Upload
kavindya-fernando
View
104
Download
0
Tags:
Embed Size (px)
Citation preview
Contents
• Pathophysiology• Oesophageo mucosal defense mechanisms• Clinical features• Diagnosis and investigations• Treatment • Complications
JMJ 2
Pathophysiology
• Between swallows,• Muscles of oesophagus are relaxed,• Except for those of sphincters.
• LOS remains closed usually • Muscles of LOS get relaxed when swallowing is initiated
• Transient lower oesophageal sphincter relaxations (TLESRs)• Part of normal physiology• But occurs more frequently in GORD patients
• Little amount of reflux is normal
• Sphincter pressure also increases in response to• Rises in intra abdominal and intragastric pressures.
JMJ 3
Other anti reflux mechanisms
• Intra abdominal segment of oesophagus• Acts as a flap valve
• Mucosal rosette formed by folds of gastric mucosa & • the contraction of the crural diaphragm at the LOS
• Acting like a pinchcock,• Prevents acid reflux• Large hiatus hernia can impair this mechanism
• Oesophagus is rapidly cleared normally or refluxate• By secondary peristalsis • By gravity• By salivary bicarbonate
JMJ 5
Factors associated with gastro oesophageal reflux
• Pregnancy and obesity• Fat, chocolate, coffee or alcohol ingestion• Large meals• Cigarette smoking• Drugs
• Antimuscuranics• Calcium- channel blokers• Nitrates
• Systemic sclerosis• After treatment of achalasia• Hiatus hernia
JMJ 6
Factors associated with gastro oesophageal reflux
• Pregnancy and obesity• Fat, chocolate, coffee or alcohol ingestion• Large meals• Cigarette smoking• Drugs
• Antimuscuranics• Calcium- channel blokers• Nitrates
• Systemic sclerosis• After treatment of achalasia• Hiatus hernia
JMJ 7
Osophageal mucosal defense mechanisms
• Surface• Mucus and the unstirred water layer trap bicarbonate• This is a weak buffering mechanism, compared to that in the
stomach and duodenum
• Epithelium• Apical cell membrane and junctional complexes between cells
act to limit diffusion of H+ into the cells.• In oesophagitis – junctional complexes are damaged.
JMJ 8
Osophageal mucosal defense mechanisms
• Postepithelium• Bicarbonate normally buffers acid, in the cells and
intracellular spaces• Hydrogen ions impair the growth and replication of damaged
cells
• Sensory Mechanisms• Acid stimulates primary sensory neurons in the oesophagus
by activating the VANILOID RECEPTOR 1 (VR1)• This can initiate inflammation and release pro-inflammatory
substances from the tissue to produce pain• Pain can also be due to - contraction of longitudinal
oesophageal muscle
JMJ 9
Heartburn
• Is the major feature
• Aggravated by • Bending• Stooping• Lying down
• Relieved by• Oral antacids
• Patient complains pain on drinking• Hot liquids• Alcohol
JMJ 11
Which promotes acid exposure
Heartburn
• Correlation between heartburn and esophagitis is poor
• Differentiation of cardiac and oesophageal pain can be difficult
• In addition to the clinical features, • a trial of PPI is always worthwhile and • if symptoms persist, • ambulatory pH and impedance monitoring should be
performed
JMJ 12
Regurgitation of food and acid
• Particularly on bending or lying flat
• Aspiration pneumonia is unusual without an accompanying stricture• But cough and asthma can occur & respond slowly (1-4
months to a PPI
JMJ 13
Sliding hiatus hernia
JMJ 16
• Oesophageal-gastro junction and part of stomach• ‘slides’ through the hiatus• That it lies above the diaphragm
• Present in 30% of people over 50 years• Produces no symptoms
• Any symptoms are due to reflux
Rolling or para-oesophageal hernia
JMJ 17
• Part of the fundus of the stomach,• Prolapses through the hiatus,• Alongside the oesophagus
• LOS remains below the diaphragm & remains competent• Occasionally severe pain occurs due to volvulus or
strangulation
Features of pain in GORD and Cardiac ischemia
GORD
• Burning, worse on bending, stooping or lying down
• Seldom radiates to the arms• Worse with hot drinks or
alcohol• Relieved by antacids
Cardiac ischemia
• Gripping or crushing
• Radiates to neck or left arm
• Worse with exercise
• Accompanied by dyspnea
JMJ 19
Diagnosis and Investigations
JMJ 20
• Clinical diagnosis can be made
• Unless there are alarm signs, (esp.dysphagia),• Patients under 45 years, • Can safely be treated initially without investigations
Investigations
Assess oesophagitis & hiatus hernia by endoscopy
Document reflux by intraluminal monitoring
Intraluminal Monitoring
JMJ 21
• 24 hour luminal Ph monitoring or,• Impedance combined with manometry is helpful • if there is no response to PPI & • should always be performed to confirm reflux before
surgery
• Excessive reflux• pH <4 for >4% of the time
Treatment
JMJ 22
• Loss of weight• Raising head end of the bed at night
• Precipitating factors should be avoided,• With dietary measures• Reduction in alcohol and caffeine consumption &• Cessation of smoking
Treatment
JMJ 24
Drugs
Alginate-containing antacids
Dopamine antagonist prokinetic
agents
H2-receptor
antagonists
Proton pump
inhibitors
Alginate-containing antacids
JMJ 25
• 10 ml tds• ‘over the counter’ agents for GORD
• They form a gel or ‘foam raft’ with gastric contents to reduce reflux
• Magnesium containing antacids• Tends to cause diarrhea
• Aluminum containing compounds• Cause constipation
Dopamine antagonist prokinetic agents
JMJ 26
• Metoclopramide and domepridone
• Enhances peristalsis &• Speed gastric emptying
H2- receptor antagonists
JMJ 27
• Cimetidine• Ranitidine• Famotidine • Nizatidine
• Acid suppressors
• If antacids fail• They can be often obtained over the counter
Proton Pump Inhibitors
JMJ 28
• Omeprazole• Rabeprazole• Lansoprazole• Pantoprazole • Esomeprazole
• Inhibit gastric hydrogen/potassium- APTase• Reduce gastric acid secretion by 90%• DOC for all mild cases
• Most respond well• 20-30% will persist with heartburns
• Severe symptoms – bd dosing & prolonged Tx
Endo luminal gastroplication
JMJ 29
• In this endoscopic procedure, • multiple plications or pleates are • made below the gastro-oesophageal junction.
Surgery
JMJ 30
• Never be performed to hiatus hernia alone
• Best predictor• Typical reflux symptoms with documented acid reflux
• Current surgical techniques –• Return the oesophageal junction to the abdominal cavity• Mobilize the gastric fundus• Close the diaphragmatic crura snugly• Involve a short tension-free fundoplication
Surgery
JMJ 31
• Indications for operation• Not clear• Intolerance to medication• Desire for freedom from medications• Expense of therapy• Concern of long-term side effects
• Patients with oesophageal dysmotility unrelated to acid reflux, • patients with no response to PPIs and • those with undelying functional bowel disease • should NOT have surgery
JMJ 34
Peptic Stricture
• Due to usage of PPI – strictures are uncommon in this era
• Usually occurs in – patients over the age of 60
• Present with intermittent dysphagia for solids • which worsens gradually over a long period
• Mild cases• May respond to PPI alone
• Severe cases• Need endoscopic dilatation • Long term PPI therapy
JMJ 35
Barrett’s Oesophagus
• Part of normal oesophageal squamous epithelium is • replaced by metaplastic coloumnar mucosa • to form a segment of ‘columnar-lined oesophagus’ (CLO)
• There is almost always a hiatus hernia
• Diagnosis is made by• Endocopy showing proximal displacement of squamo
coloumnar mucosal junction • Biopsies demonstrating coloumnar lining above the proximal
gastric folds• Interstinal metaplasia is no longer a requirement – (British
Society of Gastroenterology guidelines)
JMJ 39
Barrett’s Oesophagus
• Barret’s oesophagus may be seen as• Continual circumferential sheet• Finger like projections extending upwards from the squamo-
coloumnar junction• Islands of coloumnar mucosa interspersed in areas of residual
squamous mucosa
• Central obesity increases risk of Barrett’s by 4.3 times
• Commonest in middle aged obese men• 0.12-0.5% - develop oesophageal adenocarcinoma