GERD solo patologia gastro-esofagea?€¦ · GERD •“a prevalent and chronic condition in which reflux of the stomach contents into the oesophagus causes a range of troublesome

GERD

solo patologia gastro-esofagea?

Prof. Giancarlo D’AmbrosioUNIVERSITÀ DI ROMA “LA SAPIENZA”

Resp. UO “Chirurgia Generale ad Indirizzo Colo-Rettale”Az. Policlinico “Umberto I”, Roma

• Gastroesophageal reflux

disease (GERD) is one

of the most frequent

benign disorders of the

upper gastrointestinal

tract.

The Montreal definition and classification of

GERD

• “a prevalent and chronic condition in which

reflux of the stomach contents into the

oesophagus causes a range of troublesome

symptoms (including heartburn, acid

regurgitation and epigastric pain) and

complications”

Vakil et al. The Montreal definition and classification of GERD: a

global evidence-based consensus. Am J Gastroenterol. 2006

GERD: epidemiology

• In developed countries, the prevalence of

gastro-oesophageal reflux disease (defined

by symptoms of heartburn, acid

regurgitation, or both, at least once a week)

is 10–20%, whereas in Asia the prevalence

is roughly less than 5%.

El-Serag H, Hill C, Jones R. Systematic review: the epidemiology of gastro-oesophageal

reflux disease in primary care, using the UK General Practice Research Database. Aliment

Pharmacol Ther 2009; 29: 470–80.

Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal

reflux disease: a systematic review. Gut 2005; 54: 710–17.

GERD: epidemiology

• In the USA, this disease is the most common gastrointestinal diagnosis to prompt an outpatient clinic visit (8·9 million visits in 2009).

• The rising prevalence of gastro-oesophageal reflux disease seems to be related to the rapidly increasing prevalence of obesity.

Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States:

2012 update. Gastroenterology 2012; 143: 1179–87.

GERD: epidemiology

• incidence of gastro oesophageal reflux

disease diagnosis in uk general practice

El-Serag H, Hill C, Jones R. Systematic review: the epidemiology of gastro-oesophageal

reflux disease in primary care, using the UK General Practice Research Database. Aliment

Pharmacol Ther 2009; 29: 470–80.

GERD: Pathophysiology

Dysfunction of the oesophagogastric junction

• Three components make up the

oesophagogastric junction:

– the lower oesophageal sphincter,

– the crural diaphragm,

– and the anatomical flap valve.

• This complex functions as an antireflux

barrier.

GERD: Pathophysiology

Helicobacter pylori

• Helicobacter pylori does not have an

important role in the pathogenesis of gastro-

oesophageal reflux disease. Eradication of

the microorganism does not lead to an

increased chance of development of the

disorder

Diagnostic investigations

The most important diagnostic investigations to prove

the presence of GERD are

• endoscopy

• long-term impedance pH monitoring (or pH

monitoring).

• Endoscopy can directly evaluate the

Esophago-Gastric Junction and make

biopsies in order to identificate

precancerous lesions (Barrett’s Esophagus)


Los Angeles classification of reflux oesophagitis

•grade A, endoscopic abnormalities are restricted to one or more mucosal

lesions with a maximum length of 5 mm.

•In grade B, one or more mucosal breaks are present, with a maximum

length of more than 5 mm but non-continuous across mucosal folds.

•In grade C, mucosal breaks are continuous between at least two

mucosal folds, but less than 75% of oesophageal circumference is

involved.

•In grade D, mucosal breaks encompass more than 75% of oesophageal

circumference

GERD: definition


• Manometry studies are

important prior to any

surgical procedure to

evaluate motility

disorders, especially

spastic motility disorders

or achalasia

Typical symptoms

• heartburn (pyrosis)

• regurgitation.

GERD: Signs & Symptoms


• Although reflux and heartburn happen

predominantly during the day, in particular

postprandially, both can also occur during

sleep.

• Nocturnal reflux is associated significantly

with severe oesophagitis and intestinal

metaplasia (Barrett’s oesophagus) and can

lead to sleep disturbance.

• Laryngopharyngeal reflux (LPR) is

implicated in the pathogenesis of various

upper airway inflammatory diseases as

sinusitis or dacryostenosis.

• 20% of the children with diagnosed LPR

showed pepsin in the tears.

Extra-oesophageal (or atypical)

symptoms


Extra-oesophageal (or atypical) symptoms

• Asthma

• cough

• disturbances in cardiac rhythm

• pharyngitis, sinusitis

• recurrent otitis media

• pulmonary fibrosis


Extra-oesophageal (or atypical) symptoms

• hoarseness

• sleep apnoea

• tooth decay

• difficulty swallowing

• foreign body sensation in the throat

• growths on the vocal cords (granulomas)

GERD & ASTHMA

Asthma causes GERD or

GERD causes asthma?

• GERD present in 30-90% of adults with asthma

• 80% of asthmatic patients shows pH-metric abnormalities

• 77% of asthmatic patients show symptoms related to reflux

• 40% of asthmatic patients suffering from esophagitis

In particular, it is unclear which of the two

disorders induce the other and “vice versa”.

GERD causes asthma?

• theory of microaspiration: the aspiration of gastricmaterial refluxed in the tracheobronchial tree causesbronchoconstriction and the onset of chronic bronchitis,asthma attacks and even pneumonia. In the case of asthma,this mechanism is deemed secondary

• theory of vagal reflex: the stimulation of receptors of theesophageal submucosa induces a reflection of the vagusnerve, which causes a deterioration of respiratory function.This mechanism, which can be demonstrated through theacid perfusion test, is the most likely to explain the onset ofchronic cough and asthma.

• Student 17 year old, non-smoker, no family history of asthma and / or atopy

• Recurrent episodes of urticaria in anamnesis

• It refers to a week sense of "tightness" in the epigastric and dyspnoea predominantly postprandial

• The physical examination of the chest is negative, except for a few hisses and groans expiratory auscultation.

• spirometry is performed

CLINICAL CASE

CLINICAL CASESpirometry revealed an obstructive ventilatory defect of medium

severity with a good response to bronchodilator.

FURTHER INQUIRIES MADE

Prick test for inhalant allergens: NegativePRIST (Total IGE) 36.3: satisfactoryECP (eosinophil cationic protein) 5:32: satisfactoryBlood count: the normCXR: negative

THERAPY PRESCRIBED: beta adrenergic bronchodilator + inhaled

corticosteroid in combination: 4.5 mcg formoterol / budesonide 160 mcg x 2 / day

• 4.5 mcg formoterol / budesonide 160 mcg x 2 / day

• Budesonide 200 mcg x 2 / day

13/09/2007Discontinued therapy to improved symptoms

After a month, reappearance of oppression in the epigastric and predominantly postprandial dyspnea, while spirometry again reveals an obstructive ventilatory defect of medium severity.

It is again prescribed bronchodilator therapy, increasing the dose of inhaled corticosteroid.

gastroenterological consulting

Persists "air hunger" in post-prandial period.This symptom disappears during therapy

•Formoterol 4.5 mcg /

•Budesonide 160 mcg x 2 / day

11/10/07

gastroenterological consulting

EGDS: gastro esophageal reflux with mild

hyperemia of the gastric mucosa and

esophageal mucosa. Hp (-)

Pantoprazole 40 mg/die

23/07/13

• Currently, the patient no longer experiences the symptoms and performs maintenance therapy with proton pump inhibitor (pantoprazole 20 mg)

• It is to check once a year.

Therapy

• Antireflux therapy (both pharmacological and surgical) leads to an improvement in asthma symptoms in 70% of cases.

• The use of anti-reflux therapy also reduces the use of drugs commonly used in asthma care: Some asthma medications promote reflux.

• The intensive treatment for GERD is indicated in asthma associated with typical symptoms of reflux, non-allergic asthma, nocturnal asthma, asthma resistant to standard treatments and asthma with onset in adulthood.

GERD and COUGH

COUGH: HIDDEN EPIDEMIC

The incidence of cough symptom is

constantly growing and the

perception of doctors is that it is

not more of a problem mainly

seasonal but a symptom that

involves them all year.

Clinical Practice Guidelines

January 2006; 129(1_suppl) Diagnosis and Management of Cough: ACCP Evidence-Based

Clinical Practice Guidelines

• 70-90% of cases seen in clinical

practice• Upper airway cough syndrome (UACS)

• GERD

• Asthma

chronic cough and GERD prevalence

GERD: three prospective studies of Irwin during 17 years

• 10% (4th cause) in 1981

• 21% (3rd cause) in 1990

• 36% (2nd cause) in 1998

Jinnai M et al, Cough 2008

CRONIC COUGH

INCREASED

TRANSDIAPHRAGMATIC

PRESSURE

GASTROESOPHAGEAL

REFLUX

REFLEX DISTAL

ESOPHAGUS

TRACHEOBRONCHIAL

RELAXATION OF THE

LES IN CONNECTION

WITH SWALLOWING

TRANSITIONAL

RELAXATION OF LES

VICIOUS CIRCLE

Cough

GERD and AF

Atrial fibrillation in healthy heart

• 45 ys, ♂, smoker, alcoholic, oveweight;• Access to E.R. for prolonged palpitations on

waking;• Acknowledgement on ECG of atrial fibrillation

at 80 / min.


Cardiology consult:

• For several months extra-systolic palpitations

mainly in the early hours of the morning;

asymptomatic for angina; Echocardiogram:

Normal systolic function of the LV and normal

size of the left atrium;

• Infusion of flecainide with restoration of sinus

rhythm within one hour;

• Home tp: flecainide 100 mg 1 tablet x2 / day +

Bisoprolol 1.25 mg 1 tablet

• Holter ECG monitoring to a month.


Arrhythmological consulting

The patient reported

• worsening of extra-systolic palpitations morning despite

antiarrhythmic tp;

• an episode of atrial fibrillation after a large meal and liquor

abuse and remembers waking up just before a sense of 'weight

in the stomach associated with heartburn ";

• Holter monitoring: "... Several supraventricular extrasystoles,

mainly distributed in the night hours of recording, repetitive

(many couples and prejudice of max 15 beats) ....";

Gastroenterological consulting -> PPI


Cardiological examination

after a month of PPI:

• disappearance palpitations

• Holter ECG monitoring: satisfactory

• suspension of antiarrhythmic therapy

Atrial fibrillation in healthy heart,

but not healthy subject1. Vagal hyperstimulation induced by acid

reflux? (It has been seen that treatment with PPI would facilitate the conversion to sinus rhythm)

2. Inflammation district left atrium in patients with esophagitis?

3. Release of pro-inflammatory substances such as interleukin-1β, interleukin-6, CRP (C-reactive protein)?

4. chronic atrial ischemia induced by the reduced coronary flow because of acid reflux?

5. autoimmune mechanisms? (Autoantibodies against myosin heavy chain)

6. genetic factors? (Currently only hypothesised)

7. mechanical or inflammatory effect (linked to distal esophagitis) left atrium by a hiatal hernia?

Linz et al. Atrial fibrillation and gastroesophageal reflux disease: the cardiogastric interaction. EUROPACE. 31 May 2016

Extra-oesophageal (or

atypical) symptoms

Pharingo-laryngitis


atypical) symptoms

Hoarseness


atypical) symptoms

Recurrent otitis media


atypical) symptoms

Pulmonary fibrosis


atypical) symptoms

Sleep Apnoea


atypical) symptoms

Tooth decay


atypical) symptoms

Difficulty swallowing


atypical) symptoms

Foreign body sensation in the throat


atypical) symptoms

Growths on the vocal cords (granulomas)

Reduce fat in the diet,

Avoid spices, mint, chocolate,

carbonated drinks, coffee, tea

Stop smoking

Avoid excessive alcohol consumption

dietary and behavioral rules


Avoid those movements that increase

abdominal pressure (push-ups on the bust)

and too tight clothing

Evaluate with the treating physician:

Medications that can accentuate Symptoms

Eg. Nitrates and calcium channel blockers, anti-

inflammatory drugs..


Reduce body weight

(If the patient is overweight)

Elevate the headboard of the bed by

placing 10-15 cm thick

Bedtime no earlier than 3 hours between

meals.

A walk can be helpful

Medical therapy

The goal of medical therapy in GERD is to:

• control heartburn,

• heal gastroesophageal mucosal injuries,

• improve quality of life.

EAES recommendations for the management of gastroesophageal reflux

disease Surg Endosc (2014)

Medical therapy

• normalization of pH of gastric juice through

the use of alkali salts (weak bases)

• reduction of acid production

• administration of protective agents for the

gastric mucosa (sucralfate)

• acceleration of gastric emptying

Indication for surgical therapy

• Prior to the indication for surgery or any other invasive therapy, it must be proven that patients are in need of long- term treatment of GERD.

• Patients with continuous reduced quality of life, persistent troublesome symptoms, and/or progression of disease despite adequate PPI therapy in dosage and intake should be offered laparoscopic antireflux surgery after proper diagnostic testing.




• There is evidence that laparoscopic

antireflux surgery can improve quality of

life in patients with altered anatomy,

massive acid exposure, nonacid reflux,

severe reduction in quality of life, and

progressive disease with need to increase

PPI dosage over the years



Indication for surgical therapy• Several randomized trials comparing PPI therapy

with antireflux surgery have been conducted. Three

of these trials showed an advantage for surgical

therapy in outcome and cost-effectiveness after a

few years, whereas one showed an advantage for

PPI therapy after 5 years

EAES recommendations for the management

of gastroesophageal reflux disease Surg Endosc (2014)


Most frequently mentioned features leading to the indication for antireflux surgery:

• Typical symptoms for GERD

• Documented symptom-reflux correlation

• Year-long reflux history

• Reduced quality of life

• Need for PPI dosage increase

• Hiatal hernia

• Documented esophagitis (in the past before PPI)

• Proven LES incompetence

• Documented acid reflux




Hiatal Hernia

• Type I: sliding hiatal hernia

• Type II: paraesophageal hernia

• Type III: mixed paraesophageal hernia

• Type IV: giant hiatal hernia


Hiatal Hernia

• Type IV: giant hiatal hernia


• Most of patients with extra-esophageal signs and symptoms benefits of medical therapy.

• Several patients with typical symptoms of GERD can benefit of surgical treatment.

• Patients with documented pathologic laryngopharyngeal reflux (LPR) and positive symptom correlation may benefit from a laparoscopic fundoplication.

EAES recommendations for the management of

gastroesophageal reflux disease. 2014

Surgical therapy

• Laparoscopic partial and total

fundoplications are currently the best

available surgical techniques to treat severe

GERD.

•TOTAL FUNDOPLICATION

• PARTIAL FUNDOPLICATION: TOUPET

FLOPPY-NISSEN

NISSEN-ROSSETTI

DOR

WHICH TECHNIQUE?

Laparoscopic surgery

of gastroesophageal reflux

Exposure of the operating region

esophagus access:

incision of pars condensa and dissection of the right pillar.

incision of the phrenoesophageal

membrane

dissection of the left pillar to the

left margin of the esophagus.

passage of retro-esophageal webbing

Exposure of the hiatus after esophageal mobilization

Rapprochement pillars of the diaphragm posteriorly

esophagus

valve passage posteriorly esophagus

Process according Nissen.

360°Process according Toupet

270°.

Process according Nissen.

Nissen.mp4

Robotic Dor Fundoplicatio

First the diagnosis (opponent's study)

then the strategy (tactics)

and then the victory on the field!

[email protected]

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GERD solo patologia gastro-esofagea?€¦ · GERD •“a prevalent and chronic condition in which reflux of the stomach contents into the oesophagus causes a range of troublesome