Gastroesophageal reflux “RGO” and its complications

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I- Definition :

  • The passage through the cardia, d & rsquo; part of the stomach contents into the & rsquo; esophagus independently of any contraction of the stomach muscles.
  • GERD physiological exists in most subjects, mainly after meals. By definition, it s & rsquo; accompanies or symptom, or esophageal mucosal injury.
  • by convention called GERD, pathological reflux, characterized by symptoms and / or mucosal lesions caused by contact esophageal too often and / or too long of gastric contents with esophageal mucosa.
  • In the majority of cases, GERD is acid, alkaline rarely.

INTEREST :

*c & rsquo; is an extremely common condition.

*usually benign, may be complicated by stenosis, haemorrhage, EBO.

^ Treatment : -Medical : IPP

  • Surgical treatment has its specific indications.
  • Endoscopic treatment being & rsquo; evaluation.

II- Anatomy of & rsquo; esophagus :

1- Gross anatomy :

C & rsquo; is a conduit connecting the musculo-membranous pharynx cardia.

It measures 25cm long and 2cm in diameter.

It is divided into cervical esophagus (4cm); thoracic (18cm) et abdominal (2-3cm).

At its upper junction there is a valve called SSO.

At its lower junction does not have anatomical sphincter sphincter function but physiological "high pressure zone"

2- Phvsiologie of & rsquo; esophagus :

A – Physiology of the body of the & rsquo; esophagus :

1- Study rest :

negative intraluminal pressure relative to the atmospheric pressure.

2- primary peristalsis :

-Swallowing causes the propagation of & rsquo; a contractile wave from the pharynx until & rsquo; the body of the & rsquo; esophagus.

3- secondary peristalsis :

-This peristalsis is induced by esophageal distention and acid reflux, it has a role in clearance.

B- sphincter of Physiology & rsquo; esophagus :

1- Study at rest : C & rsquo; is a high pressure zone

2- Study after swallowing :

-WIS has a relaxation for the duration of swallowing.

-The transient relaxation WIS (RTSIO) l-2h occurs after swallowing triggered by gastric distension = GERD physiological.

III- Mechanism of GERD and predisposing factors predisposing :

1- complex multifactorial.

2- It results & rsquo; an imbalance between :

Defense Factors that protects & rsquo; esophagus :

  • The antireflux barrier : mainly presented by the ORC and the diaphragm muscle
  • The clearance of the & rsquo; esophagus:
  • physical clearance = secondary esophageal peristalsis
  • clearance = chemical buffering of salivary bicarbonate secretion
  • Tissue resistance.

Aggressive factors from stomach contents :

  • gastric acidity.

-Volume and nature of gastric contents.

3- Mechanisms of GERD :

A- Failure of the anti-reflux barrier :

* transient relaxation WIS : TLESR in patients with GERD there & rsquo; has increased frequency of transient relaxations of the LOS which are independent of swallowing especially when lying down.

* Hypotension you SIO.

* Hernie hiatal :

– Removes angle of His and the action of the diaphragm pound.

– hiatal hernia dissociates the SIO of the diaphragm which are superimposed anatomically and predisposes to GERD

Hiatal hernia causes increased stimulation of the triggering of TLESR and sequestration of & rsquo; acid in the hernial pocket may predispose to acid reflux.

B- Impaired clearance of & rsquo; esophagus : by disorder of esophageal peristalsis and / or abnormal salivation.

C- Failure of the esophageal mucosa resistance,

D- Slowing gastric emptying resulting tie :

  1. Gastric distension - ^ increase in TLESR.
  2. Stimulates gastric acid secretion.

E- Composition of the reflux material ris :

GERD is acid mainly from gastric acid secretion.

GERD may be mixed containing secretions biliary-pancreatic secretions with acids.

GERD may be purely alkaline so total gastrectomy.

IV- clinical Manifestafions :

Type Description: Uncomplicated GERD

1- typical symptoms :

  • A typical symptoms n & rsquo; is present only in half of the patients.
  • Typical symptoms are :
  1. – le pyrosis, defined by a burning retro sternal ascending, most postprandial, positional(ante trunk flexion, decubitus).
  2. – acid indigestion They specificity 90%.
  • Signs of & rsquo; alarms are absent, but we must seek systematically : digestive hemorrhage, dysphagie, odynophagie, abdominal mass, alteration of the & rsquo; condition, anemia ; emaciation.

2- atypical symptomatology :

Dental sYMPTOMS
digestive
Manifestations
O.R.L
Manifestations
lung
Manifestations
Pseudo
heart
  • Gingivites
  • Dental caries repeatedly
  • heartburn
  • nausea
  • Eructations
  • Hoarseness
  • chronic pharyngitis
  • Posterior laryngitis chronic
  • night cough
  • wheezing dyspnea
  • recurrent chest infections
  • pain nickname- anginal
  • retro-sternal chest pain

V- Additional tests :

1- SHUT :

* unsystematic

*n & rsquo; is positive that & rsquo; in case & rsquo; peptic esophagitis "does not d & rsquo; exclude the diagnosis of & rsquo; GERD if negative"

*11 are many classifications for d & rsquo; establish the severity of the & rsquo; esophagitis.

/The most used is the classification of Savary-Miller / most recently the Los Angeles classification simple and reproducible, whose complications are excluded (stenosis and Barrett).

De Savary and Miller classification

Stade 1: isolated erosion
Stade 2 : erosions confluent but not circumferential
Stade 3 : erosions confluent and circumferential
Stade 4 : complication : oesophageal ulcer – peptic stricture, endobrachyoesophage

Classification de Los Angeles

Grade A One or more "gaps mucous" not exceeding 5 mm
Grade B At least a "breach mucosa" more 5 mm without continuity between the tops of two mucosal folds
Grade C At least a "breach mucosa" extending in continuity between the tops of several mucosal folds,
but not circumferentially
Grade D "Breach mucosa" circumferential

OGDF INDICATED IN 5 SITUATIONS :

  1. Age > 50 years
  2. d & rsquo signs warning
  3. atypical symptoms: A diagnostic purposes
  4. initial treatment failed properly conducted
  5. preoperative

2- PH metry of 24 hours :

  • C & rsquo; is & rsquo; review of reference whose reproducibility, Sensitivity and specificity are around 90 %.
  • is to record the pH in the lower esophagus in the usual conditions, sure 24 hours, through an electrode placed in 5 cm- WIS above and connected to a portable digital recorder with d & rsquo; a marker & rsquo; event that the patient can activate to report symptoms, meals, changes in position…etc.
  • Indications:
  1. RGO punishment without œsophagite
  2. Atypical forms without esophagitis (SHUT normale).
  3. medical treatment resistance

3- Le test DC Another IPP :

TRT is a short and high dose, administered for diagnostic purposes. It could be an alternative to the pH monitoring of 24 hours.

4- Other explorations :

TOGD: useless unless d & rsquo; HH, stenosis.

Esophageal manometry : reported pre-on & rsquo; une antireflux surgery : search engine Disorder & rsquo; esophagus, hypotension du SIO.

esophageal scintigraphy

Acid infusion test (Bernstein) : substituted PH metry of 24 h.

WE- EVOLUTION :

  • GERD is often a chronic disease with frequent relapses.
  • After d & rsquo; a monitoring 5 at 10 years, 2/3 patients complain of persistent symptoms, imposing a TRT.
  • L & rsquo; d & rsquo évolution; a benevolent forms of RGO, without severe lesions d & rsquo; esophagitis, to a severe or complicated seems unusual.
  • Complications are more common in elderly patients and in case of & rsquo; severe esophagitis.

VII- Complications :

1- Reflux oesophagitis :

  • The most common complication.
  • In the majority of cases, injuries d & rsquo; esophagitis are not severe. They are not correlated to the & rsquo; symptom intensity
  • In a minority of cases, severe esophagitis is present.
  • Clinique : asymptomatic, RGO, Odynophagie, gastrointestinal bleeding, dysphagie.
  • SHUT : identifies lesions : erythema, erosion, ulcer.

2- peptic stricture :

  • Rétrécissement benin du caliber of light œsophagienne aux consecutive lesions of RGO.
  • 2 Phases : reversible (edema, vascular congestion) and irreversible (fibrosis).
  • Clinique : RGO, organic dysphagia, emaciation, gastrointestinal bleeding.
  • SHUT :

– short regular stenosis especially 1/3 lower ulcerated or not.
– remove a malignant causes, biopsies after expansion.

3- Endobrachyoesophage :

Definition :

  • endoscopic : replacing the squamous mucosa of & rsquo; distal end of the & rsquo; esophagus mucous glandular.
  • histologic : presence of glandular metaplasia that can be gut + + + to & rsquo; origin of dysplasia (the most common) or gastric.

Clinique : RGO.

SHUT : orange-red coloration up above the gastroesophageal junction, EBO can be long> 3cm or short.

f. evolution : can progress to the & rsquo; esophageal adenocarcinoma, c & rsquo; is a pre-neoplastic lesion.

VII- DIAGNOSTIC :

1- POSITIVE DIAGNOSIS :

—> Typical symptoms without signs of & rsquo; alarm in a subject under 50 years : Medical TRT immediately, without the need for further investigations ;

—> typical symptoms, with symptoms & rsquo; alarm or age >50 years : SHUT.

—> atypical symptoms, digestive or extra digestive : OGDF completed, in the & rsquo; & rsquo absence; esophagitis, by pH-metry oesophageal

2- DIFFERENTIAL DIAGNOSIS :

  • Typical symptoms (pyrosis + acid regurgitation) : specificity 90% :
  • Pyrosis dyspepsie, other pain.
  • Régurgitations pituite, mérycisme.
  • atypical manifestations : linking with GERD.
  • Esophagitis and strictures causes of stenosis.

VIII- Treatment :

1- BUT :

  • Improvement in symptoms and quality of life.
  • Wound healing in severe esophagitis.
  • Preventing recurrence
  • Prevention and TRT complications.

2- TRT weapons :

A- medical TRT :

1- the lifestyle changes and postural :

– Raise the bed level (head) from 10 at 15 centimeters
– Avoid large meals especially at night
– Do not s & rsquo; lying down immediately after a meal
– Reduce the weight if overweight
– Remove tobacco and & rsquo; alcohol
– Avoid tight clothes.

2- prokinetic :

  • accelerate gastric emptying.
  • can contribute to the & rsquo; symptom improvement

3- antacids :

With or without alginates neutralize & rsquo; gastric acidity

  • have a duration of & rsquo; brief action of & rsquo; order 30 minutes.
  • quickly relieve the symptoms but are not effective long-term.

4- The H2 receptor antagonists :

They improve symptoms in half of the cases and heal injuries d & rsquo; esophagitis in a third to half the cases.

5- Pump Inhibitors Proton (IPP) :

– Are very effective as on symptoms than on wound healing d & rsquo; esophagitis, with excellent tolerance.

6- Agonists on the GABA : baclofen : A proven effective on TLESR

B- TRT chirurgical :

  • Goal : reconstruct an anti reflux barrier.
  • Methods :

– Total fundoplication "Nissen" "best long-term effectiveness"
– partial posterior fundoplication "Toupet" "low morbidity".
– Other : cardiopexie, duodenal diversion.

  • Indications :

– GERD invalidating resistant to medical treatment.
– RGO récidivant necessitant the IPP aux recours au long cours
– Surgical treatment should be considered in young patients without comorbidity or anesthetic risk provided that the patient is fully informed of the possible risks of surgery.

C- endoscopic TRT :

Ongoing d & rsquo; evaluation, several methods :

1- radiofrequency : Its principle of & rsquo; inducing thermal damage WIS and cardia.
2- endoscopic suture = cardioplicature
3- prosthesis implantation at the cardia

3- INDICATION :

A- initial strategy :

—> Typical symptoms and spaced (less & rsquo; once a week), and in the absence of alarm symptoms —> demand treatment.

antacids, alginates or H2 blockers low dose can be used, this regulation must s & rsquo; d & rsquo support; information on lifestyle changes and postural.

—> Typical symptoms close (once a week or more) in patients under 50 years, without alarm symptoms —> Treatment of 4 weeks. Un IPP, an anti-H2 standard dose, can be used. If successful, Treatment should be stopped. If & rsquo; inefficiency or early recurrence, endoscopy must be carried.

—> An endoscopy should be performed if the subject is older than 50 years or if symptoms & rsquo; alarm.

In the & rsquo; & rsquo absence; esophagitis or if there & rsquo; not severe esophagitis : treatment 4 weeks by anti secretory, preferably PPI, should be considered. If & rsquo; endoscopy was justified by therapeutic failure, PPI full dose should be used.

If & rsquo; severe esophagitis (circumferential) or complications : PPI therapy at full dose for 8 weeks should be initiated and followed & rsquo; an endoscopic control to check the healing of the anatomical lesions.

In the & rsquo; lack of healing or symptomatic remission, an increase doses should be considered.

—> If extradigestive events : PPI standard dose or double dose for 4 at 8 weeks, sous réserve que le diagnostic de RGO summit établi.

B- Long-Term Strategy :

  1. Initial treatment should be stopped when & rsquo; it allows the disappearance of symptoms.
  2. Widely spaced recurrence of symptoms (without esophagitis or with a non severe esophagitis), the patient can be treated intermittently
  3. if d & rsquo; severe esophagitis or compliquée.En case & rsquo; severe esophagitis ; because of the almost constant recurrence of symptoms and esophageal lesions in & rsquo; stop anti secretory ; it is recommended to prescribe a long-term PPI minimum effective dose.
  4. frequent relapses or early in & rsquo; stopping treatment, resounding quality of life, impose a processing & rsquo; maintenance PPI doses adapted to seeking the lowest effective dose.

C- TRT complications :

1- The peptic stricture :

  • Traitée en continu by IPP, usually at high doses.
  • Si dysphagie : endoscopic dilatation (Balloon or candles) + IPP.
  • Surgery is discussed in case of & rsquo; failure of the medical strategy :

2- L’endobrachyoesophage :

  • Symptomatic or associated with oesophagitis : IPP.
  • endoscopic and histological surveillance is essential in search of high-grade dysplasia and carcinoma in situ.

IX- CONCLUSION :

RGO = pathologie issues => Pb multifactorial pathophysiology public health
The diagnosis is usually easy but you have to evoke From front atypical manifestations.
L & rsquo; n & rsquo endoscopy, is not systematic.
L & rsquo; evolution is often chronic.
Complications are rare but can be serious.
The reduction in & rsquo; chlorhydro-peptic aggression is very effective ( IPP ++ ) but does not cure the disease.
Surgery has specific indications.

Course of Dr L. BELGHAZI – Faculty of Constantine