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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1401_Библиотеки_им_академика_М_И_Перельмана.pdf
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Contributors
ThomasC.Tsai Division of General and Gastrointestinal Surgery, Massachusetts
General Hospital, Boston, MA, USA
SaraWelinsky Columbia University Medical Center, New York, NY, USA
Erik B. Wilson Division of Minimally Invasive and Elective General Surgery,
Department of Surgery, McGovern Medical School, University of Texas Health
Science Center at Houston, Houston, TX, USA
AricWogsland
Department of General Surgery, University Hospitals of Cleveland,
Cleveland, OH, USA
NatanZundel Department of Surgery, University at Buffalo, Miami, FL, USA
Gastroesophageal Reflux Disease:
Workup andEvaluation
MarcoDi Corpo, KamilNurczyk, andMarcoG.Patti
General Considerations
Gastroesophageal reux disease (GERD) is the most frequent gastrointestinal disorder with an increasing incidence likely due to the rising obesity epidemic [1]. GERD
is secondary to the backow of gastric contents through an incompetent gastroesophageal junction (GEJ), causing symptoms and/or complications [2]. The most
common GERD symptom is heartburn, often associated with regurgitation and dysphagia. However, some patients may present with atypical or extraesophageal
symptoms such as laryngitis, hoarseness, cough, or asthma.
Clinical Findings
1
Symptoms
GERD patients may present with typical “esophageal” symptoms or atypical “extraesophageal” symptoms (Table1.1).
There is some evidence about the value of empiric medical therapy with proton
pump inhibitors (PPI) for GERD patients presenting with heartburn and regurgitation,
the so called “PPI trial,” which consists of a 14-day course of high-dose PPI, on the
assumption that a response would conrm the diagnosis of GERD.In the American
College of Gastroenterology (ACG) guidelines published in 2013, the PPI trial strategy was proposed as a diagnostic method, based on the extent of symptom relief [3].
M. Di Corpo
Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
K. Nurczyk · M. G. Patti (
Departments of Surgery and Medicine, University of North Carolina, Chapel Hill, NC, USA
e-mail: marco_patti@med.unc.edu
© Springer Nature Switzerland AG 2021
N. Zundel et al. (eds.), Benign Esophageal Disease,
https://doi.org/10.1007/978-3-030-51489-1_1
*)
1
2
M. Di Corpo et al.
Table 1.1 Symptoms
associated with
gastroesophageal reux
disease (GERD)
Clinical presentation of GERD
Esophageal Heartburn
Regurgitation
Dysphagia
Gastric Bloating
Early satiety
Belching
Nausea
Pulmonary Aspiration
Asthma
Wheezing
Cough
Dyspnea
Ears, nose, throat Globus
Water brash
Hoarseness
Cardiac Chest pain
Conversely, it has been shown by Patti etal. [4] that 30% of ~800 patients with
symptom and endoscopy-based GERD diagnosis (excluding patients with biopsyproven Barrett’s esophagus) referred for esophageal function testing had a normal
esophageal acid exposure as determined by esophageal manometry and 24-hour pH
monitoring. These results were later conrmed by Bello etal. [5] in a similar study,
showing that among 134 patients referred for laparoscopic anti-reux surgery
(LARS) with a diagnosis of GERD based on symptoms and endoscopy, 24-hour pH
monitoring showed that 42% (56 patients) had a normal reux score. Two of those
patients were found to have type II achalasia by high-resolution manometry.
Based on these and similar data, the World Gastroenterology Organization
(WGO) guidelines, published in 2017 [6], have discouraged the use of the PPI trial
as a diagnostic method due to the lack of sensitivity and specicity.
Clinical Evaluation
Given this evidence, GERD patients should undergo a thorough objective evaluation prior to surgical treatment.
Endoscopy
Often this is the rst test done, particularly when dysphagia is present, to rule out
complications (such as a stricture) or other conditions such as eosinophilic esophagus or cancer [7, 8]. However, EGD presents two major limitations: [1] about 2/3 of
GERD patients do not have esophagitis and [2] there is major inter-observer variability for the low grade of esophagitis [9]. In order to classify the EGD ndings, the
“Los Angeles” (LA) classication was introduced by Lundell etal. [10]. Mucosal
breaks were graded as A, B, C, or D based on the severity of the erosions (Table1.2).
1 Gastroesophageal Reux Disease: Workup andEvaluation
Table 1.2 Los Angeles classication system for esophagitis
Los Angeles grading
system for esophagitis
Grade A
Grade B Mucosal breaks >5mm long, none of which extends between the
Grade C
Grade D
Mucosal breaks ≤5mm long, none of which extends between the
tops of the mucosal folds
tops of two mucosal folds
Mucosal breaks that extend between the tops of ≥2 mucosal folds,
but that involve <75% of the esophageal circumference
Mucosal breaks that involve ≥75% of the esophageal
circumference
Unfortunately, there is evidence of high inter-observer discrepancy among lower
LA grades [11], and due to this observation, the Esophageal Diagnostic Advisory
Panel recommends further studies such as 24-hour pH monitoring in order to certify
GERD [12].
Barium Swallow
The barium swallow is used to assess anatomical and functional characteristics of the
swallowing process (pharynx, esophagus, and GEJ), while the sensitivity and specicity for the diagnosis of GERD is low. Bello etal. [6] conrmed these data by nding positive radiological reux signs in less than 50% of GERD patients (whose
diagnosis was obtained by pH monitoring). Furthermore, a study from the Netherlands
[13] found similar results when comparing barium swallow to 24-hour pH-impedance monitoring for GERD diagnosis (sensitivity 46% and specicity 44%).
On the other hand, barium swallow gives valuable information about esophageal
and GEJ anatomy, and helps to determine the presence, size, and type of hiatal hernias.
Moreover, it can assess GERD complications such as ring or strictures [3, 14] (Fig.1.1).
3
Esophageal Manometry
This study provides information about the exact location of the LES (important for
the correct positioning of the pH catheter), and about LES pressure and relaxation.
In addition, it characterizes esophageal peristalsis, rules out achalasia, and allows
the choice of the proper anti-reux operation (Fig.1.2).
Ambulatory pH Monitoring
Ambulatory 24-hour pH monitoring is considered the gold-standard test for GERD
diagnosis, having a reported sensitivity and specicity around 90% [3, 15]. It is the
only study that can determine objectively the esophageal acid exposure; thus, having a normal pH study of acid control medications strongly suggests the absence of
4
Fig. 1.1 Hiatal hernia in
barium swallow
M. Di Corpo et al.
Fig. 1.2 Normal HRM.
GERD [14]. Esophageal pH assessment can be done with a trans-nasal probe for
24hours or with a wireless probe for 48hours [16]. Six parameters are considered:
number of reux episodes, duration of the longest one, number of episodes lasting
>5minutes, total percentage of time the pH is <4in total, and in the supine and
upright positions. On the basis of these data, the DeMeester score is generated, and
it is considered abnormal when the nal composite score is more than 14.7
(Table1.3) [17]. In addition, the study allows the determination of a temporal correlation between symptoms experienced by the patient and episodes of reux. While
analyzing the tracings, it is considered positive when the reported symptom occurs
within 2minutes of the reux episode [18]. Moreover, a positive correlation is a
predictor for treatment success after LARS [19], being more sensitive for patients
with typical symptoms rather than atypical ones [20] .
1 Gastroesophageal Reux Disease: Workup andEvaluation
Table 1.3 Normal values for pH monitoring
Normal values for ambulatory 24-hour pH monitoring
Percentage of total time pH<4.0 5%
Percentage of upright time pH<4.0 8%
Percentage of supine time pH<4.0 4%
Number of episodes of reux 47
Number of episodes >5minutes 3.5
Longest episode (minutes) 20
Composite score
a
The composite score indicates the extent to which the patient’s values deviate from the normal
means of the six variables. It allows one to express in a single gure the degree of the patient’s
abnormality
a
14.7
5
Fig. 1.3 Abnormal pH.Orange spots indicate symptoms reported by the patient, used for analyzing symptom correlation with reux episodes
Due to the fact that the pH catheter should be placed 5cm proximal to the upper
border of the LES and with the aim to diminish the false-positive and false-negative
rates, the best-case scenario is to perform this study after having manometric knowledge of the exact position of the LES.Molena etal. [21] conrmed these data showing only 25% of accuracy when positioning the pH probe using the “step” technique
(placing the pH catheter into the stomach through the nose and after conrming the
intra-gastric pH value, the probe was progressively withdrawn until obtaining pH
values >4). Patients should hold anti-acid medications prior to the study (7days for
PPI and 3 for H
blockers) and they are encouraged to continue with their normal
2
lifestyle and meals. (Fig.1.3).
6
Based on the evidence from The Esophageal Diagnostic Advisory Panel [12] and
the ACG guidelines [3], the ambulatory pH monitoring is recommended for the
following:
• Patients with refractory GERD.
• Patients with GERD symptoms and negative EGD ndings.
• Patients with EGD ndings compatible with LA “A” or “B”.
• Patients scheduled for LARS.
• Patients with persistence or recurrence of symptoms after LARS.
Interestingly, a combination of conventional pH monitoring and impedance technology allows a comprehensive evaluation of esophageal reux events, either for
non-acidic, weakly, or acidic episodes, providing key information particularly for
refractory GERD patients [19, 22]. Contrary to conventional pH monitoring, pHimpedance can be performed on anti-reux medications. However, the indication
for LARS is not clear for patients with non-acidic reux events who underwent
pH- impedance on PPI or H2 blockers or for patients with negative ndings on pH
monitoring but abnormal number of reux events measured by pH-impedance [12,
23] (Fig.1.4a,b).
M. Di Corpo et al.
Gastric Emptying Study
This is not a requirement for all GERD patients undergoing LARS, but it provides
valuable information for patients with nausea or bloating, particularly if they are
known to have diabetes mellitus of connective tissue disorders [12] (Fig.1.5).
Differential Diagnosis
Heartburn can be the presenting symptom of irritable bowel syndrome, achalasia,
cholelithiasis, coronary artery disease, or psychiatric disorders. Esophageal manometry and pH monitoring are essential to determine with certainty if GERD is present
and if reux is the cause of the symptoms.
Complications
Esophagitis is the most common complication. Peptic strictures are uncommon,
particularly in the era of proton pump inhibitors. Barrett’s esophagus is found in
about 10–15% of patients with reux documented by pH monitoring. Some patients
may eventually progress to high-grade dysplasia and adenocarcinoma. Respiratory
complications vary from chronic cough to asthma, aspiration pneumonia, and even
pulmonary brosis. Vocal cord and dental damage can also occur.
1 Gastroesophageal Reux Disease: Workup andEvaluation
a
7
b
Fig. 1.4 (a) Normal pH-impedance (b) Abnormal pH-impedance
8
M. Di Corpo et al.
Fig. 1.5 Normal gastric emptying study
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