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·
Failure of
anti-reflux mechanisms à prolonged contact of gastric contents with LES mucosa.
Pathogenesis
Table.
Factors associated with increased GERD.
Impaired efficiency of LES
q
Hiatus hernia
q
Cardiomyotomy.
↓
in LES pressure.
q
Fat
q
Chocolate
q
Caffeine
q
Alcohol
q
Cigarette smoking
↑
in intra-abdominal pressure
q
Pregnancy
q
Obesity
q
Ascites
q
Straining
q
Heavy lifting
↑
gastric content available for reflux
Impaired
gastric emptying:
o
Large volume meals.
o
Anti-cholinergics.
o
Gastric outlet
obstruction.
Clinical
Features
1.
Heartburn.
2.
Pain:
o
Due to:
§
Direct stimulation of
hypersensitive esophageal mucosa.
§
Spasm of distal
esophageal muscles.
o
Aggravated by bending,
stooping, lying down.
o
Relieved by antacids.
3.
Regurgitation.
N.B.
20% of cases admitted to CCU have GERD.
Investigations
1.
Barium
swallow:
most widely used.
2.
24
hr intra-luminal pH monitoring:
most accurate test.
3.
Esophagoscopy.
Treatment
Simple measures:
1.
Raising head of bed at night.
2.
Weight loss.
3.
Avoid food & fluid intake before bedtime.
4.
Avoid precipitating factors.
5.
Antacids [e.g. Mg (OH)2 / Al (OH)3 ]
Measures for resistant cases:
1.
Alginate-containing antacids:
most frequently prescribed.
2.
H2-receptor antagonists.
3.
PPIs (Omeprazole).
4.
Metoclopramide:
·
Dopamine antagonists.
·
Enhances peristalsis
& speeds gastric emptying.
5.
Cisapride:
§
↑ Esophageal
peristalsis.
§
↑ LES pressure.
Complications
1.
Peptic
stricture: Patients > 60
yrs.
2.
Barret’s
esophagus.
written
by:
Khalid Bin Yaroof. FMHS, UAE University.
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