Gastroesophageal reflux disease (GERD)

Magenreflux Sodbrennen FundoplikatioRisks of reflux

  • (Peptic) oesophagitis ( ulcers in the distal Gallet)
  • Oesophageal stricture
  • (Barrett’s) oesophagus
  • (Adenocarcinoma.) cancer in distal esophagus

Epidemiology
15-20% of adults experience heartburn at least once a week.

Predisposing Factors

  • Hiatal hernia
  • Dietary components
    > fat, chocolate, caffeine, alcohol, smoking, Obesity (BMI >30 kg.m-2), first-degree relative with heartburn
  • Connective tissue diseases such as scleroderma
  • Chronic respiratory disease, asthma and cystic fibrosis
  • Patients nursed in a supine position for prolonged periods are at increased risk of reflux disease.

Natural history

  • Reflux disease is a chronic disorder.
  • Mild symptoms
  • May vary in intensity and occur only on some days.
  • With increasing severity
  • Symptoms tend to occur daily.

Most patients will therefore require long term management.

Pathogenesis
Reflux of gastric contents. acid and pepsin

  • Although bile and pancreatic enzymes may contribute in some patients
  • Increased frequency of reflux episodes
  • Impaired clearance of stomach contents from the oesophagus

Clinical features

  • Directly related to reflux episodes
  • Caused by complications of reflux disease

Symptoms directly related to reflux episodes

  • Heartburn, Epigastric pain, Regurgitation, Waterbrash
  • Oesophageal acidification may cause such sudden and brisk stimulation of salivation that the patient’s mouth fills with saliva.

Atypical symptoms

  • Angina-like chest pain
  • Xcessive belching
  • Yspepsia
  • Nausea
  • Respiratory symptoms asthma, chronic cough, laryngitis and sinusitis, wheeze, hoarseness or sore throa
  • Dysphagia: Dysphagia that is associated with symptoms of bolus impaction is highly suggestive of a stricture.
  • Odynophagia (painful swallowing)
  • Bleeding from oesophagitis

Diagnosis

  • History: symptom based
  • substantial overlap between the symptoms of reflux disease and those of ulcer disease, non-ulcer dyspepsia and irritable bowel syndrome
  • Dyspepsia: approximately two-thirds of patients will also complain of (upper abdominal pain or discomfort)
  • about 40% of patients with IBS also complain of reflux symptoms.
  • Therapeutic trial
    1. Double-dose proton pump inhibitor for two weeks
    2. Sensitivity and specificity for reflux disease that is comparable to that of oesophageal pH monitoring and substantially superior to endoscopy

Investigation

  • Endoscopy
    1. sensitive test for reflux oesophagitis
    2. gives the most accurate diagnosis of other mucosal lesions such as infective oesophagitis, peptic ulcer disease, malignancy or other
  • Barium swallow and meal
    1. This is an inappropriate primary diagnostic and non-specific for reflux disease.
    2. To assess and plan management in patients with persistent dysphagia large hiatal herniae.
  • 24-hour ambulatory oesophageal pH monitoring

Management

  • Objectives
    1. Relieve symptoms
    2. Restore quality of life
    3. Heal oesophagitis if present
    4. Reduce the risk of complications
  • Mild and occasional reflux symptoms
    1. Lifestyle modification
    2. Antacids
    3. H2 receptor antagonists
  • Significant reflux disease
  • Proton pump inhibitors

Anti-reflux surgery
Indications

  1. Failure to respond satisfactorily to adequate doses of medical therapy
  2. Intolerable side effects
  3. Failure of compliance
  4. A desire to be free of long-term medication

We perform the laparoscopic antireflux-surgery in our center as a routine. The operation is called laparoscopic Fundoplication. We do have excellent results.

The need for surgery is individually assessed by every patient.
It is well known that the best results can be achieved in centers specialized in the treatment of gastroesophageal reflux disease

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