14: Gastroesophageal Reflux Disease and Esophageal Motility Disorders

Epidemiology

• Gastroesophageal reflux disease (GERD) is one of the most frequently encountered problems seen in clinical practice today. It is estimated that 60 million adults report suffering from reflux symptoms at least once a month. Almost 24 percent of the population report heartburn daily and 43 percent have weekly episodes.

• Achalasia is a disease affecting 1/10,000 people, making it the second most common esophageal motility disorder. It affects men and women equally from the ages of 20 to 40 years.

Pathophysiology

• GERD develops when the normal protective barrier of the esophagus is overcome and exposed to chronic insult. The pathogenesis of GERD is multifactorial, including anatomic factors, motor abnormalities, impaired esophageal clearance, and altered mucosal resistance.

• Achalasia is a result of neuronal degeneration of the myenteric plexus. The consequence is an unopposed sympathetic response and increased pressure at the level of the lower esophageal sphincter (LES), leading to a functional obstruction of the esophagus.

Clinical features

• GERD is variable in its presentation. Heartburn, regurgitation, and chest pain are the most common complaints. Extraesophageal symptoms include pneumonia, airway inflammation, chronic cough, laryngitis, and hoarseness.

• Achalasia presents as progressive dysphagia, initially presenting with dysphagia to solids and then to liquids.

Diagnostics

• Diagnostic studies for GERD include 24-hour pH monitoring, BRAVO probe, endoscopy, and manometry.

• The pathognomonic finding in achalasia is of a “bird’s beak” on esophagogram. Manometry is the gold standard for achalasia. Classic findings are a hypertensive LES (resting pressure > 45 mm Hg), incomplete relaxation of the LES with swallowing, residual pressure > 8 mm Hg, and esophageal aperistalsis.

Treatment

• Initial management of GERD includes lifestyle medication and proton pump inhibitors (PPIs). Failure of medical therapy or inability to tolerate PPIs is an indication for surgery. Laparoscopic Nissen fundoplication is the surgery of choice. Alternate options include partial fundoplication or Collis gastroplasty for patients with esophageal motility disorders or a short esophagus.

• Multiple options for the treatment of achalasia include smooth muscle relaxants, dilation, botulinum toxin, and Heller myotomy.

Outcomes

• Laparoscopic Nissen fundoplication has shown equal efficacy to an open approach in controlling GERD and is associated with decreased length of stay (LOS), less pain, and lower costs. The overall complication rate is between 5 and 10 percent. Laparoscopic antireflux surgery (LARS) is associated with an improvement in symptoms compared with those treated medically but is associated with a 6-percent rate of severe dysphagia.

• Laparoscopic Heller myotomy has been shown to be superior to botulinum toxin injection and pneumatic dilation. Recent series show excellent long-term relief of symptoms at 2 years.