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Esophageal Reflux Disease (GERD) (Ref. Hari. 18th ed., Pg - 2433)

  1. Dysfunction of the lower esophageal sphincter predisposes to the gastro oesophageale reflux of acid. If reflux is prolonged or excessive, it may cause oesophagitis, benign esophageal stricture, peptic ulceration or Barrett's oesophagus.
  2. In Barrett’s Oesophagus - Oesophageal squamous lining is replaced by columnar cell intestinal metaplasia (AIIMS May 2010) occur, in lower oesophagus or whole oesophagus.
  3. Associations
    1. Smoking
    2. Alcohol
    3. Hiatus hernia
    4. Pregnancy
    5. Obesity
    6. Drugs (tricyclic, anticholinergics, nitrates);
  4. Symptoms
    1. It is more common in males.
    2. Heartburn (burning, retrosternal discomfort related to meals, lying down, stooping, and straining, relieved by antacids)
    3. Belching
    4. Acid brash (acid or bile regurgitation)
    5. Water brash (excessive salivation)
    6. Odynophagia (painful swallowing, eg from esophagitis or ulceration); nocturnal asthma (cough/wheeze with apparently minimal inhalation of gastric contents).
  5. Complications
    1. Oesophagitis
    2. Ulcers
    3. Benign stricture, 
    4. Barrett's oesophagus
    5. Oeophageal adenocarcinoma
    6. Iron deficiency anemia
Extra oesophageal complications
  1. Chronic cough
  2. Acute laryngitis
  3. Asthma
  4. Dental erosion
  1. Tests:
    1. Documentation of muscle injury.
      1. Upper GI endoscopy at endoscopy, Velvety appearance
      2. Barium swallow may show hiatus hernia. 
    2. Documentation of reflux & quantification of reflux.
      1. 24h oesophageal pH monitoring ± oesophageal manometry help diagnose GORD when endoscopy is normal.
    3. Documentation of pathophysiological factor, Motility studies.

Extra Edge Most sensitive test for GERD is 24 hrs pH monitoringQ.

  1. Treatment:
    1. Drugs:
      1. Antacids
      2. PPI (the most effective drug)
      3. Prokinetic drugs
    2. Surgery
      Not indicated unless symptoms severe, refractory to medical therapy and there is pH-monitoring evidence of severe reflux. Laparoscopic repairs are done.
    3. Treatment of Barrett’s oesophagus:
    4. If premalignant changes i.e. high grade dysplasia seen on endoscopy than do esophageal resection. (Fundoplications) Otherwise high dose of PPI initially.
    5. Photo dynamic treatment
      Photodynamic therapy (PDT) involves light. induced activation of an orally administered photosensitizer such as 5-aminolevulinic acid which causes the accumulation of protoporphyrin IX in GI mucosal cells. Local laser light then causes necrosis, which is confirmed by finding squamous re-epithelialization.
    6. Repeat endoscopy is must.
Recent Advances: (Ref. Hari. 18th ed., Pg - 2420)
  1. Endoscopic biopsy is the gold standard for confirmation of Barrett's esophagus, and for dysplasia or cancer arising in Barrett's mucosa. Endoscopic therapies such as
    1. endoscopic mucosal resection (EMR),
    2. endoscopic submucosal dissection (ESD),
    3. photodynamic therapy (PDT),
    4. radiofrequency ablation (RFA) are effective modalities for treatment of high-grade dysplasia and intramucosal cancer in Barrett's esophagus.
  2. New drug for treatment for Non ulcer dyspepsia is Acotiamide. It enhances acetylcholine release via antagonist action on M1 and M2 muscuranic receptors. 


Natural Orifice Transluminal Endoscopic Surgery (Notes) (Ref. Hari. 18th ed., Pg - 2411)
NOTES is an evolving collection of endoscopic methods that entail passage of an endoscope or its accessories through the wall of the gastrointestinal tract (e.g., stomach) to perform diagnostic or therapeutic interventions. Some NOTES procedures, such as percutaneous endoscopic gastrostomy (PEG) or endoscopic necrosectomy of pancreatic necrosis, are established clinical procedures, others, such as endoscopic appendectomy, cholecystectomy, and tubal ligation, are in development.
Boerhaave’s syndrome
Rupture of oesophagus during vomiting. Perforation usually occur on the left side giving rise to mediastinal and pericardial emphysema and left plural effusion.
Meckler’s triad (LQ 2012) of vomiting, Pain and subcutaneous emphysema are the characteristic feature.
Mediastinal air, which is seen after this syndrome, is best detected by CT chest.Q
Hiatus hernia
Hiatus hernia is a herniation of viscera, most commonly the stomach, into the mediastinum through the esophageal hiatus of the diaphragm. It has got 4 types.
Type 1 also known as sliding hernia – Gastric cardia slides from diaphragmatic opening into the mediastinum.
Type 2, 3, 4 are also known as paraesophageal hernia.
Type 2 gastric fundus also herniates but gastroesophageal junction remain fixed.
Type 3 gastro esophageal junction is displayed.
Type 4 viscera other than the stomach herniate into the mediastinum, most commonly the colon.
Schatzki ringQ
Patient typically present more than 40 years. It is a very common cause of intermittent food impaction. It is a lower esophageal mucosal ring and its origin is unknown. It is not premalignant
Dysphagia lusoria.
It is a dysphagia caused by esophagus being compressed by an aberrant right subclavian artery arising from the descending aorta and passing behind the esophagus. 
Pill esophagitis (Ref. Hari. 18th ed., Pg- 2437)
It occurs when a swallowed pill lodges within the lumen of esophagus. Most common location mid-esophagusQ.
The medications implicated are doxycycline, tetracycline, quinidine, phenytoin, potassium chloride, ferrous sulfate, nonsteroidal anti-inflammatory drugs (NSAIDs), and bisphosphonates.

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