Only 14 pages are availabe for public view
he main function of the esophagus is to transport swallowed food into the stomach. Another important function of the esophagus is to prevent gastroesophageal reflux.
The esophagogastric junction (EGJ) area has a specialized valve mechanism formed by the lower esophageal sphincter (LES) and abdominal esophagus, the diaphragm, the angle of His, and the phrenoesophageal membrane.
GERD is present when pathologic exposure of the esophageal lumen to gastric juice occurs, and this can be a pathologic amount of acid and/or a pathologic amount of duodenal components such as bile.
Acute esophageal exposure to gastric and/or duodenal refluxate can result in pyrosis and symptomatic gastroesophageal reflux disease (GERD), as well as erosive esophagitis. chronic esophageal acid exposure can result in anatomic and structural changes to the esophagus ranging from benign lesions (peptic stricture) to premalignant lesions (Barrett’s esophagus), to esophageal adenocarcinoma.
The diagnosis of gastroesophageal reflux disease (GERD) is frequently based on the symptomatic evaluation and upper endoscopy. However, both symptoms and endoscopic findings have low accuracy, leading to a wrong diagnosis in up to 30 % of patients. As a consequence, many patients without GERD are often treated with expensive medications or are referred for antireflux surgery on the assumption that symptoms are caused by reflux.
Typical symptoms of GERD include (heartburn, regurgitation, and dysphagia) and atypical symptoms include (cough, hoarseness, chest pain, dental erosions).
The presence of gas bloating, nausea, and diarrhea should be always investigated as they often suggest the presence of other diseases rather than GERD.
Barium esophagram can be used but its main goal is to define the anatomy of the esophagus, the gastroesophageal junction, and the stomach and not to establish the diagnosis of GERD.
Upper endoscopy aims to detect Barrett’s esophagus and erosive esophagitis and to rule out gastric and duodenal diseases.
The primary purposes of esophageal manometry before antireflux surgery are to rule out primary esophageal motility disorders; to measure LES resting pressure, length, and relaxation & to assess amplitude and propagation of esophageal peristalsis.
Main indications for ambulatory pH monitoring are failure of medical therapy, preoperative evaluation, presence of atypical symptoms such as cough, hoarseness, and chest pain, presence of symptoms without endoscopic evidence of esophagitis, and evaluation of patients who have recurrent symptoms after antireflux surgery.
Four classes of treatments exist for GERD. These include:
Lifestyle modifi cation
Avoidance of dietary triggers:
o Carbonated beverages.
o Spicy food.
Avoidance of late-night eating, within 3hours of bedtime.
Elevation of the head of the bed
PPIs are the main stem of medical therapy. These medications have been proved to be the most effective medical treatment for GERD in terms of esophagitis healing and symptom relief.
A laparoscopic total fundoplication is considered today the gold standard for the surgical treatment of gastroesophageal reflux disease (GERD). Short-term outcome is excellent, with low perioperative morbidity and fast recovery. Longterm follow-up has shown that symptom control is achieved in about 80–90 % of patients 10 years after a fundoplication.
Exciting new devices and endoscopic as well as laparoscopic techniques have been introduced and are actively and increasingly used in patients with GERD, particularly in those who are not responding to PPI therapy.
Stretta is a safe, effective, and mature technology and repeatable if necessary. Further, it is the least expensive alternative to medical therapy, and it does not preclude the subsequent use of any other alternative therapy for GERD.
Transoral incisionless fundoplication (TIF) has emerged as a safe and effective alternative to GERD patients who do not respond completely to PPI without the adverse event profile associated with LARS.
The magnetic sphincter augmentation has so far proven to be both safe and effective for patients with GERD. It provides effective resolution of GERD. The procedure does not significantly alter gastric anatomy and can be reversed if necessary.