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GastroEsophageal Reflux Disease
(GER)


About 70% of diseases of esophagus are represented by gastroesophageal reflux. Reflux is followed by peristaltic wave of esophagus, which efficiently clears the gullet, alkaline saliva neutralizes the residual acid and symptoms do not occur.

Simply we can determine this disease as backflow of gastric and duodenal contents but precise definition still doesn’t occur. There were some attempts to describe this disease on the basis of clinical signs especially as most prominent sign as heartburn but this sign is also characteristic for other diseases as gastric and duodenal ulcer, cancers of stomach and acute pancreatitis etc. second attempt was done to define this disease on the basis of endoscopic findings. As a matter of fact in 90% of reflux disease cases esophagitis occur but reflux disease may occur without concomitant esophagitis. At last esophagitis itself may not be considered as a cause of reflux disease. The third current point of definition is increased period of gastric juice exposure on the esophageal mucosa. The abovementioned is one of the specific evaluation tests for reflux disease. Within the period of 24 hours, we have pH level in esophageal lumen is decreased four times more than four times, a condition of prolonged exposure to gastric juices.

There are three main factors for increased gastric juices exposure in esophagus.
  1. Incompetence of lower esophageal sphincter (LES)
  2. Inadequate esophageal clearance
  3. The Ventricle as a reservoir
Incompetence of lower esophageal sphincter (LES):
  • Usually LES is tonically contracted only on swallowing. So decreased LES tone permits reflux when the intra-abdominal pressure rises. In others, basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter relaxation (as in the case of scleroderma). In short, it may be due to abnormalities in the muscular sphincter, which can’t provide enough pressure, which may be due to pathologic changes in muscular fibers or neural atrophy (decreased endogenous gastrin production).
  • Shortening of abdominal esophagus causes increased intra-abdominal pressure as occurs in operation on esophageal hiatus (vagotomy and gastrectomy). Shortening of over all length of esophagus results in increased intra-gastric pressure, which itself promotes reflux.
  • Hiatus hernia causes reflux because pressure gradient between abdominal and thoracic cavities, which normally pinches the hiatus, is lost. In addition oblique angle between cardia and esophagus disappears.
Inadequate esophageal clearance:
  • Gravitational
  • Esophageal motility
  • Lack of salivation
  • Abnormal anchoring of LES
The Ventricle as a reservoir:
  • Dilation of ventricles
  • Gastric outlet obstruction
  • High acidity
:. Morphological injuries are more evident in the case when gastric content has not only HCl but also bile and the pancreatic juice.

Complications:

  • Esophagitis – Ulceration with stricture formation
  • Barrett’s esophagus – (Endoscopically recognized as a confluent areas or fingers of pink, gastric like mucosa extending from cardia to the esophagus
  • Anemia – Iron deficiency anemia as a consequence of chronic, insidious blood loss from long standing esophagitis and with large Hiatal hernia
  • Strictures – Fibrous strictures due to long term esophagitis
  • Ulcer formation with their complications
Clinical Symptoms:

Dysphagia

Treatment:
Drug Therapy:
gives temporarily relief. Currently we use antacids, H-2 blockers and Omeprazole.

Surgical treatment:
  • Nissen type of funduplication is performed when we create so-called wrap from gastric fundus, which circles with the distal part of esophagus. In this case, wrapping is done 360 degree but complete funduplication may be complicated, which provides obstacles for esophageal reflux (blocking, vomiting etc.). That is why wrapping may be performed at 260 degrees so called Belsey Mark IV operation. If we have Barrett’s esophagus and hiatal hernia, there is need for the lengthening of the esophagus and choligastroplasty may be performed. In this case we will create some additional tube from ventricles.
  • Hill Repair: postgastrolexy, which causes the arcuate ligament to re-establish transabdominal position of distal esophagus.


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This article has been written by Dr. M. Javed Abbas.
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20:59 21/12/2002