GERD

Dr/ Hytham Nafady

Definition• Excessive retrograde movement of the acid

containing gastric secretions into the esophagus.

Patho-physiology of GERDThe esophagus is an antegrade pump

Poor esophageal motility

result in decrease in clearance of the acidic secretions.

The LES is a valve. LES dysfunction(this is the most common cause).

result in reflux of large amounts of acidic gastric secretions.

The stomach is a reservoir.

Delayed gastric emptying

result in increased gastric volume & pressure.

Role of hiatus hernia in GERD

• Hiatus hernia Intrathoracic migration of the LES loss of its abdominal high pressure.

Complications of GERD

Esophagitis

Inflammation of the esophageal

mucosa with erythema,

erosions & ulcers.

Stricture

Circumferential fibrosis due to

deep injury.

Barret’s esophagus(premalignant)

Columnar metaplasia of the

esophageal stratified

squamous epithelim.

C.P

• Heart burn, • Regurgitation & • Dysphagia for solids and liquids.

CXR

• Hiatal hernia.• Aspiration pneumonia.

Trendlenberg position

Findings of reflux esophagitis

1. Granular mucosal pattern.2. Shallow ulcers in the distal esophagus.3. Esophago-gastric pseudo-polyp.4. Transverse fixed mucosal folds (step ladder pattern).5. Buckering & sacculations.6. Feline esophagus.7. Peptic stricture.8. Schatizki ring.9. Barret’s esophagus.10. Pseudo-diverticulosis.

Granular or finely nodular mucosa• Numerous ill defined lucencies on mucosal surface.Pathology:• inflammation & edema.

GERD Candida esophagitis

Fine granular mucosa Foamy esophagus

Mucosal edema Plaques or pseudomembranes

Nodules have illdefined margins that fade out peripherally.

Nodules have well defined margins.

Shallow ulcers in the distal esophagus

inflammatory esophago-gastric polyp

• A single thickened mucosal fold arising at the gastric cardia & extending through the gastro-esophageal junction.

Thick fixed transverse folds (step ladder pattern)

• Crinkled mucosa due to longitudinal scarring.

Step ladder pattern Feline esophagus

Thick fixed transverse folds Fine transient transverse folds

Longitudinal scarring. Contraction of muscularis mucosa.

Localized. Extend for more than 1/2 way across the esophagus.

Puckering & sacculations:

• Due to eccentric scarring.

Feline esophagus:

• Transient transverse folds due to contraction of longitudinal muscularis mucosa.

Hiatal hernia reflux esophagitis (feline esophagus)

Peptic stricture

• Smooth tapered area of concentric narrowing of the distal esophagus due to circumferential scarring.

Schatizki ring = narrowed B ring

• Pathological ring at the gastro-esophageal junction that causes dysphagia & measures less than 13 mm in diameter.

Schatzki ring

Esophageal rings

Esophageal ringsA ring B ring

Muscular ring at the junction between tubular and vestibular esophagus.

Mucosal ring at the squamo-columnar junction (z line)

If narrowed < 13 mm pathological Schatizki ring

Barret esophagus

Pathology:• Columnar metaplasia of the esophageal stratified

squamous epithelium.Findings:• Mid esophageal stricture• Reticular mucosal pattern.

Pseudo-diverticulosis

TTT

• Laparoscopic Nissen fundoplicatoin.

Nissen fundoplication

• Smooth narrowing of the GEJ 2-3 below the diaphragmatic hiatus.

Post-operative complications

• Dysphagia (tight Nissen fundoplication).• Perforation.

Tight Nissen fundoplication

Perforation after Nissen fundoplication