Brannon Hyde, MD

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Understand the natural history of reflux disease

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Understand how to identify candidates for antireflux surgery

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Understand the complications of antireflux surgery and patient’s satisfaction with surgery

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Americans experience reflux symptoms  44% monthly  20% weekly  4-7% daily

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Most common gastrointestinal diagnosis on outpatient physician visits

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Frequency and severity does not predict esophagitis, stricture, or cancer development

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Montreal consensus panel (44 experts): “a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications”

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Troublesome—patient gets to decide when reflux interferes with lifestyle Vakil N, et al. Am J Gastroenterol 2006;101:1900

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Heartburn  1-2 hours after eating, often at night, antacid

relief 

Regurgitation  Spontaneous return of gastric contents

proximal to GE jxn; less well relieved with antacids 

Dysphagia (40%)—difficulty with swallowing should prompt search for pathologic condition

 Atypical symptoms (20-25%)

 Cough  Asthma  Hoarseness  Non-cardiac chest pain

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Diagnosis based on symptoms alone is correct in only 2/3 patients Differential (ALL CAN KILL YOU!)      

Achalasia Diffuse esophageal spasm Other esophageal motility disorder Cancer Ulcer disease Coronary artery disease

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Spectrum of disease theory:

Nonerosive disease  erosive disease  Barrett’s  esophageal adenocarcinoma

Am J Gastroenterol 2004;99:946.

3,894 patients had baseline and repeat endoscopy at 2 years, regardless of symptoms.

ProGERD study Am J Gastroent 2006;101:2457-62

Mild esophagitis

Severe esophagitis

Conclusion: progression and regression occur despite PPI therapy

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Answer: alteration from normal physiology

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Normally, the lower esophageal sphincter exists as a zone of high pressure between esophagus and stomach; when the HPZ is lost, reflux occurs

Proximal esophagus

Swallow

Transducer tracing identifies the LES High pressure drops only after a swallow or when fundus is distended with gas (to belch)

Distal esophagus

Distal esophagus Distal esophagus Distal esophagus

Gastric baseline

Relaxation of LES

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Three components of high pressure zone  Absolute pressure  Overall length  Intra-abdominal length

Overall length shortens as stomach distends, increasing the pressure necessary to maintain competence (neck on a balloon)

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If intra-abdominal length is short, LES pressure can be overcome by small increases in intra-abdominal pressure

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Increased abdominal pressure needs even distribution over high pressure zone abdominal length to prevent reflux

Normal physiology

If sufficient intraabdominal length is present, squeeze (increased abdominal pressure) will occur around “neck of balloon,” and reflux will not occur

Parameter Pressure (mm Hg) Overall length (cm) Abdominal length (cm)

Median value 13

Defective sphincter