Definition of gastroesophageal reflux disease (GERD)
A condition that develops when reflux of stomach contents causes troublesome symptoms (regurgitation and heartburn) affecting QOL with or without complications.
Refractory GERD definition: < 50% response in reflux related symptoms to an 8 - 12 weeks course of once a day PPI.
What is Lower esophageal sphincter ( LES)?
Lower esophageal sphincter (LES) is defined by manometry as a zone of increased intraluminal pressure at the COJ. It is a physiological sphincter 3- 4 cm length at COJ.
Pathphysiological of GERD
- Gastroesophageal sphincter function is maintained by:
- Positive intra-abd pressure on abdominal esophagus
- Physiological high pressure at lower end esophagus
- Valve like effect of obliquity of COJ
- Pinch cock effect of crural sling of diaphragm
- Plug like action of mucosal fold.
- Physiology
- Transient relaxation of LES < 8s to allow food passage
- Food passage by peristalsis
- Acid pocket is a physiologic phenomenon that occurs in all individuals, caused by gastric acid that does not mix properly with food and, as such, floats on top of ingested.
Etiology of GERD
Acid pockets
- Patients with GERD, gastric acid floats, or refluxes, back from the stomach or the pocket into the esophagus more often than in healthy individuals. It is unclear why this happens.
Lower resting LES pressure
- Coffee, alcohol, smoking, Ca-channel blocker, β blocker, morphine.
Hiatal hernia
- Migration of LES → lost positive intra-abdominal pressure → lost pinch cock effect of crura → sequestration of gastric content or places the acid pocket inside the thoracic cavity above the diaphragm.
Obesity
- ↑ intra-gastric pressure → partial hiatal hernia → decrease LES pressure & with delayed gastric emptying.
Impaired clearance of esophagus & gastric - achalasia, scleroderma
LES dysfunction & delayed gastric emptying → acid reflux into lower esophagus leads to:
- Esophageal inflammation
- Chronic exposure leads to benign stricture, Barrett’s & malignancy
- Respiratory complications : Laryngitis, pneumonia, bronchospasm
Food products - chocolate, peppermint, citrus juices but not carbonated beverages.
Classification of GERD
- Erosive reflux disease (ERD): Reflux-induced inflammation or ulceration of distal esophagus + abnormal pH ± Extraesophageal Syndromes
- Non-erosive reflux disease (NERD): Normal esophagus + abnormal pH ± Extraesophageal Syndromes
Presentation of GERD
- Other Symptoms
- Waterbrash (excessive salivation), laryngeal irritation (hoarseness, throat clearing), pneumonia.
- Alarm symptoms - Progressive dysphagia, LOW, LOA, anemia, age > 55. Need immediate workup for CA.
A Clinical diagnosis - Treatment can be started based on clinical diagnosis alone if no alarm symptoms (PPI 1 month)
- Differentials include: PUD, gastritis, gallstone disease, IHD, pneumonia.
Investigation for GERD
1) OGDS
2) Barium studies
3) Esophageal manometry
4) 24 hour ambulatory pH monitoring
5) Cardiac investigation
Investigation - OGDS, barium studies & Esophageal manometry
- Diagnosis : Esophagitis, ulcer, stricture, Barrett’s, Cancer, Hiatus hernia.
- Patients who failed empirical PPI treatment should have OGDS +/- biopsy (AGA grade B)
- Patients with troublesome dysphagia should have biopsy (AGA Grade B)
- No role for endoscopic monitoring of response to treatment.
- Assessment of severity
- Los Angeles Classification
- Savary& Miller Grading Scale
- Therapeutic : Stricture dilatation, ESD, EMR
Barium studies
- Assessment of strictures if OGDS unable to pass through
Esophageal manometry
- If functional disorder is suspected (normal OGDS)
Investigation - 24 hour ambulatory pH monitoring
- Gold standard for diagnosis of GERD, Suspected GERD not responding to PPI with normal OGDS &manometry
- To be done with esophageal manometry to confirm LES. Sensor need to be placed 5 cm above LES & 5 cm below UES.
- Scoring based on DeMeester score.
- Prerequisite : STOP PPI 1 week & ranitidine 2 days before. NBM.
- Patient need to record time of lying down, ambulation, eating.
Types:
1) Conventional pH
2) Dual probe (pH impedance)
3) wireless pH monitoring ( Bravo pH device)
4) Multichannel intraluminal impedance and pH monitoring
- Reflux is defined as pH < 4. Complications of GERD occur with pH < 4 due to pepsin activation.
- Why pH < 4?. Pepsinogen converted to pepsin at pH 4, pH < 4 was one that tends to produce symptoms.
- Confirm volume reflux with impedance.
- Confirm bile reflux with bilitec 2000.
-Normal study but symptomatic?
- Patient reduce activity during recording.
- Weak acidic reflux (pH 4- 7 with impedence show volume reflux)
- Alkaline reflux (pH > 7) – need Bilitec to confirm bile reflux.
Investigation - Cardiac investigation
ECG, Stress test, ECHO TRO cardiac abnormality (HEARTBURN OR HEART ATTACK!!)
Management of GERD
Aim of Treatment:
1) GERD symptom control
2) Heal esophagitis
3) Reduce risk of essophageal cancer
Before starting treatment, RULE OUT CARDIAC PROBLEM
Management divided into:
1) Conservative ( non pharmacological and pharmacological)
2) Surgical management ( Laparoscopic & Endoscopic)
Conservative management ( non pharmacological)
- Life-style modification
- Weight loss (if obese)
- Avoid alcohol, citrus juice, smoking
- Avoid large meals & late meals.
- Wait 3 hours after meal before lying down
- Elevate head end of bed
Conservative managment ( Pharmacological)
- Prokinetics
- Generally indicated in delayed gastric motility or esophageal dysmotility (functional dyspepsia)
- Diagnosis of exclusion after proper evaluation.
- Ganaton, maxolon
Ganaton is the brand name for Itopride hydrochloride, a prokinetic agent used primarily to treat functional dyspepsia and gastroparesis. It enhances gastric motility and improves symptoms like bloating, early satiety, and nausea.
⚙️ Mechanism of Action of Ganaton (Itopride)
1. Dopamine D2 Receptor Antagonist
Itopride blocks dopamine D2 receptors in the gastrointestinal (GI) tract.
Dopamine normally inhibits acetylcholine (ACh) release — by blocking this, Itopride increases ACh availability, enhancing gut motility.
2. Acetylcholinesterase Inhibition
It also inhibits the enzyme acetylcholinesterase, which breaks down acetylcholine.
This leads to more sustained action of acetylcholine at muscarinic receptors in the GI smooth muscle.
🧠 More ACh = Stronger, coordinated GI contractions = Better gastric emptying
✅ Effects of Ganaton:
- Promotes gastric emptying
- Enhances esophageal and antral contractions
- Reduces gastrointestinal stasis-related symptoms
- No significant crossing of blood-brain barrier → fewer central side effects (e.g., extrapyramidal symptoms) compared to older prokinetics like metoclopramide
Surgical Management - overview
- Indications
- Failed medical treatment
- Intolerable medical treatment
- Patient refusing medical treatment
- Young patients
- Anatomical defect with large hiatal hernia
Surgical management - Laparoscopic
- Fundoplication
- Complete Fundoplication - Higher resolution of GERD but higher complication rates (dysphagia - common for 1st 4 weeks, gas bloat syndrome - common up to 2 months, early satiety, colic, inability to vomit, diarrhea, nausea, flatulence).
- Nissen
- Partial Fundoplication - Good resolution of GERD, Lower complication rates (dysphagia, gas bloat syndrome)
- Belsey : 270⁰ anterior transthoracic fundoplication
- Dor : 180⁰⁰ anterior fundoplication
- Toupet : 270⁰ posterior fundoplication - difficult to belch
- Complete Fundoplication - Higher resolution of GERD but higher complication rates (dysphagia - common for 1st 4 weeks, gas bloat syndrome - common up to 2 months, early satiety, colic, inability to vomit, diarrhea, nausea, flatulence).
POEF: Per- oral endoscopic fundoplication
Surgical management - Laparoscopic (2)
- Laparoscopic Nissen vs. PPI : Better symptomatic & QOL outcome. Curative in 85- 90% patients. Good long term outcome
- Aim:
- Restore anti-reflux barrier
- Strengthen esophageal peristalsis
- ↑ gastric emptying
- Operative steps
- Crural & circumferential dissection of esophagus include division of short gastric artery
- Hiatal Hernia reduction
- Crural closure
- Recreation of angle of His
- Fundoplication (tension free & not too tight)
- Esophagopexy
- Aim:
Surgical management - Laparoscopic (3) - latest advancement
The LINX® Reflux (GERD) Management System (Magnetic sphinnter augmentation) consists of tiny magnetic titanium beads that are placed, through minimally invasive laparoscopic surgery, around the area where your stomach and esophagus meet.
- When you swallow, the rings open to let in food and liquids, but quickly close again to keep your stomach acid from traveling up your esophagus and causing heartburn.
- LINX is designed to restore your stomach’s natural acid barrier.
Surgical management - Laparoscopic (4)
Complication post lap fundoplication
Surgical management - Endoscopic
Divided into:
1) Radiofrequency energy application
2) Plication Suturing
3) Mucosal resection procedure
4) Mucosal injection procedure
Radiofrequency Energy Application
- Stretta procedure
- Radiofrequency energy is delivered via 4 needle electrodes are deployed starting 1 cm above and below the z line to obtain nerve ablation and collagen remodeling.
Surgical management - Endoscopic (2) - Endoscopic Plication Suturing
Endoscopic Plication Suturing
- EsophyX TM
- Endocinch
- Wilson-Cook endoscopic suturing system
- MUSE (Medigus Ultrasonic Surgical Endostapler)
- Create transoral incisionless fundoplication (TIF) immediately below or at level of GEJ.
- Method is based on aspiration of the mucosa within a hollow capsule, fixed at the end of an endoscope, with subsequent piercing by a hollow needle.
- Both folds are approximated and sutured together to constitute a single plication.
Surgical management - Endoscopic (3) - Endoscopic Mucosal Resection Procedures
- Endoscopic Anti-reflux mucosectomy (ARMS)
- Endoscopic mucosal resection along the lesser curvature side of gastric cardia to reshape the mucosal flap valve.Inject area with saline, apply band, resect, Heals with fibrosis.
Surgical management - Endoscopic (4) - Endoscopic Mucosal Injection Procedures
- Enteryx
- Biocompatible non-biodegradable polymer (an ethylene-vinyl-alcohol copolymer known as Enteryx) mixed with radiopaque tantalum, which is injected into the muscle of the cardia under fluoroscopic control. Once the polymer comes in contact with water, it is transformed into a foamy particle.
- Bovine collagen or Teflon, biocompatible non-biodegradable polymer (Ethylene-Vinyl-Alcohol), encouraging but transient results in terms of symptoms.
- Gatekeeper system
- Consists of placing several dry hydrogel cylinder-shaped prostheses in the submucosal layer.
- Each prosthesis absorbs fluids and gradually swells, reaching up to 15 mm in length and 6 mm in diameter. A specially designed overtube is used for prosthesis placement.
- A region of the distal esophageal mucosa is sucked into an opening of the overtube and physiological saline is injected.
- Saline creates an artificial chamber into which the prostheses are placed.
- Implantation of several prostheses above the z line reduces the diameter of the gastro-esophageal junction.
Grading for Esophagitis
