Dustin A. Carlson, John E. Pandolfino, and Peter J. Kahrilas Northwestern University, Chicago, IL, USA Gastroesophageal reflux disease (GERD) is a condition which develops when reflux of stomach content causes troublesome symptoms and/or complications. The clinical manifestations of GERD can be subdivided into esophageal and extraesophageal syndromes. The esophageal syndromes can be defined by any combination of reflux‐related symptoms and/or reflux‐related pathology. There are also multiple extraesophageal syndromes that have been attributed to reflux, some with strong pathophysiological associations and others that are more speculative. Upper gastrointestinal endoscopy is essential for grading of reflux esophagitis, identifying and treating strictures, and complications such as Barrett metaplasia. High‐resolution esophageal manometry findings can be helpful in the management of patients with GERD as they identify features that help in the selection of treatment, such as the integrity of peristalsis, presence of hiatal hernia, and/or a weakened antireflux barrier. Other testing with pH‐metry or pH‐impedance metry can quantify the occurrence of reflux and the efficacy of physiological clearance mechanisms. Figure 10.1 The Montreal definition of reflux disease. The clinical manifestations of GERD can be subdivided into esophageal and extraesophageal syndromes. The esophageal syndromes can be defined by any combination of reflux‐related symptoms and/or reflux‐related pathology. There are also multiple extraesophageal syndromes that have been attributed to reflux, some with strong pathophysiological associations and others are more speculative. Source: Modified from Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence‐based consensus. Am J Gastroenterol 2006;101(8):1900–20 with permission. Figure 10.2 High‐resolution esophageal manometry findings in patients with GERD. In all panels, the isobaric contour (black line) is set at 30 mmHg indicating the domain in which the intraluminal pressure exceeds that value. Basal esophagogastric junction (EGJ) pressure and morphology are assessed during a resting period (a,b,c); deep breaths (during gray bar) aid in identification of the diaphragmatic hiatus. (a) Type I EGJ morphology: no hiatal hernia. (b) Type II EGJ morphology: small (2 cm) hiatal hernia. (c) Type III EGJ morphology: 4 cm hiatal hernia. Single liquid test swallows (d,e,f; gray arrows). (d) Failed peristalsis with hiatal hernia and hypotensive lower esophageal sphincter (LES). The combination of weak LES and weak peristalsis causes prolonged esophageal acid exposure. (e) Weak peristalsis. Note the faint pressure signal at the LES. (f) Hypertensive peristalsis. This is a common finding in patients with reflux‐related hypersensitivity. Source: Reproduced with permission from the Esophageal Center at Northwestern University, Chicago, IL. Figure 10.3 Transient lower esophageal sphincter relaxation, the most common mechanism of reflux. Transient LES relaxation is a vagovagal reflex triggered by proximal gastric distension and causes LES relaxation, crural diaphragm inhibition, and esophageal shortening. It is the physiological mechanism of belching. Source: Reproduced with permission from the Esophageal Center at Northwestern University, Chicago, IL. Figure 10.4 Hill grade and EGJ flap valve. Endoscopic grading of the EGJ flap valve. In Grade I, one can see the gastric sling straddling the EGJ. In Grade II, the ridge of mucosa adjacent to the EGJ is less prominent and opens with respiration. In Grade III, the hiatus is patulous and open throughout the respiratory cycle. In Grade IV, the hiatus is grossly patulous, and the Z‐line is displaced proximally. Source: Hill LD, Kozarek RA, Kraemer SJ, et al. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointest Endosc 1996;44(5):541–7. Reproduced with permission of Elsevier. Figure 10.5 Types of hiatus hernia. (a)
CHAPTER 10
Gastroesophageal reflux disease
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