Pathophysiology of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease pathophysiology is multifactorial and linked to a misbalance between the aggressiveness of the refluxate into the esophagus or adjacent organs and the failure of protective mechanisms associate or not to a defective valvular mechanism at the level of the esophagogastric junction incapable of dealing with a transdiaphragmatic pressure gradient. Antireflux mechanisms include the lower esophageal sphincter and abdominal esophagus, the diaphragm, the angle of His, the Gubaroff valve, and the phrenoesophageal membrane. Protective mechanisms include esophageal motility, saliva production, and epithelial protection. Disruption of this balance occurs most commonly due to the presence of a hiatal hernia, esophageal dysmotility, a rise in abdominal pressure (obesity), and decrease in thoracic pressure (chronic lung diseases).     

Pathological Basis of Gastroesophageal Reflux Disease

Many of the present definitions of Barretts esophagus are based on the dogma that 2 to 3 cm of cardiac mucosa normally line the distal esophagus and proximal stomach. Recent autopsy data refute this dogma. Cardiac mucosa has been shown to be frequently absent from the squamocolumnar junctional zone. When present, its extent is less than 0.5 cm in almost all children and most adults. Cardiac mucosal length increases with age. Patients who have cardiac mucosa are significantly more likely to have abnormal acid exposure in the esophagus as measured by 24-hour pH studies. The length of the cardiac mucosa correlates significantly with the amount of reflux: the greater the length of the cardiac mucosa, the more reflux there is. These new data provide insights into the pathology of gastroesophageal reflux. Normalcy is defined as an esophagus lined by squamous epithelium and a stomach lined by gastric mucosa. Reflux disease is defined by the presence of cardiac mucosa in a junctional biopsy. The severity of reflux disease is quantifiable by the length of cardiac mucosa present. Mutational reflux disease (Barretts esophagus) is defined by the occurrence of intestinal metaplasia in cardiac mucosa and is quantitated by the amount of intestinal metaplasia present. Neoplastic reflux disease is defined as the occurrence of low grade dysplasia, high grade dysplasia, and adenocarcinoma in Barretts esophagus. An attempt is made here to develop a rational grading system for reflux based on these highly objective histologic criteria.     

Surgical Treatment of Gastroesophageal Reflux Disease

Background

Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) therapy are effective in the majority of patients and remain the mainstay of treatment of GERD. However, some patients will need surgical intervention because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI therapy.

Aims

The aim of this study was to review the available evidence that supports laparoscopic antireflux surgery, and to study the effect of surgical therapy on the natural history of GERD.

Results

The key elements for the success of antireflux surgery are proper patient selection, careful analysis of the indications for surgery, complete pre-operative work-up, and proper execution of the surgical technique.

Conclusions

When the key elements are respected, antireflux surgery is very effective in controlling GERD, and it is associated to minimal morbidity and mortality.

     

Medical Treatment of Gastroesophageal Reflux Disease

Medical treatment is effective in the majority of patients with gastroesophageal reflux disease (GERD). Lifestyle modifications are often recommended for patients with GERD, although the data supporting lifestyle recommendations are limited. Antacids are often used to treat the symptoms of GERD, but their effect is short-lived. H2-receptor antagonists and proton-pump inhibitors provide more effective options for remission of GERD symptoms and healing of esophagitis. Prokinetic medications (e.g., metoclopramide) have not been proven to help in the control of symptoms. Baclofen, which inhibits transient lower esophageal sphincter relaxations, provide an additional option for patients with persistent symptoms related to GERD; however its use is limited by side effects. Long-term medical therapy for GERD should be tailored to each patient to provide symptomatic control and maintain esophageal mucosal healing.     

New Approaches to Gastroesophageal Reflux Disease

Journal of Gastrointestinal Surgery - Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder of the esophagus. It is a chronic, progressive disorder that presents most...     

腹腔镜胃底折叠术治疗胃食管反流病

目的探讨腹腔镜胃底折叠术治疗胃食管反流病的临床效果。方法2008年1月-2011年11月对40例胃食管反流病行腹腔镜胃底折叠术。腹腔镜单纯胃底折叠术7例（Toupt式）,腹腔镜食管裂孔疝修补加胃底折叠术33例（Nissen式5例,Toupet式28例）。结果手术均获成功,无中转开腹及死亡病例,无术后严重并发症。手术时间75～215min,平均112min;术中出血量10-350ml,平均52ml;术后住院5—10d,平均7d。40例术后随访1—24个月,平均16个月,34例临床症状完全消失,6例症状明显好转。结论腹腔镜胃底折叠术治疗胃食管反流病疗效满意。     

Emerging Concepts of Bile Reflux in the Constellation of Gastroesophageal Reflux Disease

Rationale

Reflux of gastric and duodenal contents in patients with gastroesophageal reflux disease (GERD) has been postulated as a major cause of complications, such as Barrett’s esophagus or malignant degeneration.

Findings

We present a summary of experimental, clinical, and immunohistochemical studies that show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett’s esophagus, and are possibly related to the development of esophageal adenocarcinoma.

     

Gastroesophageal Reflux Disease: Diagnosis and Patient Selection

Gastroesophageal reflux disease (GERD) has a high prevalence worldwide. Recent reports have noted a high prevalence even in Asian countries. GERD significantly affects the quality of life and can present with a wide variety of symptoms. Not all reflux is acid, and non-acid reflux disease can be more difficult to diagnose and can lead to a variety of extra-esophageal symptoms. Although proton pump inhibitors (PPIs) are effective in the majority of patients, but they are not without side effects, and their effect often diminishes with time. For patients who do not desire to be on long-term PPIs or have incomplete symptom resolution with medication, various endoscopic and minimally invasive treatment modalities are now available. The etiology of GERD can be multifactorial including dysfunctional LES, presence of a hiatal hernia, and transient lower esophageal sphincter relaxations (TLESRs). We hence believe that the treatment should be individualized to the cause of the reflux. In the following review, we describe the etiology of reflux disease and attempt to lay a framework for the diagnosis and selection of patients for the various interventions available for treatment, along with their evidence base.