ReWrite!

Dear eructating agonizing reader

Yes, you. You can’t possibly deny it. Nobody can. Gastro-esophageal Reflux Disease (GERD) is a very common disease; to the extent that you can safely assume that every living Homo sapiens went through it at a particular time through their life, for the simple fact that; it’s a normal physiological phenomenon.

It is both. It’s a physiological phenomenon that happens occasionally whilst the stomach is evacuating gas upwards, or during straining, and probably certain positions. Normal subject has about 20 minutes of reflux during waking hours, which is usually cleared down by the normal reflex of swallowing of saliva, along with the esophageal peristalsis. It’s however tolerable within limits. Taking place more often, or in excessive amounts; the GERD would start to show its pathological ugly face.

‘LES is more’ or so they say…

The reasons why such a spectacular mechanism should fail one day could simply be summated into two major categories. Logically; either the gate itself will collapse even though the attackers are practically stable, which we refer to as Primary GERD, and reasons may range from Hiatus Hernia, to even excess chocolate and tea consumption. Alternatively, the attackers would change in character, and then the gate wouldn’t be able to hold them back any longer, and that is what we call Secondary GERD. Usually it takes place due to pyloric stenosis, or spasm, which leads of course to Delayed Gastric Emptying state.

You should know a little bit about the GERD Vicious Circle technique, a technique that leads to all the aforementioned complications through a very simple direct mechanism.

In such a case, you need to perform a 24-hours pH monitoring to confirm the reflux first of all. Then, through fiber-optic esophageoscope you can detect the patency of the cardiac opening, as it opens during inspiration whereas it should close and descend. You could also detect the inflammation extent, along with any other changes as leukoplakia or superficial ulceration, which of course helps you to determine the grade of the reflux. And eventually, you may perform a barium meal in Trendelenburg’s position to reveal causative sliding hernia, or developing stenosis.

N.B. Grading system:

• • Grade I – Erythema
  • Grade II – Linear nonconfluent erosions
  • Grade III – Circular confluent erosions
  • Grade IV – Stricture or Barrett esophagus (Barrett esophagus [grade IV] is thought to be caused by the chronic reflux of gastric juice into the esophagus. Barrett esophagus occurs when the squamous epithelium of the esophagus is replaced by the intestinal columnar epithelium. Barrett esophagus is present in 8-15% of patients with GERD and may progress to adenocarcinoma.

How would you proceed from this point depends on the results of your investigations. Whereas in early cases the management would be conservative all along, through changing lifestyle by adopting semi-sitting position during sleeping, avoiding increased intra abdominal pressure on all costs, like heavy work, lifting weights, excessive bending, and tight corset, also weight reduction, and small non-bulky, frequent meals-diet. Drugs in such case are only for symptomatic treatment, as alkalis and antacids.

I-Surgeries to protect the esophagus and lungs from damage (Anti-Reflux Measures/no stricture):

Nissen’s Fundoplication: where you’d completely wrap the lower part of the esophagus with the fundus of the stomach, forming an air-tight jacket around the lower part of the esophagus, which completely seals the way up. A very effective operation, which can be applied through many routs, and accompanied by other procedures, however, your patient would be banging their heads to the wall in a couple of days, since they wouldn’t be able to burp, they would even crave vomiting!! A syndrome called Gas-Bloat syndrome. Suggestions were made to loosen out the sutures at the wrapping site, to allow some air up.

Belsey Mark IV operation: to avoid that syndrome, a modification was made to allow the patient to pass some gas upward. Fundoplication is done only to the anterior 2/3 of the esophagus, and then the whole complex is sutured under the diaphragm to fix it there. A less effective technique that however excluded the previous complications.

Collis Gastroplasty: in cases where the esophagus has shortened too much that the reduction of the hernia is quite impossible, we reshape the fundus of the stomach into an elongation of the esophagus, then perform Fundoplication and then fix it under the diaphragm.

II- Surgical procedures to relieve obstruction in presence of a stricture:

In benign strictures, you should dilate the dilatable ones, and you may perform Thal’s patch in non-dilatable ones (a longitudinal incision through the stricture that is closed transversely, making the place wider and relieving the obstruction).