10. Reflux Contents
Stomach produces caustic substances that aid in
digestion
Parietal cells-HCl
Chief Cells-
Pepsinogen
Mucous Neck Cells-
Lipase
11. Reflux Contents cont.
In addition to the stomach, other organs involved
in digestion also secrete damaging substances.
Pancreas- Trypsinogen, amylase, lipase
Liver - Bile salts
12. Esophageal damage
Largely depends on contents of reflux
Gastric acid only: mild damage
Combination of gastric acid,
pancreatic enzymes, bile salts,
pepsin: severe mucosal damage
13. Medical Treatment of GERD
Acid Suppressants
Antacids – Al toxicity & osteomalacia
H-2 Blockers – Usually sufficient
Proton Pump Inhibitors –
Omeprazole; Rapebprazole
16. Under Pressure
Each sphincter is maintained at a high resting
pressure.
This prevents movement of ingesta and chyme
into the esophageal body when fasting.
17. Control of reflux
Main control is the mechanical and intrinsic tone
of the LES
Other mechanisms:
-Interdigitating rugal folds
-Right diaphragmatic crus
-Oblique entrance into stomach
-Gastric distention
-Abdominal portion of esophagus
18. LES
The gastroesophageal
junction
Ring of increased
thickness
A high pressure zone, not a
true sphincter.
Resting tone from
myogenic and neurogenic
forces
THE MAJOR DEFENSE
AGAINST REFLUX
19. Causes of LPR
Decreased resting tone of the LES
Transient LES relaxations
Delayed gastric emptying
Impaired esophageal
clearance
Reduced salivation
Anesthesia
26. LPR TREATMENT
Acid suppression
H2 / PPI / Antacids
Improve Motility
Metoclopramide/Cisapride
Antireflux surgery
27. Reflux Strictures
2-10% of LPR
Decreasing incidence due to PPI
Chronic inflammation and fibrosis
Most are less than 1cm in length
Common in scleroderma
28.
29.
30. Surgery for reflux strictures
Indications:
Frequent dilatations while on maximal PPI
Oesophageal perforation complicating dilatation
Non-dilatable stricture, eg longitudinal strictures
More than one previous failed anti-reflux surgery
Severely disordered oesophageal body motility
31.
32. Malignant Oesophageal Obstruction
Early curable oesophageal cancers uncommonly cause
oesophageal obstruction
Radical resection is required
Most oesophagectomies will prove to be palliative because occult
metastatic disease
Represents locally advanced oesophageal cancer requiring
palliative treatment
Palliated patients usually survive 4-6 months
33.
34.
35.
36.
37.
38. Laser treatment
Nd:YAG is most widely used
Alleviates obstruction ( 90%)
Controls haemorrhage
Complications ( 1-5% )
No procedural mortality
Hurley JF et al Aust N Z J Surg 1997
41. Combination of laser treatment
External or internal XT
Internal after-loading iridium-192 improves first
dysphagia-free interval in SCC group
Sander R et al Gastrointest Endosc 1991
42. Chemically induced tumour necrosis
Ethanol or polidocanol
Tumour oedema/ swelling may temporary worsen
dysphagia
Inexpensive and readily available
As effective as laser but more pain
Carazzone A et al Eur J Surgery 1999
44. Investigations
Gastrografin and/or barium oesophagram
22% positive barium on negative gastrogafin
Buecker A et al.Radiology 1997
11%25% false negative results
Jones WG et al. Ann Thorac Surg 1992
45.
46. Primary repair
Usually recommended in early injuries
Recent series extended to late injuries with acceptable
results ( 1/9 mortality)
Lawrence DR et al. Ann Thorac Surg 1999
Leak rate: 23% in early injury, 50 % late injury
Reinforced primary repair: leak rate 7%
Wright CD et al. Ann Thorac Surg 1995
49. etiology
Iatrogenic injury accounts 70% of perforations
In normal oesophagus ( injury in cervical part)
Piriform fossa is most common location
Kyphosis, hyper-extension of the neck, cervical
osteophytes, oesophageal diverticulum
Obstructed oesophagus injury in thoracic
part
75-90% endoscopic injuries are in lower
oesophagus
51. Penetrating injury
Approximately 19% of all oesophageal injury
Stabbing usually involves cervical oesophagus
Gunshot wounds thoracic oesophagus
Often associated injuries
52. Oesophageal perforation from blunt
trauma
Exceedingly rare
Blast injury, MCA, fracture dislocation of Cx spine
Diagnosis usually delayed due to associated injuries