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Prensentation - GORD - Definition PATHOPHYSIOLOGY ANTI – REFLUX

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Prensentation - GORD - Definition PATHOPHYSIOLOGY ANTI – REFLUX Powered By Docstoc
					                                                      GORD - Definition
                                                It is the abnormal exposure of the
                                                oesophagus to gastric contents :
                                                Results in symptoms complexes – mild
                                                symptoms 2X / week or moderate
                                                symptoms 1X/ week
                                                Affects quality of life
         OESOPHAGEAL REFLUX
                                                Mucosal injury to the oesophagus
                     Sandie R Thomson




        PATHOPHYSIOLOGY                           ANTI – REFLUX BARRIER
OFFENCE                   DEFENCE
GASTRIC RESERVOIR         LUMINAL CLEARANCE
REFLUXATE                 ANTI-
                          ANTI-REFLUX BARRIER




            HIATUS HERNIA                        CLINICAL PRESENTATION
                                                       TYPICAL SYMPTOMS
Traps gastric acid
Abolishes valve
                                                Heartburn       Acid regurgitation
  mechanism
Widens
  oesophaeal
  hiatus

GORD symptoms
 and severity of
 oesophagitis
                                                        ENDOSCOPY

                                                                           > 45yrs
                                                                           < 45yrs that fail Rx
                                                                           Alarm symptoms
                                                                           Long standing
                                                                           symptoms (> 5 yrs)
                                                                           Suspicious Barium
                                                                           study




   LA GRADING SYSTEM                             Shift in management

                                    1940         1970              1980            1990         2000+


                                    Antacids       H2 RA               PPI’
                                                                       PPI’s                      PPI’
                                                                                          “Better PPI’s”
                                                  prokinetics




                                       OPEN SURGERY :                            LAPAROSCOPIC
                                                                           laparoscopic
                                       Refractory oesophagitis                   Alternative to PPI
                                                                                    alternative to
                                       Complications                                 PPI therapy




 MEDICAL MANAGEMENT                            MEDICAL MANAGEMENT
                                                 > 45yrs or alarm symptoms = endoscopy
Lifestyle modification
Over the counter medication         < 45yrs with typical            Full dose PPI for 1 month with H
 Antacids and alginates                 symptoms                      pylori eradication if needed

 Prokinetics                                                      Relapse after             Response
 Histamine 2 receptor antagonists                               stopping therapy


                                                                Maintenance therapy
                                                                                          On demand
Proton pump inhibitors                                          Daily maintenance Rx
                                                                Intermittent Rx
                                                                                          treatment
                                                                                          Stop
                                                                On-demand Rx
                                                                On-                       treatment
  ANTI – REFLUX SURGERY                                            PATIENT SELECTION

 25000
                                                              POSITIVE PREDICTORS

 20000
                                                               Good response to PPI
 15000                                                         Typical symptoms
 10000                                                         Volume refluxers
  5000

     0
                      1985        1997                                            JACKSON P – American journal of surgery 2001

                           USA




                                                                 RECOMMENDATIONS FOR
         PATIENT SELECTION
                                                                      SURGERY
NEGATIVE PREDICTORS
                                                                Young patients
  NERDS
  Females                                                       Respond well to PPI therapy
  Patients with psychiatric disorders
                                                                Proven erosive disease
  Atypical symptoms
                                                                Typical symptoms of
                                                                  heartburn
    Thibault, Alimentary pharmacology and therapeutics 2006
                                                                  regurgitation
    Velanovich V, Surgical Endoscopy year




    GOALS OF ANTI – REFLUX
                                                              PRE – OPERATIVE EVALUATION
          SURGERY
                                                               Mandatory
                                                                 Endoscopy
Restore sphincter structure                                      Barium Swallow
                                                               Selective investigation
Preserve normal swallowing                                       pH studies
                                                                 Motility studies
Preserve ability to belch                                        Impedance
                                                                    NERDS
                                                                    Extraoesophageal symptoms
                                                                    Poor responders to PPI
  CONTRAST RADIOLOGY                                       24 hr pH STUDIES

Can show ulcers,
erosions and strictures
                                                 Indications
Hiatus hernia                                      No response to PPI
Indications for contrast                           NERD
study
  alarm symptoms eg                                Atypical symptoms
  dysphagia
  GORD before antireflux                           Recurrence after
  surgery
                                                   surgery
  symptomatic reflux after
  antireflux surgery




OESOPHAGEAL MANOMETRY                                  LUMINAL IMPEDANCE
                                                   Measures electrical
                                                   conductivity of
                             Placement of a pH     intraluminal contents
                             electrode
                             Dysphagia after       It measures volume
                             exclusion of          and nature of content
                             structural lesion
                             Confirmation of       It is used to
                                                   investigate patients
                             effect of Rx eg
                                                   with non – acid reflux
                             achalasia




         PARTIAL WRAPS                             SHORT FLOPPY NISSEN’S
                                                   Crural dissection
                                                   Circumferential dissection of the
                                                   oesophagus
                                                   Reduce hernia
                                                   Crural closure
                                                   Division of short gastrics
                                                   1.5 – 2 cm wrap over bougie
                                                         COMPLICATIONS
                                               Intraoperative and immediately post op

                                              Oesophageal perforation

                                              Bleeding

                                              Pneumothorax

                                              Vagal nerve injury




        COMPLICATIONS                          Local audit of anti – reflux surgery in
                                                         private practice
         New symptoms
                                                                            Yes      No
                                              Burping with Ease?            65.5%    30.9%
Dysphagia
                                              Excess Flatulence?            72.7%    27.3%
Gas Bloat
                                              Satisfied (Long Term)         60.0%    40.0%
                                              334 patients
Diarrheoa , nausea , vomiting
                                              Satisfied (Short Term) 535    79.4%    20.6%
                                              patients
                                              30 – 47% of patients were taking medication post
                                              operation             Losibekan, SAMJ 2005




             SUMMARY                                     COMPLICATIONS
PPIs work very well – even long term           Strictures
Surgery is good BUT not perfect

Patient selection is key                       Barretts oesophagus
Informed consent for surgery

Endoluminal therapy for specialised centres
and clinical trials in NERDS
                                                  BARRETT’S OESOPHAGUS
                          Site of stricture
                                              Incidence
                                              5–19% of pts with
                                                GORD



                                              Premalignant
                                              carcinoma risk 2– 5 %
Barium                                        high grade dysplasia
assessment                                    carcinoma risk 30 %




  4. Maximum           3. Maximum                 BARRETT’S OESOPHAGUS
  height of            circumferential
  Barrett`s            Barrett`s

                                              Screening not
  5. Measure C/M                               indicated
  grade

                       2. Locate the OG
                       Junction               Diagnosis established
                                                Endoscopically
  1. Identify hiatus
  hernia                                        Histologically




           PRAGUE CLASSIFICATION




 NARROW BAND IMAGING                                  AUTOFLUORESCENCE
   CONFOCAL ENDOSCOPY                              BARRETT’S OESOPHAGUS
                                              Treat reflux first
                                              Surveillance
                                           Barrett’
                                           Barrett’s no       Low-
                                                              Low-grade dysplasia   High-
                                                                                    High-grade dysplasia
                                           dysplasia

                                                                                    Confirm diagnosis
                                                                            6-
                                                              Rpt endoscopy 6-12
                                                                    monthly
                                           Surveillance
                                           endoscopy every                          Oesophagectomy
                                           3 yrs                                    Mucosal resection
                                                                                    Intensive surveillance




   SURGERY FOR BARRETTS                                   ENDOLUMINAL THERAPY
                                                   Alternative to surgery? adjunct to accurate
        The problem                                                diagnosis ?


Traditional oesophagectomy                    Mucosal resection
     Mortality 5 – 10 %                         Knife resection
     Significant morbidity                      Suction cap snare resection
Minimally invasive vagus sparing surgery
                                              Mucosal ablation
     Mortality 5%
     Morbidity decreased                           Radiofrequency




               GORD                                          BARRETTS
                                                   Screening out
                                                   Surveillance in
Medical management for everyone
                                                   Prague standardised grading
                                                   Imaging advances
Patient selection for surgery is key
                                                   HGD
                                                     Endoluminal therapy
Floppy Nissen’s is the surgery of choice
                                                     Oesophagectomy
Thank you for paying attention!

				
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