- 29. Results Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002 - 86% 5.3 + 1.6% 30.9 + 19% % time with bilirubin 100% 93% 12.5% 96% Pathologic acid reflux 100% 70% 21% 61% Incompetent LES 65 77 65 68 Length of Barrett’s (mm) 100% 82% 0% 95% Symptoms Adenoca. (n=4) Dysplasia (n=17) Visick Visick I-II (n=52) III-IV (n=74)
- 40. Proper diagnostic workup is essential. It may alter the algorithm of management
- 42. Proper preoperative workup will help manage recurrent postoperative symptoms
- 44. Take home message : In order to achieve good postoperative results, there must be a thorough preoperative workup
Editor's Notes
- 44 percent of the adult american population have symptoms of gastroesophageal reflux disease (GERD), and 13 percent of them take some form of medication weekly for this condition.
- First line of therapy is lifestyle modification. This includes diet modification, weight loss, smoking cessation, change in sleeping habits, but unfortunately these are not adhered to consistently.
- Medical therapy is the first line of management of GERD. Esophagitis will heal in ~90% of cases with intensive medical therapy. However, medical management does not address the condition’s mechanical etiology, thus symptoms recur in more than 80% of cases within one year of drug withdrawals. In addition, while medical therapy may effectively treat the acid-induced symptoms of GERD, esophageal mucosal injury may continue due to ongoing ALKALINE REFLUX.
- Antacids, while the cheapest and most accessible form of medical management, provide long-term symptomatic relief in only 20% of the patients, a rate only slightly better than that observed with placebo treatments. Prokinetic agents, while a logical approach to treating a defect in esophagogastric motility, provide symptomatic relief in a variable percentage of patients, but have not been shown to be effective in healing esophagitis. Until recently, H2 blockers were the mainstay of medical management of GERD. Multiple controlled trials have evaluated the alleviation of symptoms, both short-term and long-term, as well as rates of endoscopically proven healing. Short term symptomatic relief occurs in ~61% of patients and resolution of esophagitis occurs in approximately 45% of patients. In addition, symptomatic improvement does not regularly correlate with endoscopic healing. Also, long-term H2 blocker therapy is associated with a symptomatic recurrence rate of 50% which does not differ significantly from placebo therapy. Proton pump inhibitors have consistently shown superior rates of symptomatic relief when compared to H2 blockers. More importantly, since symptomatic relief does not always correlate with healing of esophagitis, studies have shown superior rates of endoscopically proven healing with omeprazole. Long-term use of proton-pump inhibitors is questionable in terms of safetly and efficacy. PPI therapy induces hypergastrinemia which has been demonstrated to induce carcinoid tumors in a species of rats. Although this has not been demonstrated in humans. Also, studies have demonstrated a rapid rate of relapse when PPI doses are reduced.
- As above, Symtoms thought to be indicative of GERD such as heartburn or acid regurgitation are very common in the general population and cannot be used alone to guide therapeutic decisions, particularly when considering antireflux surgery. A common error is to define the presence of GERD by the endoscopic finding of esophagitis. Limiting the diagnosis to patients with endoscopic esophagitis ignores a large population of patients without mucosal injury who may have severe symptoms of gastroesophageal reflux and could be candidates for antireflux surgery.