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Gastro Esophageal Reflux Disease (GERD): Symptoms, Diagnosis, Treatment, Complications

Source: www.bizjournals.com
Anatomy of Esophagus

Length: 25-30 cm, 5 cm cervical, 20 cm chest, 2-3 cm abdominal.
muscular: circular interior and external longitudinal
Innervation: upper third: striated muscle tissue innervated by Recurrent laryngeal nerve
lower two-thirds: smooth fibers innervated from the vagus nerve.
The Arterial perfusion is in the form of a piece (each piece has an artery)
The arterial perfusion of the esophagus is provided mainly from the Inferior thyroid artery at the top, and the left gastric artery at the bottom.
The venous return: the upper part of the esophagus flows into the jugular, then from the jugular moves to the superior vena cava.
The middle part flows into the azygos vein and hemiazygos vein and from it to the superior vena cava
The lower part flows into the portal vein and from it to the inferior vena cava.

Gastro Esophageal Reflux Disease (GERD)
The most common diseases of the esophagus.
80% of patients have nighttime symptoms (occurring when the person lies down and gastric secretions return to the esophagus if the lower esophageal sphincter is weak) and 63% of the patients suffer from lack of sleep and their work is affected the next day.

Typical clinical symptoms
First: Heartburn behind the sternum:
It increases with spicy, sour foods, tomato sauce, coffee, chocolate, and alcohol.
Start after 1-2 hours of food, often at night, improve with antacids.

Second: food reflux:
It increases at night or when lying down after food (non-projectile vomiting).
Not much better with antacids, but less severe.

Third: Dysphagia:
With chronicity of the disease, the disorder occurs in esophageal motility and cause esophageal Dysphagia.
In 40% of patients with gastroesophageal reflux disease when examined well, they develop slowly.

Non-typical symptoms
Night cough, non-heart chest pain, dyspnea, hoarseness, and pharyngeal pain.

Anti-reflux barrier mechanism
Through lower sphincter and effective oesophageal cleaning (via peristalsis) and proper function of the gastric reservoir.
properties of the lower esophageal sphincter are a total length (2 cm), pressure (13 mmHg), and length of the part exposed to positive abdominal pressure (greater than 1 cm).
The most common cause of permanent lower sphincter failure is the insufficient length of the abdominal part (sliding hiatal hernia).

Pathogenesis of gastro-esophageal reflux
  • The patient is compensated with excessive swallowing, which causes abdominal bloating and stomach enlargement (the excessive swallowing reflex after surgery continues for 6 months, during which the patient complains of bloating until the patient forgets the reflex).
  • Frequent enlargement of the stomach leads to recurrent injury in the stratified squamous epithelium (esophagitis).
  • Prolonged inflammation to muscularis propria causes a weak sphincter permanently (fibrosis of the sphincter).
  • Intestinal metaplasia of the mucosa of the cardia is established for the pre-malignant phase.
Diagnosis of gastroesophageal reflux
  1. There is no need for diagnostic investigations with a classic story of gastroesophageal reflux.
  2. Upper gastrointestinal endoscopy: the most important diagnostic investigations, where the location of the gastroesophageal junction (which must be within the abdomen) is investigated, mucosal assessment, the presence of a hiatal hernia, and the presence or absence of Barrett's esophagus, as well as taking biopsies.
  3. Measurement of the pressure of the esophagus: To determine the function of the lower sphincter and its location within the abdomen, and the motility of the esophagus (where the motility of the esophagus is disturbed at constant scratching).
  4. Measurement of acidity of the esophagus: Measurement of PH and bilirubin of the esophagus for 24 hours: There are natural proportions of bilirubin present in the esophagus through the reflux during meals, and at a high rate, this refers to the Bile reflux.
Conservative treatment
Lift the head of the bed and avoid meals three hours before sleep, avoid lying down after meals, avoid alcohol, smoking, chocolate, coffee, large meals and eating multiple small meals, weight loss and avoiding tight clothes.

Most patients with mild symptoms take medication alone because of the prevalence of the disease. Heartburn For the first time needs to initial treatment with antacids (bicarbonate) for 8-12 weeks.

Proton Pump Inhibitors PPI
The basis of pharmacotherapy when symptoms persist.
High doses cure mild esophagitis and only 50% when there is severe esophagitis.
When the back acid is a stomach and duodenum acid, symptoms improve but the inflammation continues because the acid inhibitor treatment is not enough to make the esophageal-pH 7 all the time.
The recurrence is 80% within 6 months of discontinuation of treatment and must be treated for life.
The exposure of the esophagus to acid continues to 40-80% of patients with Barrett's esophagus despite a dose of 20 mg twice daily PPIs.
Drug therapy is not useful in the case of permanently weak sphincter: pressure less than 6 mmHg and the total length of the press is less than 2 cm and the length of the abdominal part is less than 1 cm.

Gastro-esophageal reflux complications
  • 42% of patients without complications
  • stomach and duodenum acid is the most harmful, especially the bile acidity.
  • The sphincter becomes permanently weak
  • Esophageal-pH becomes 4-7 (acidic)
  • Mucosa complications: inflammation of the gastric cardia, esophagitis, stricture, ulceration, PH = 4-7
  • Respiratory complications: asthma, bronchitis, chronic pharyngitis, aspiration pneumonia, progressive pulmonary fibrosis, non-related to PH
  • Metaplasia complications: intestinal metaplasia of the mucous of the gastric cardia, Barrett's esophagus, high-grade dysplasia, esophageal adenocarcinoma, PH = 4-7

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