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  • Julio Alejandro Murra Saca, MD
    Gastroenterologist

  • Tel: (503) 2226-3131, 2225-3087, 2530-3334 al 37
    Edificio Centro Scan, Colonia Médica

  • San Salvador, El Salvador

GASTROESOPHAGEAL REFLUX

Gastroesophageal reflux, also known as acid reflux, occurs when the stomach contents reflux or back up into the esophagus and/or mouth. Reflux is a normal process that occurs in healthy infants, children, and adults. Most episodes are brief and do not cause bothersome symptoms or complications.

In contrast, people with gastroesophageal reflux disease (GERD) experience bothersome symptoms as a result of the reflux. Symptoms can include heartburn, regurgitation, vomiting, and difficulty or pain with swallowing. The reflux of stomach acid can adversely affect the vocal cords causing hoarseness or even be inhaled into the lungs (called aspiration).

WHAT IS GASTROESOPHAGEAL REFLUX?

When we eat, food is carried from the mouth to the stomach through the esophagus, a tube-like structure that is approximately 10 inches long and 1 inch wide in adults . The esophagus is made of tissue and muscle layers that expand and contract to propel food to the stomach through a series of wave-like movements called peristalsis.

At the lower end of the esophagus, where it joins the stomach, there is a circular ring of muscle called the lower esophageal sphincter (LES). After swallowing, the LES relaxes to allow food to enter the stomach and then contracts to prevent the back-up of food and acid into the esophagus.

However, sometimes the LES is weak or becomes relaxed because the stomach is distended, allowing liquids in the stomach to wash back into the esophagus. This happens occasionally in all individuals. Most of these episodes occur shortly after meals, are brief, and do not cause symptoms. Normally, acid reflux should occur only rarely during sleep.

Acid reflux — Acid reflux becomes gastroesophageal reflux disease (GERD) when it causes bothersome symptoms or injury to the esophagus. The amount of acid reflux required to cause GERD varies.

In general, damage to the esophagus is more likely to occur when acid refluxes frequently, the reflux is very acidic, or the esophagus is unable to clear away the acid quickly. The most common symptoms associated with acid reflux are heartburn, regurgitation, chest pain, and trouble swallowing. The treatments of GERD are designed to prevent one or all of these symptoms from occurring.

Hiatus hernia — The diaphragm is a large flat muscle at the base of the lungs that contracts and relaxes as a person breathes in and out. The esophagus passes through an opening in the diaphragm called the diaphragmatic hiatus before it joins with the stomach.

Normally, the diaphragm contracts, which improves the strength of the LES, especially during bending, coughing, or straining. If there is a weakening in the diaphragm muscle at the hiatus, the stomach may be able to partially slip through the diaphragm into the chest, forming a sliding hiatus hernia.

The presence of a hiatus hernia makes acid reflux more likely. A hiatus hernia is more common in people over age 50. Obesity and pregnancy are also contributing factors. The exact cause is unknown but may be related to the loosening of the tissues around the diaphragm that occurs with advancing age. There is no way to prevent a hiatus hernia.

ACID REFLUX SYMPTOMS

People who experience heartburn at least two to three times a week may have gastroesophageal reflux disease, or GERD. The most common symptom of GERD, heartburn, is estimated to affect 10 million adults in the United States on a daily basis. Heartburn is experienced as a burning sensation in the center of the chest, which sometimes spreads to the throat; there also may be an acid taste in the throat. Less common symptoms include:

  • Stomach pain (pain in the upper abdomen)
  • Non-burning chest pain
  • Difficulty swallowing (called dysphagia), or food getting stuck
  • Painful swallowing (called odynophagia)
  • Persistent laryngitis/hoarseness
  • Persistent sore throat
  • Chronic cough, new onset asthma, or asthma only at night
  • Regurgitation of foods/fluids; taste of acid in the throat
  • Sense of a lump in the throat
  • Worsening dental disease
  • Recurrent lung infections (called pneumonia)
  • Chronic sinusitis
  • Waking up with a choking sensation

When to seek help — The following signs and symptoms may indicate a more serious problem, and should be reported to a healthcare provider immediately:

  • Difficulty or pain with swallowing (feeling that food gets "stuck")
  • Unexplained weight loss
  • Chest pain
  • Choking
  • Bleeding (vomiting blood or dark-colored stools)

 


Endoscopy of Hiatal Hernia


Dilation Esophageal Peptic Stenosis


Endoscopy of Barrett Adenocarcinoma


The Untold History of The Gastrointestinal Endoscopy Part 2 (2/6)


The Endoscopic Sonata no 8 Pathetique

 





Complications of GERD.





 

Flexible endoscopic Suturing Device

Suturing System and standard video endoscopy, sutures are placed in the upper part of the stomach at or just below the LES. Two stitches can be placed and tied together to create a pleat near the LES and treat symptomatic reflux. The image and the video clip display a flexible suturing device which has been passed through the external accessory channel, with a friction-fit adapter and tube guide, provides a pathway for the flexible endoscopic suturing device.

51 year-old male with hiatus hernia and heart burning since 3 years. An endoscopic gastroplicature was performed. The treatment is delivered via an endoscope.
final status from a Endoscopic Anti-Reflux Procedure was archived that is done on an outpatient basis patient go home the same day. 24 year-old female who has been
suffered of Gastroesophageal Reflux Disease (GERD) since 8 years even with PPI. 
She has incompetence of the inferior gastroesophageal sphincter.
Another image of the inferior gastroesophagic junction..  flexible device with treads is
shown, the tip of flexible endoscopic (flexible Sew-Right Device).
The clamp with threads is suctioning the gastroesophageal
junction.
The image and the video clip display the traction exerted
by the treads that tied the tissues.
The gastroplication has been completed.
Plication techniques create a mechanical barrier to reflux through apposition of 2 mucosal surfaces at the gastroesophageal junction or in the cardia.
Final statust of the endoscopic gastroplicature.
Patient relief the symptoms.
 
Final statust of the endoscopic gastroplicature.
Patient relief the symptoms.
 

ACID REFLUX COMPLICATIONS

The vast majority of patients with gastroesophageal reflux disease will not develop serious complications, particularly when reflux is adequately treated. However, a number of serious complications can arise in patients with severe gastroesophageal reflux disease.

Ulcers — Ulcers can form in the esophagus as a result of burning from stomach acid. In some cases, bleeding occurs. You may not be aware of bleeding, but it may be detected in a stool sample to test for traces of blood that may not be visible. This test is performed by putting a small amount of stool on a chemically coated card.

Stricture — Damage from acid can cause the esophagus to scar and narrow, causing a blockage (stricture) that can cause food or pills to get stuck in the esophagus. The narrowing is caused by scar tissue that develops as a result of ulcers that repeatedly damage and then heal in the esophagus.

Lung and throat problems — Some people reflux acid into the throat, causing inflammation of the vocal cords, a sore throat, or a hoarse voice. The acid can be inhaled into the lungs and cause a type of pneumonia (aspiration pneumonia) or asthma symptoms. Chronic acid reflux into the lungs may eventually cause permanent lung damage, called pulmonary fibrosis or bronchiectasis.

Barrett's esophagus — Barrett's esophagus occurs when the normal cells that line the lower esophagus (squamous cells) are replaced by a different cell type (intestinal cells). This process usually results from repeated damage to the esophageal lining, and the most common cause is longstanding gastroesophageal reflux disease. The intestinal cells have a small risk of transforming into cancer cells.

As a result, people with Barrett's esophagus are advised to have a periodic endoscopy to monitor for early warning signs of cancer.

Esophageal cancer — There are two main types of esophageal cancer: adenocarcinoma and squamous cell carcinoma. A major risk factor for adenocarcinoma is Barrett's esophagus, discussed above. Squamous cell carcinoma does not appear to be related to GERD. Unfortunately, adenocarcinoma of the esophagus is on the rise in the United States and in many other countries. However, only a small percentage of people with GERD will develop Barrett's esophagus and an even smaller percentage will develop adenocarcinoma.





There is a reflux esophagitis ulcers and gastroesophageal junction stricture.
For more endoscopic details download the video by clicking on the image.



Photography of a Video computed endoscopy observing a reflux ulcer in retroflexion maneuver, the endoscope is observed (color black) to download the video click on the image.



Photography of Video endoscopy, 59 year-old male who reported dysphagia. The are in the middle third signs of reflux esophagitis,



Barrett's Esophagus, Endoscopic image of Barrett's esophagus typically observed displacement
the gastroesophageal junction, the redder tissue (gastric) has displaced the esophageal tissue (pink), as a result of chronic gastroesophageal reflux disease, must be confirmed with biopsies.



Reflux esophagitis, ulcers observed radial, and hiatal hernia, to download the video click on the image.



Hemorrhagic esophagitis, shows the severity of inflammation of the esophageal mucosa, fibrin, edema and hemorrhagic areas, to download the video click on the image.



Same as above noted, the severity of reflux ulcers with retroflexion maneuver.
to download the video click on the image.



Adenocarcinoma caused due to Barrett's esophagus.