non neoplastic disease of esophagus (p)

most esophageal lesions arise from

lower 1/3 of esophagus

epidemiology of gerd

* Common in all ages

* No sex difference

* Barrett's esophagus is a serious complication

* 20% of population have GERD

Physiologic vs. Pathologic Reflux

Physiologic : Postprandial, short-lived, asymptomatic/nocturnal absent, due to TLESR.

Pathologic : Symptoms needing treatment, mucosal injury, long-lived, nocturnal, due to barrier loss.

pathopgysiology of gerd

LES is functional sphincter (diaphragm, gastric sling, angle of His, intra-abdominal pressure, mucosal folds).

Factors reducing les tone

Factors reducing LES tone: some drugs, foods, alcohol, nicotine, hormones.

Other factors: anatomical defects (hiatal hernia), poor clearance, delayed gastric emptying.

hiatal hernia types

Types : I (sliding), II (paraesophageal), III (mixed), IV (other organs herniate), V (recurrent).

Sliding HH → may present with GERD; GERD can occur without HH

GERD erosive vs nerd

Erosive esophagitis : 40-60% of GERD symptoms severity not corrolate with level of erosion

NERD : 60% where endoscope show no visible erosions, proven by pH study.

gerd complications

Peptic stricture and fibrosis

Barrett's esophagus : 10% of long-standing GERD → ↑ risk adenocarcinoma ×40.

Dysplasia & carcinoma risk → surveillance & treatment.

Functional heartburn: symptoms but normal endoscopy & pH

characters of barret esophagus

Barrett's esophagus (BE) involves columnar epithelium that can resemble gastric mucosa or intestinal mucosa (with mucin-producing goblet cells

atients with BE have a ….times higher risk of adenocarcinoma than normal individuals

40

About ….% of BE cases develop adenocarcinoma within 20 years.

10

The type of BE is premalignant.

Intestinal

the only known predisposing factor for adenocarcinoma of the lower esophagus.

Barrets esophagus

treatment of BE without dysplasia

BE without dysplasia: May regress after fundoplication (antireflux surgery).

Treatment of BE with low gradedysplasia

BE with low-grade dysplasia: Endoscopic mucosal resection or endoscopic submucosal dissection, or ablation by radiofrequency or photodynamic therapy, followed by fundoplication.

Treatment of BE with high grade dysplasia

BE with high-grade dysplasia: Esophagectomy is recommended due to the high risk of carcinoma in situ.

gerd typical symptoms

Heartburn80%, regurgitation, water brash, belching, late dysphagia

increase in recumbent position bending over and heavy meals

gerd atypical symptoms

Cough and asthma mc 40%, hoarseness, pharyngitis, chest pain, dental erosions, globus

harder to diagnose need 24hr ph metr

gerd alarm symptoms

Dysphagia, bleeding, weight loss, anemia, persistent pain → urgent endoscopy.

gerd diagnosis

Clinical if typical symptoms & no alarm signs → trial of H2RA/PPI.

No response → ↑ dose, then investigate

gerd inv

Endoscopy (erosions, HH, BE, carcinoma, grading).

Manometry (before surgery).

24h pH (gold standard).

Impedance pH (non-acid reflux or on medication).

Barium swallow (mainly for HH).

medical treatment of gerd

Lifestyle: weight loss, avoid triggers, head elevation, meal timing, avoid tight clothes & bending.

Drugs: H2RAs, PPIs, alginates, prokinetics.

Risks of long-term PPI: micronutrient deficiency, infections, nephritis, lupus.

indications of fundoplication in gerd

* Non-response to 2-12 months of medical treatment

* Patient preference to avoid long-term medication

* Presence of regurgitation

* Incompetent lower esophageal sphincter (LES)

* Complications or contraindications to medical therapy (e.g., osteoporosis)

* Complicated reflux with stricture or Barrett's esophagus (excluding high malignancy risk)

* Young/middle-aged patients responding to PPIs but unwilling to continue medication long-term

* Alkaline reflux

* Symptomatic hiatal hernia larger than 5 cm requiring surgical repair

* Symptoms due to non-acid reflux despite maximum PPI dose

types of fundoplication

Nissen (360°), Toupet (270°), Dor 200(partial anterior)

contraindications of fundoplication in gerd

psychic patient ,severe motility disorder, negative pH study.

complications of fundoplication

dysphagia, recurrent reflux, gas-bloat.

endoscopic ttt in gerd

Radiofrequency (Stretta), Transoral Incisionless Fundoplication (TIF).

treatment of complications of gerd

Strictures: balloon dilatation; surgery if recurrent.

Barrett's: surveillance, endoscopic therapy, surgery if high-grade dysplasia

achalasia

Primary motility disorder: LES fails to relax, absent peristalsis.

Bimodal age distribution.

↑ Risk SCC (5% after 15-20 years).

achalasia symptoms

Dysphagia (solids & liquids), regurgitation, weight loss, nocturnal aspiration, chest pain

achalasia diagnosis

CXR (wide mediastinum, fluid), endoscopy main stay (also to exclude pseudoachalasia), barium swallow ("bird beak"), manometry (↑ LES pressure >40, no relaxation)

treatment of achalasia

1. Medications (limited role).

2. Botulinum toxin injection.

3. Pneumatic dilatation (risk perforation).

4. Surgery: Heller's myotomy + partial fundoplication (Dor/Toupet).

5. POEM (endoscopic myotomy).

types of esophageal diverticula

Zenker's (upper third, pulsion):lack of coordination bet inferior contrictor and cricophayngeus killian dihesince regurgitation, double swallowing , dysphagia.might develop scc

Epiphrenic : often with achalasia.

treatment of esophageal diverticula

excision + myotomy, diverticulopexy, endoscopic stapling

esophageal webs

Circumferential mucosal folds → in anterior postciricoid area dysphagia, carcinoma risk.

Lower esophageal webs often secondary to GERD.

give account on PVS

dysphagia + iron deficiency anemia + atrophic glossitis.

iron replacement Dilatation if symptomatic.