Risk factors: GERD

- Smoking- Caffeine- Alcohol- Male gender- Ageall ↓ LES tone!+ Stress+ Obesity+ Pregnancy - common (↑IAP/hormones → ↓ LES tone)Angle of His >60° = angle between eso and gastric fundus - infants have a flat angle:+ Sliding hiatal hernia (↑ angle of His - see image)+ Gastrectomy (↑ angle of His) + Drugs (TCAs, anticholinergics, nitrates) + Scleroderma

Clinical features: GERD

1) Heartburn - retrosternal burning painWORSE when lying down/after food/straining!Relieved by antacids - Pressure sensation- Regurgitation- BelchingMicroaspirations in the resp tract →- Chronic non productive cough- Nocturnal cough/asthma- Laryngitis (hoarseness, throat clearing)- Dysphagia (later on); RED FLAG

Red flag signs

DysphagiaWeight lossEarly statietyMalaiseLoss of appetite

Complications: GERD

-- > Esophagitis --> strictures!Barret's esophagus (metaplasia, from squamous to columnar)> 3 cm of columnar epithelium between Z-line and GEJ) → higher cancer risk!Aspiration pneumonitis IDA (--ulcerations -- chronic bleeding)

Diagnostics: GERD

1) Exclude cardiac cause for chest pain2) No indications for endoscopy? --> emperic therapy with PPIsResponse? - Assumed GERDRelapse? ---> endoscopy Endoscopy (-)? --> 24 esophageal pH monitoring (nasogastric tube with a pH probe)Sudden drops of pH <4 + symptoms of reflux

Indications for endoscopy: GERD

>55 years- New onset indigestion - Unexplained/persistentOR- Worsening of symptoms At any age- Progressive dyspepsia despite PPI treatment+ history of barret's or cancer+ previous gastric surgery+ FH + recent NSAID use- Weight loss- Dysphagia - IDA- Vomiting

Treatment: GERD

1) Lifestyle modifications 2) Medical3) Surgery

Lifestyle modifications for GERD

- Small portions- Avoid eating <3 hours before bed- Exercise- Stop smoking, alcohol, caffeine...- Reduce acidic foods (citrus fruits, tomatoes, onions, fizzy drinks...)- Elevate bed head

Medical treatment of GERD

PPIs - once daily dose, at least 8 weeks No response/relapse? - Test/treat for H. pyloriPartial response: - ↑ the dose (to twice daily therapy) or switch to a different PPIGood response? - Discontinue PPI after 8 weeks

Surgery for GERD

Nissen fundoplication (see above)

Complications: Nissen fundoplications

Damage to the stomach, surrounding organs especially the esophagus, spleen, lungs/pleura (→ pneumothorax)Gas bloat syndrome: X belching → ↑ bloating/flatulence (stomach is wrapped too tight - LES tone is ↑↑ - "overcorrection" - gas cannot be released orally, leave via intestine)Dysphagia (especially to solids) - due to edema/inflammation - usually lasts 2-3 monthsTelescope phenomenon ("slipped Nissen"): the esophagus slides out of the wrapped stomach portionGastric denervation: Vagal nerve injury leads to bloating and cardiac complaints