Surgery - Gastro-Oesophageal Reflux Disease(GERD)
Introduction excessive stomach acid reflux into the oesophagus, which can result in discomfort or damage to the mucosa. Etiology The physiological lower oesophageal sphincter, mucosal rosette, angle of His, diaphragmatic crura, and intra-abdominal section of the oesophagus are among the mechanisms that prevent reflux. Frequent and inappropriate temporary relaxations of this sphincter also occur. Impaired stomach motility/emptying and ineffective oesophageal antegrade peristalsis can also be factors. Risk Factors causes include hiatus hernias, obesity, pregnancy, medicines like tricyclic antidepressants, smoking (which lowers the oesophageal sphincter pressure), increased gastric volume from large meals, caffeine, alcohol, fat, or smoking, and systemic sclerosis. Epidemiology In Western civilizations, heartburn is a common occurrence, affecting 10-20% of people; roughly one-third of these individuals will exhibit symptoms of GORD. History Typical symptoms include heartburn or discomfort in the retrosternum or epigastrium that is exacerbated by bending, lying supine, alcohol, or heavy meals and is eased by antacids, waterbrash, or mass regurgitation of stomach contents. Atypical symptoms include hoarse voice, halitosis, chronic coughing or wheezing, especially at night, and chest and back pain. Examination Typically, normal. Occasionally, dysphonia, wheezing, and epigastric discomfort. Pathogenesis. Prolonged acid and bile reflux results in ulcers, erosions, and inflammation of the oesophageal mucosa. Fibrosis and stricture development are potential side effects of chronic reflux. Barrett's oesophagus is a precancerous condition that results from metaplasia of the lower oesophagus, which is the replacement of squamous epithelium by columnar, intestinal-type epithelium. Investigations Endoscopy: Symptoms and findings are frequently not well correlated. Oesophagitis (occurs in less than 50% of cases with typical GORD symptoms); severity is rated using either the Los Angeles classification (grades A–D) or the modified Savary–Millar classification (1: erythema, 2: isolated erosions, 3: confluent erosions or superficial ulcers without stenosis, 4: deep ulceration, stricture formation). Barium swallowing: May reveal anatomical irregularities (such as strictures or hiatus hernias). The 24-hour pH monitoring and oesophageal manometry method: Manometry allows the pH probe to be positioned above the LES and evaluates oesophageal peristalsis. Studies on pH measure the link in time between symptoms and oesophageal pH (significant reflux occurs if pH is less than 4 for more than 4.7% of the time). Management Conservative measures include altering one's lifestyle, quitting smoking, losing weight, raising the head of the bed, avoiding triggers, and avoiding heavy meals late at night. Medical: Proton pump inhibitors, H2 receptor antagonists, and antacids or alginates. Surgical: Antireflux surgery is recommended for patients who cannot tolerate medicine or who have symptoms or difficulties even with the best medical care. Laparoscopic fundoplications, such as the Nissen fundoplication, involve wrapping the stomach's fundus 360 degrees around the lower oesophagus and securing it with seromuscular sutures following a posterior hiatal repair. This procedure can be modified to include partial fundoplications, such as the Toupet (270-degree wrap). Endoscopic: Enables Barrett's oesophagus surveillance or stricture dilatation. Complications Barrett's oesophagus, stricture, oesophageal ulceration, and oesophageal adenocarcinoma. syndromes of reflux reflux asthma, cough, and laryngitis. Following surgery: recurring symptoms, increased flatus, gas bloat syndrome (difficulty belching), dysphagia (3–8%, typically transient), infrequently oesophageal perforation, pneumothorax, and splenic injury. Prognosis Just lifestyle measures elicit a 50% response. Drug therapy works well, although withdrawal is frequently linked to relapse. In 85–90% of cases, antireflux surgery effectively controls symptoms.
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