Gastroesophageal reflux disease (GERD) is defined by the passage of a portion of the gastric contents into the esophagus. This phenomenon is usually accompanied by recognizable symptoms in the interrogation.
Reflux can be complicated by esophageal damage: reflux esophagitis of varying severity, but which may be complicated by stricture, bleeding, or columnar metaplasia of the lower esophagus: the Barrett’s esophagus (BO).However gastroesophageal reflux may evolve in the long term without esophageal injury and, in most cases, there is a benign condition.
Major improvements gained in recent years in the pathophysiological understanding of the phenomenon and efficient methods of investigation currently available in clinical practice helps identify its natural history and atypical clinical forms frequently encountered.
Therapeutically, the onset of antisecretory and particularly inhibitors proton pump (PPIs) provide good symptom control in a majority of cases. At that medical progress is added the evolution of surgical treatment, currently performed laparoscopically.
This surgical approach that allows surgery with short-term capital determined a revival of this indication. The favorable results now reported in large series confirm the place that surgery should occupy in the treatment of chronic GERD, in particular in young patients.
EPIDEMIOLOGY:
GERD is extremely common, but its true prevalence is difficult to define. Heartburn remains the best characterized reflux symptom is very common in the population between 30 and 50%, of which more than 15% at least once a week. However the majority of patients with reflux symptoms do not consult.
It is the reign of self-medication with use of counter treatments such as antacids or H2 blockers low dose. Among patients with gastroesophageal reflux, about 15% have daily symptoms and 39% weekly symptoms.
Further prevalence studies are complicated due to the existence of pathological paucisymptomatic GERD and atypical GERD who escape epidemiological surveys.
The prevalence of esophagitis lesions appears to be of the order of 30 to 40% of symptomatic patients, that is to say a little more than one in three patients.
The complications of reflux disease remains benign in its evolution in most cases are dominated by peptic stricture and Barrett’s esophagus (BO). The prevalence of BO is not well established, but overall is estimated at 10-15% of patients with chronic and past symptoms of gastroesophageal reflux. The incidence of reflux increases with age as well as the risk of complications. There is a discrete male predominance in patients with a severe form especially in EBITDA.
PHYSIOLOGICAL PHENOMENON:
The pH in the esophageal lumen is between 6 and 7 in normal times, fasting gastric pH is of the order of 1. To maintain this gradient, a barrier is required between the two esophageal and gastric lights. This barrier can not be perfectly sealed so that acid reflux can occur in normal subjects and therefore a physiological phenomenon.
The two main antireflux factors are:
– The lower esophageal sphincter, which is the main obstacle;
– The extrasphinctériens factors: the angle of His, the pillars of the diaphragm and the intraabdominal segment of the esophagus.
Hiatal hernia alone, is neither necessary nor suffi cient for the occurrence of gastroesophageal reflux. However, in the presence of reflux, hiatal hernia is usually associated with more severe forms of reflux.
Three main mechanisms are the cause of reflux:
– Transitional and spontaneous sphincter relaxations which are the usual mechanism of physiological reflux;
– The permanent hypotonia of the lower esophageal sphincter, rarer;
– Excessive pressure of the abdominal cavity (pregnancy, ascites, obesity).
It is observed in chronic patients reflueurs significant abnormalities of esophageal motility during manometric recordings.
These anomalies are still inconsistent.
Oesophageal sensitivity to GERD is another interesting variable. Indeed, a majority of physiological reflux episodes are asymptomatic. This suggests that in case of frequent reflux, there is a gradual awareness of the esophageal lining that determines the onset of symptoms.
However, there are patients with abnormally high sensitivity which results in symptoms typical reflux contrasting with a normal reflux quantitatively pHmetry.
This is called irritable or hypersensitive esophagus. Conversely, esophageal hyposensitivity is considered in patients in whom it is discovered EBO contrast, examination, with a complete absence of symptoms.
EVOLUTION:
She is now better known. About 1/3 of symptomatic reflux are complicated when endoscopy is performed. 1/3 of symptomatic patients no longer follow treatment after three years. 2/3 therefore keep treatment either permanent or intermittent long periods. Reflux is therefore a persistent disease but whose evolution is usually benign, worsening lesions observed endoscopically, where they exist are rare. The reflux is not a systematic tendency to get complicated.
However, serious complications exist, mainly peptic stricture, rare, and especially Barrett’s esophagus.
Besides age predisposes to complications, the only two criteria which seem reliable to predict a poor outcome are firstly hypotonia of permanent sphincter, but that is only highlighted by the esophageal manometry, unsolicited review first line and secondly the severity of esophagitis endoscopy before treatment.
DIAGNOSIS:
Clinical signs:
The diagnosis of GERD is whether clinical signs are suggestive: ascending retrosternal burning, followed by acid regurgitation: heartburn, pathognomonic symptom of the disease. Reflux is often responsible for high epigastric pain whose immediate postprandial and nocturnal nature is evocative, especially if there is a postural character.
The pain may nevertheless be later, back high. They are sometimes accompanied by dysphagia, which is not always a reflection of a peptic stricture. The symptoms are atypical, in about 30% of cases, taking a look pseudocardiaque including mimicking a typical angina. ENT signs are frequent, in particular a pharyngeal discomfort, postural chronic cough or occurring at night with morning hoarseness.
Respiratory events should also be considered GERD, before a late-onset asthma, for example, episodes of unexplained recurrent pneumonia. The frequency of dental erosions in chronic GERD was recently highlighted.
All these symptoms should be systematically sought in the interrogation.
Additional tests:
Upper gastrointestinal endoscopy:
The upper gastrointestinal endoscopy is easy to achieve the first stage of patient carrying the balance of a chronic GERD.
It should be underlined the lack of clinicopathological parallelism, noisy and suggestive symptoms that may be associated with a normal endoscopy and vice versa. We must therefore remember that a normal endoscopy esophagus absolutely not exclude the diagnosis of gastroesophageal reflux.
In contrast, reflux esophagitis endoscopy is recognized in the formal witness a gastroesophageal reflux, even if there are no symptoms. Several degrees of severity of peptic esophagitis were written. Among the different classifications, the most commonly used is that of Savary and Miller which includes 4 stages of evolution:
– Stage I: erosive esophagitis;
– Stage II: non-circumferential ulcerated esophagitis;
– Stage III: circumferential ulcerated esophagitis;
– Stage IV: peptic stricture or EBO.
According to the recent consensus conference, when the symptoms are typical and that the subject is young, the use of endoscopy is not systematic. It must be indicated by cons in case of atypical manifestations that do not allow, on simple clinical criteria to make the diagnosis. In case of alarm symptoms such qu’amaigrissement, dysphagia, bleeding or anemia, endoscopy is also needed.
The occurrence of reflux symptoms beyond 50 years from the start requires the practice of endoscopy to look for complications (EBO ).
Note that endoscopy performed while the patient is under IPP recent weeks, if it allows search of Barrett’s esophagus, has the disadvantage of ignoring the initial intensity of esophagitis whose prognosis nature has been stressed higher.
It is better to perform an endoscopy remote treatment, if possible.
24-hour pH monitoring:
It allows direct diagnosis by recording the reflux using a sensor positioned in the esophagus for 24 hours.
The advantage of this approach is twofold:
– It allows quantification of reflux and thus differentiates the physiological reflux reflux disease;
– Its main interest lies in the diagnosis of atypical since it allows to establish a causal link between gastroesophageal reflux and the same symptom it is unusual: the patient during the examination has indeed a marker event which allows to correlate symptoms and acid reflux episodes.
Note that the esophageal pH monitoring will recognize that acid reflux. The non-acidic gastric contents lifts are not recognized by this technique.
Esophageal impedance:
The esophageal impedance is further very promising new technique of pH monitoring to which it may be associated, which can detect gaseous or liquid lifts in the esophagus. A non-acid reflux can be easily recognized, thus completing the information on the traditional pH monitoring. Yet widespread, its potential interest should determine its rapid development, currently limited by its cost.
Esophageal manometry:
Esophageal manometry measures the esophageal peristalsis and lower sphincter tone of the esophagus. She has no interest in routine clinical practice. It is expected that if surgical treatment is proposed (see below).
COMPLICATIONS:
They can be serious but fortunately rare.
Peptic stricture:
She sits at the junction of esophageal and gastric mucosa. Its frequency is uncertain, varying according to the authors, between 1 and 10%. The peptic stricture rarely complicates an old and experienced reflux. Stenosis is often by dysphagia that reveals little symptomatic GERD far. The first concern is to formally eliminate the hypothesis of cancerous growth by biopsies. Dysphagia is a formal indication for endoscopy.
Barrett’s esophagus or Barrett’s esophagus:
This is a gastric metaplasia of the epithelium esophageal squamous occurring during esophageal ulcers healing phenomena induced reflux. Its prevalence is difficult to estimate, could be in the order of 10% of patients with chronic GERD. In the classic definition of EBITDA, metaplasia should be at least 3 cm, circumferential from the Z line
Several histological types of EBO (cardia, fundus and intestinal) are described, but only those associated with intestinal metaplasia are currently considered real, because associated with risk of dysplasia.
Alongside this classical definition, we now speak of EBO short, the height is less than 3 cm, not circumferentially and whose recognition is not always easy, especially when associated hiatal hernia.
The disadvantage of these short EBO is also present a risk of degeneration where there is intestinal metaplasia. The evolutionary potential of EBO is indeed cancer.
The risk of developing adenocarcinoma is multiplied by 40 compared to the general population. Too often, cancer complicating EBITDA is discovered at the same time
the OBC itself.
If the EBO is known, it is now accepted that endoscopic surveillance every two years is necessary with every time, many biopsies to remove high-grade dysplasia.
There are no specifi clinical symptom in EBITDA which is a discovery of endoscopy, which explains the necessity of endoscopy from the age of 50 years to eliminate this complication (Fig. 1 and 2, see also Figures in color specifications).
TREATMENT:
The therapeutic goal of treatment of GERD are symptom relief if possible a return to a normal quality of life and also in case of peptic lesions, wound healing and the prevention of recurrence in patients with severe esophagitis or complicated.
The treatment is always medical and sometimes surgical.
The lifestyle measures also have an interest, more modest.
Lifestyle measures:
The most important measure is the elevation of the head of the bed during sleep. Other measures (weight loss, cessation of alcohol, tobacco, low fat diet) have less proven efficacy, but are a good adjunct.
Medical treatment:
Antacids and alginates have proven efficacy, but limited in time, and are often used as self-medication.
Inadequate treatment often triggers the consultation.
The prokinetic have only partially effective.
The only documented efficacy, cisapride was withdrawn for this indication due to risk of heart rhythm disorders.
The essential treatment of reflux is represented by antisecretory. H2 blockers were rapidly superseded in this indication by inhibitors of the proton pump (PPI) to be preferred due to their greater efficiency proved. The involvement of Helicobacter pylori in the pathogenesis of reflux is not established and the eradication of this germ, if present, should not be systematic in the treatment of reflux.
Initial Strategy:
In case of moderate symptoms typical but spaced in time, alginates antacids and low-dose anti-H2 may be provided associated with hygienodietetic and postural measures.
If typical symptoms but closer (more than once a week), and if the subject within 50 years without alarm symptoms, continuous treatment for about 4 weeks with a PPI half or full dose or H2 blockers can be provided. If successful, a stop test can be attempted. In case of relapse, an endoscopy should be made to clarify the instructions.
Endoscopy should be performed from 50 years systematically, first line, and of course if an alarm syndrome (dysphagia, bleeding) is present. In the absence of esophagitis or peptic low-grade lesions (stage I and II), a full dose PPI therapy may be offered for 4 weeks.
In patients with severe esophagitis or complication (stage III and IV), treatment should be continued for at least 8 weeks with control of the endoscopic evolution. In the absence of symptomatic remission or healing, an increase in dose should be considered.
If extradigestive events, use a standard dose for 4-8 nes semai to possibly double in case of treatment failure.
Strategy Long-term complications outside:
Initial treatment should be stopped if it allows the disappearance of symptoms, unless there is a high-grade esophagitis complicated. In the frequent case spaced recurrence, the patient can be treated only at the request in the manner identical to those that allowed the initial remission. By cons, in case of frequent relapses, with loud and annoying symptoms on quality of life, a maintenance PPI therapy in appropriate dose (half dose or full dose) may be indicated. If there is a dependency on PPIs, and if the patient’s age is not too advanced, the surgical solution may be considered.
Treatment of complications:
The peptic stricture should be treated continuously with PPI in full or double dose.
If significant dysphagia, endoscopic dilatation (by candle or balloon) can often improve or even eliminate, dysphagia. If this fails, surgery should be considered.
Symptomatic EBO should be treated permanently PPI full dose. The decision to treat an EBO is not symptomatic, is not clearly defi ned. Indeed, it is not certain that treatment, medical or surgical, decreasing the risk of neoplastic degeneration beaches of BE with intestinal metaplasia.
Destruction techniques by endoscopic methods (argon plasma, for example) from the beaches of EBO are being evaluated and can currently be subject to specific recommendation.
Surgical treatment:
Surgical treatment of the classic reflux laparotomy had only mixed support among both physicians and patients for several reasons: a medium efficiency reputation perhaps because of the many techniques developed by many
teams, poorly standardized and therefore difficult to compare. The other explanation was of course the need for laparotomy: apart from serious forms which we have seen, are not the most frequent surgical solution therefore repelled well relieved by medical treatment patients.
The emergence of laparoscopic surgery, which after some technical infancy in the early 1990s, has now reached maturity: many studies show the feasibility of the laparoscopic surgery, especially its safety and effectiveness.
Achieving a target antireflux valve is now considered the surgical technique of reference in the treatment of reflux.Other techniques must be abandoned. The choice is simply placed between the realization of a complete valve 360 ° (intervention Nissen) or incomplete valve 270 °. The superiority of one or the other technique has not been formally established.
Preoperative:
The pH monitoring is indicated that in the absence of peptic lesion in the esophagus to formally affirm the reflux before surgery.
Manometry, however, seems interesting preoperatively to assess the quality of esophageal motility, useful knowledge for prolonged postoperative dysphagia.
The consequences of making a valve are indeed postoperative dysphagia lasting rule in three weeks to a month perfectly regressive. There are a few cases of prolonged dysphagia whose mechanism is not always well understood. In exceptional cases, dysphagia is sufficiently large and persistent to consider reoperation.
Laparoscopic operative mortality is around zero, and morbidity is very low. The results are good with 90% good results.
The procedure can generate some unwanted side effects: feeling small stomach, difficulty or inability to belch.Sometimes there is a postoperative loose stools whose pathophysiological mechanism could be closer to the dumping syndrome old vagotomies (the latter may be accidental when fundoplication).
Patients to be operated:
The indication for surgery is considered in patients carrying a chronic GERD without significant comorbidity, that have either significant complications of their reflux (high-grade esophagitis, BO) who are addicted to PPIs, imposing a long-term treatment by IPP.
The poor candidates for surgery are intermittent or moderate GERD whose reflux symptoms are associated with dyspeptic phenomena likely to worsen after surgery.