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.
*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 :
- Gastric distension - ^ increase in TLESR.
- 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 :
- – le pyrosis, defined by a burning retro sternal ascending, most postprandial, positional(ante trunk flexion, decubitus).
- – 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 :
V- Additional tests :
1- SHUT :
*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 :
- Age > 50 years
- d & rsquo signs warning
- atypical symptoms: A diagnostic purposes
- initial treatment failed properly conducted
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.
- RGO punishment without œsophagite
- Atypical forms without esophagitis (SHUT normale).
- 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 :
- Initial treatment should be stopped when & rsquo; it allows the disappearance of symptoms.
- Widely spaced recurrence of symptoms (without esophagitis or with a non severe esophagitis), the patient can be treated intermittently
- 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.
- 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