Is Endoscopic Gastric Fundoplication indicated for a patient with reflux esophagitis, small hiatus hernia, and gastroparesis?

Endoscopic Gastric Fundoplication for Reflux Esophagitis with Hiatus Hernia and Gastroparesis

Endoscopic Gastric Fundoplication is indicated for this patient with reflux esophagitis LA grade B, 2 cm hiatus hernia, and gastroparesis who has documented bile reflux gastritis and incompetent cardia on pH monitoring. 1

Assessment of Current Condition

The patient presents with:

• Reflux esophagitis LA grade B (confirmed by endoscopy)
• 2 cm hiatus hernia (confirmed by endoscopy)
• Gastroparesis (confirmed by pH monitoring)
• Incompetent cardia with bile reflux gastritis
• Moderate amount of fluid noted on pH monitoring

Treatment Decision Algorithm

Step 1: Confirm GERD Diagnosis and Severity

• LA grade B esophagitis represents objective evidence of pathologic GERD 1
• The presence of a hiatus hernia (2 cm) increases the likelihood of more severe GERD 2
• Incompetent cardia on pH monitoring confirms pathologic reflux

Step 2: Evaluate Medical Management Options

• Standard PPI therapy would be first-line for most GERD patients 1
• However, this patient has:
  • Documented gastroparesis (requiring prokinetic consideration) 1
  • Bile reflux (not responsive to acid suppression alone)
  • Moderate fluid accumulation
  • Structural defect (hiatus hernia)

Step 3: Consider Anti-Reflux Intervention Options

1. Endoscopic Gastric Fundoplication

   • Appropriate for patients with proven GERD and small hiatus hernia 1
   • Specifically mentioned as an effective endoscopic option in the AGA guidelines 1
   • Can address both the reflux and the small hiatal hernia

2. Laparoscopic Fundoplication

   • Alternative surgical option for proven GERD 1
   • More invasive than endoscopic approach

3. Magnetic Sphincter Augmentation

   • Another surgical option for proven GERD 1
   • Often combined with crural repair for hiatal hernias

Why Endoscopic Gastric Fundoplication is Indicated

1. Documented Pathologic GERD: The patient has LA grade B esophagitis, which constitutes objective evidence of pathologic GERD according to the AGA guidelines 1

2. Appropriate Anatomical Features:

   • Small hiatus hernia (2 cm) is amenable to endoscopic repair
   • Transoral incisionless fundoplication is specifically recommended for "carefully selected patients with GERD in the absence of a large hiatal hernia" 1

3. Addressing Multiple Mechanisms:

   • Will help correct the incompetent cardia
   • Can reduce bile reflux by restoring the anti-reflux barrier
   • Improves the mechanical barrier against reflux in the setting of gastroparesis

4. Gastroparesis Consideration:

   • The AGA guidelines specifically mention that "prokinetics for coexistent gastroparesis" should be part of personalized therapy 1
   • Endoscopic fundoplication can be combined with medical management of gastroparesis

Important Caveats and Considerations

• Pre-procedure Assessment: Complete assessment of esophageal peristaltic function should be performed before any anti-reflux procedure 1

• Patient Selection: Candidacy for anti-reflux procedures requires:

  1. Confirmatory evidence of pathologic GERD (present in this case)
  2. Exclusion of achalasia
  3. Assessment of esophageal peristaltic function 1

• Potential Limitations:

  • Endoscopic fundoplication may be less effective for bile reflux than surgical options
  • The presence of gastroparesis may affect long-term outcomes and requires ongoing management

• Follow-up: Regular post-procedure follow-up is essential to monitor symptom resolution and potential complications

Conclusion

Based on the AGA Clinical Practice Update (2022), this patient with documented LA grade B esophagitis, small hiatus hernia, gastroparesis, and incompetent cardia with bile reflux is an appropriate candidate for Endoscopic Gastric Fundoplication. This approach addresses the anatomical defect while being less invasive than surgical alternatives, with the understanding that ongoing management of the gastroparesis will be necessary.