Diagnosis of GERD

Usually, classic clinical symptoms are enough to start initial symptoms. Endoscopy with biopsy is essential in diagnosing GERD. Barium swallow with or without fluoroscopy can diagnose reflux but cannot identify esophagitis. Twenty-four-hour esophageal pH testing associates reflux with symptoms and is useful in some patients. Gastric secretory or gastric emptying tests are occasionally helpful. Manometry of the esophagus and LES is required whenever an esophageal motility disorder is suspected and before any surgical intervention.

Is hiatal hernia an essential defect in patients with GERD?

No. Not all patients with GERD have a hiatal hernia, and not all patients with a hiatal hernia have GERD. A total of 50% of patients with GERD have an associated hiatal hernia.

Initial management of a patient suspected of having GERD

• Change diet to avoid foods known to induce reflux (e.g., chocolate, alcohol, and coffee).
• Avoid large meals before bedtime.
• Stop smoking.
• Do not wear tight, binding clothes.
• Elevate the head of the bed 4-5 inches.
• Take antacids when symptomatic.
• Weight loss can be very effective in reducing GERD symptoms.

If initial treatment fails, what should be recommended?

About 50% of patients show significant healing with H2 blockers, but only 10% of these patients remain healed 1 year later. Metoclopramide promotes gastric emptying but rarely relieves symptoms consistently in the absence of acid reduction.

KEY POINTS: DIAGNOSTIC WORK-UP OF GERD

• Underlying anatomic abnormality may cause functional incompetence of the lower esophageal sphincter (LES).
• Endoscopy and biopsy are paramount in diagnosis.
• Swallow studies delineate possible anatomic causes.
• 24-hour pH monitoring can link reflux to patient's symptoms.
• Manometry of the LES is required if esophageal motility disorder is suspected.

When should operation for GERD be recommended?

Failure of nonoperative (medical) therapy is the primary indication for surgery. Noncompliance with prescribed treatment is a frequent cause of failure and even stricture unresponsive to dilation. With PPIs, most patients' symptoms can be controlled for long periods of time. Current recommendations for surgical intervention include:

• failed medical therapy (e.g., intractable disease, intolerance or allergy to medications, noncompliance, and recurrence of symptoms while on medical therapy),
• complications (e.g., stricture, respiratory symptoms, medicosocial changes, and premalignant mucosal changes),
• patient preference (e.g., cost-long-term medical prescriptions can be expensive-or lifestyle issues).

The goal of surgical treatment?

Operations for GERD attempt to prevent reflux by mechanically increasing LES pressure and, in most procedures, to restore a sufficient length of distal esophagus to the high-pressure zone of the abdomen. Hiatal hernia, when present, is reduced simultaneously.

Surgical procedure for hiatus hernia:

Laparoscopic/ minimally invasive surgical procedures are now standard of care…

The success rates for surgical therapy

All of the procedure eliminate GERD in almost 95% of patients who are followed for 10 years. But the Nissen fundoplication wins in comparison studies. Recurrent symptoms should be thoroughly worked up because they are frequently associated with other disorders and not recurrent GERD.

Hiatus Hernia

ACHALASIA CARDIA

This condition is due to degeneration of the myenteric nerve plexus so that there is a failure of peristalsis and of relaxation of the lower esophageal sphincter. It can present at any age but usually presents between 30 and 60 years of age. It is more common in women, the male-to-female ratio being 2 to 3, and there is a risk of malignancy in the long term.

Clinical presentation

The usual symptoms are progressive dysphagia, weight loss, and aspiration pneumonia. Management The diagnosis is made by:

• Chest radiography-may show a grossly dilated esophagus with a fluid level and signs of aspiration pneumonia.
• Barium swallow-this will show a grossly dilated, tortuous esophagus with a very narrow smooth segment ("rat tail") at the lower esophageal sphincter
• Manometry-will demonstrate failure of relaxation of the sphincter.
• Endoscopy and biopsy-to rule out malignant change.

Medical treatment is usually ineffective. Pneumatic dilatation of the sphincter may give temporary relief, but surgery (laparoscopic Heller's cardiomyotomy, which divides the lower esophageal sphincter to the level of the mucosa) provides the best results. Recently POEM has promising results.

Esophageal perforations

This Can Occur:

• As a result of swallowing a foreign body.
• During esophagoscopy and dilatation, especially if there is a malignant stricture.
• Spontaneously as a result of violent vomiting (i.e., Boerhaeve's syndrome).

Clinical presentation

The symptoms are sudden onset of pain in the chest, upper back, and neck. The patient may develop circulatory collapse, pyrexia, and emphysema in the supraclavicular region of the neck due to the escape of air.

Diagnosis and management

A chest radiograph may show mediastinal air, a left pneumothorax, or fluid in the peritoneal cavity. Water-soluble contrast study confirms the site of rupture.

If the underlying problem is benign, then surgical treatment may be performed to resect or repair the damaged esophagus. Nonoperative treatment may be attempted in selected patients. (i.e., those with early small perforations and those unfit for major surgery). The patient is placed on NPO status, and intravenous fluids, antibiotics, and parenteral nutrition are prescribed. A chest drain is inserted to drain the infected pleural space. If the patient's condition deteriorates, surgery should be considered.

The complications of perforation of the esophagus are mediastinitis and empyema, and the mortality rate is high.

• ACID – CORROSSIVE ESOPHAGEAL STRICTURE
• Stomach perforations
• Pyloric stenosis
• Stomach GIST

Esophagus cancer

The risk factors for developing esophageal cancer

Both alcohol and tobacco increase the risk of carcinoma of the esophagus by a factor of 10. Additional risk factors include Barrett's esophagus with dysplasia, carcinogen exposures (e.g., nitrosamines in the Eastern world), vitamin and trace element deficiencies, and Plummer-Vinson syndrome.

The epidemiology of carcinoma of the esophagus

Esophageal cancer accounts for 1% of all cancers and 2% of cancer-related deaths. Generally, it is three times more common in men and occurs most commonly in the seventh decade of life. Worldwide, 95% of all esophageal cancers are of squamous cell origin; however, in the Western world, the relative incidence of adenocarcinoma has increased dramatically over the past 20 years because of the comparable increase in the incidence of Barrett's esophagus.

The most common presenting symptoms of esophageal cancer.

Dysphagia occurs in 85% of patients. Others symptoms include weight loss (60%), chest or epigastric pain (25%), regurgitation of undigested food (25%), hoarseness caused by recurrent laryngeal nerve involvement (5%), cough or dyspnea (3%), and hematemesis (2%).

The diagnostic work-up for patients presenting with these symptoms

• History and physical examination
• Upper gastrointestinal series (contrast study of the upper GI tract)
• Upper endoscopy with biopsies of all concerning luminal structures
• Computed tomography (CT) scan of chest and abdomen to define nodal and potential metastatic disease.
• Endoscopic ultrasound (EUS) to define the T stage (i.e., size) of the primary mass and regional lymph node involvement with possible fine-needle aspiration (FNA) biopsy
• Positron emission tomography (PET) scan to define distant metastatic spread

KEY POINTS: DIAGNOSTIC WORK-UP OF GERD

• Most common in older patients with dysphagia (85% of cases) and weight loss (60% of cases).
• Major causative factors are alcohol and tobacco (10-fold increase in risk).
• Diagnosis is made by upper GI endoscopy and biopsy.
• Most common variant is adenocarcinoma; second most common is squamous cell cancer.
• Radiographic work-up is necessary to stage disease.

Benefits

This is chemotherapy, radiation therapy, or both to the primary lesion before surgical resection.
The Benefits include:

• Potential downstaging (to shrink the tumor or treat locoregional lymph node involvement)
• Early treatment of micrometastatic disease
• Treatment is better tolerated before surgical stress
• Calibrates the patient's ability to tolerate major surgery
• Verification of primary tumor's sensitivity to the chemotherapy or radiation therapy

The surgical options for treatment of carcinoma of the esophagus

Surgery alone or combined with chemoradiotherapy offers the only hope for cure.

The surgical approaches include: robotic/ laparoscopic route is preferred.

• (1) transabdominal resection of lesions located at the gastroesophageal junction
• (2) resection with intrathoracic anastomosis by left thoracoabdominal (Sweet procedure) or combined midline laparotomy and right thoracotomy (Ivor-Lewis procedure)
• (3) transhiatal esophagectomy with cervical anastomosis. Laser therapy, esophageal stenting procedures, and dilatation are reserved for palliation.

The risks of surgery

• Hemorrhage
• Anastomotic leak
• Empyema and sepsis
• Anastomotic stricture
• Local recurrence of cancer
• Dysphagia

The natural history of esophageal cancer

In a collected series of almost 1000 untreated patients, the 1- and 2-year survival rates were 6.0% and 0.3%, respectively. Untreated patients typically succumb to progressive malnutrition complicated by aspiration pneumonia, sepsis, and death. Formation of a fistula between the aorta or pulmonary artery and the esophagus or pulmonary tree is a somewhat more dramatic (or perhaps merciful) mode of exit. Treated or untreated, esophageal cancer is a bad disease.

"R0" (or "R zero") resection, and how does it impact survival?

All gross disease is removed, and microscopically, the margins of resection are negative for tumor. Achieving an R0 resection is the surgeon's goal and is the most robust predictor of a favorable outcome after surgery for esophageal cancer. An R1 resection represents removal of all gross disease, yet resection margins are microscopically positive for tumor. The overall 5-year survival (any stage) for patients with microscopically positive margins decreases by an order of magnitude (e.g., 30% down to 3%).

Esophageal GIST

Stomach cancer

Stomach Neuro endocrine tumor