Which is for the good of mankind remains in the earth INSTRUCTIONS TO AUTHORS All material submitted for publication should be sent exclusively to the 'Pakistan Journal of Gastroenterology'. Three copies of manuscripts should be sent by registered post three months prior to the date of next publication, addressed to: The Executive Editor Pakistan Journal of Gastroenterology Welcare Liver & G.I. Clinic, 93-B Shadman, Main Boulevard, Shadman Chowk, Lahore The authors should comply with the following policy: 1. The editorial board retains the customary rights to style, shorten or reject the article submitted for publication. 2. Original articles should normally contain research related to Gastroenterology and may be in the form of clinical research papers, unusual case reports, new ideas and innovations regarding techniques, procedures and instruments, and short reports. 3. Special articles related to medical education, new and useful statistical techniques and those related to any drug, special procedure, etc. will also be entertained. 4. Review articles should constitute critical analysis and latest developments. Prior permission of the editors should be sought before sending a review article. 5. Manuscripts should be typed double spaced on one side of the paper and the pages should be numbered. 6. Scientific articles should conform to the internationally recognized structure viz. abstract, introduction, material and method, results, discussion and references. Tables and illustrations should be submitted separately from the text. Technically incorrect articles will not be accepted. 7. The references should be presented according to the style of Index Medicus. Titles of books should be followed by place of publication, publisher and year. 8. The article once submitted will not be returned irrespective of its publication. The author is advised to retain a copy. 9. The author is requested to send their materials on floppy computer disc to minimize the typing errors. 10. All authors must give written consent for publication on the attached proforma. BIANNUAL MARCH, 2007 LAHORE - PAKISTAN To: THE EXECUTIVE EDITOR PAKISTAN JOURNAL OF GASTROENTEROLOGY WELCARE LIVER & G.I. CLINIC, 93-B SHADMAN, MAIN BOULEVARD, SHADMAN CHOWK, LAHORE FROM: NAME OF FIRST AUTHOR: ___________________________ POSTAL ADDRESS: ___________________________ ___________________________ PHONE NOS: ___________________________ SUBJECT: UNDERTAKING BY THE AUTHORS I Dr. 1. ________________________ ______________________ 2.________________________ ______________________ 3.________________________ ______________________ 4.________________________ ______________________ 5. ________________________ ______________________ 6.________________________ ______________________ solemnly declare that my / our articles entitled” __________________________________ _____________________________________________________________ has not been submitted before for publication in any other Journal and if approved for publication in Pakistan Journal for Gastroenterology, it will not be submitted again elsewhere. I / We further declare that it is review / original article / case report. *(The copies of article once submitted will not be returned irrespective of its publication). Signature of 1st Author CORRIGENDUM In the last Pakistan J. of Gastroenterology, Vol. 27 (Biannual Apr. – Sep., 2013), published and circulated last year, the volume number was printed inappropriately as Vol. 27. Actually it was Vol. 28 Biannual October 2013). Therefore, it should be read as Pakistan J. of Gastroenterology, Vol. 28 (Biannual October 2013) for future reference. 75 Pakistan J. of Gastroenterology, Vol. 29, Biannual Mar., 2014 The Pakistan Journal of G A S T R O E N T E R O L G Y Editor-in-Chief: Patron: Executive Editor: Editors: Editorial Advisory Board: Peer Review Committee: For Correspondence: Executive Editor Address: Welcare Liver & g. i. Clinic, 93-B Shadman, Main Boulevard, Shadman Chowk, Lahore Phone: 03008477287. E-mail: [email protected] Web: www.psg.org.pk EDITORIAL GASTROESOPHAGEAL REFLUX DISEASE (GERD) Gastroesophageal reflux disease (GERD) or dyspepsia of normal anti - reflux mechanism to protect against is recurrent or persistent discomfort or pain involving abnormal frequency and quantity of GER. GER itself is upper abdomen which is characterized by early satiety, not a disease process but rather a normal physiologic postprandial fullness, nausea, and bloating. In phenomenon, which occurs many times each day, Pakistan though hospital-based surveys are showing especially after large meals, without making symptoms upto 24% prevalence, actually it is more in general or mucosal damage. When acid reflux occurs, fluid or people both in the cities and villages as well due to food can be tasted in the back part of the mouth. When modernization of life style, food choices and their refluxed stomach acid meets the lining of the timings. esophagus it may result burning sensation in the Reflux of gastric juices and hiatus hernia are the throat or the chest called acid indigestion or most common causes. Adults with GERD usually heartburn. Persistent reflux that happens more than encounter the symptoms after eating a meal, lying on twice a week is labeled as GERD, and it can ultimately their backs, when bending over or if they are lifting bring about more serious health problems. People of heavy weight things. Symptoms often become very any age group can suffer GERD. Two factors distinct during the night. GERD is very commonly contribute to mucosal damage i.e., direct toxic injury noticed in pregnant women (> 50% experience acid and prolonged mucosal contact time with gastric acid reflux and/or heartburn). If symptoms and reflux or pepsin or both. episodes occur together < 25% or > 75% of time, causal Esophageal clearance occurs by primary or association is low or high respectively. In symptomatic secondary peristaltic waves. Acid neutralization by patients who are using aggressive acid suppressive swallowed saliva and esophageal mucosal resistance, therapy, demonstration of complete acid suppression acid residue at mucosal surface maintains low clearly indicates that acid reflux is not a major factor, esophageal pH immediately after peristaltic and if acid reflux is still occurring then there is a need contractions. Salivary bicarbonate neutralizes mucosal of different therapy. pH in a stepwise fashion in 8 – 10 swallows. Duration Adults with GERD, may experience any of the of time from reflux event until restoration of normal symptoms, including heartburn, belching, esophageal pH is the Esophageal Acid Clearance Time. regurgitation, bad breath (halitosis), nausea, Delayed gastric emptying leads to retention of solid dysphagia, odynophagia (painful swallowing), chest foods, secretion of food - induced acid, gastric pain, particularly after eating, water brash (increased distension and LES relaxations. In post – prandial salivation), reflux esophagitis, peptic stricture in state, possible delayed gastric emptying results in esophagus, Barrett’s esophagus, esophageal increased esophageal acid contact time. carcinoma, abdominal pain, sinusitis, asthma, Drugs may aggravate GER by decreasing LES laryngitis, pharyngitis, sensitive teeth, choking feeling, pressure e.g. beta – agonist, theophylline, chronic coughing, and damage to the esophagus itself. anticholinergic, tricyclic anti – depressants, The damaged esophagus will begin to scar, may start progesterone, diazepam & calcium channel blockers or to become narrow resulting strictures formation, direct esophageal mucosal injury e.g. tetracycline, which can lead to dysphagia. If the esophagus is quinidine, KCL, iron, NSAIDs, Aspirin, Alendronate. injured even more, it could evolve to Barrett’s Hiatus hernia is present in 50% patients having > 50 esophagus; will cause the esophagus to change in color years of age. Endoscopically 80% patients with GERD and shape, and there is a raised risk of cancer too. have hiatus hernia and > 50% patients of hiatus hernia Gastroesophageal reflux disease (GERD) is a more do have GERD. On endoscopy, majority of the patients crucial form of Gastroesophageal reflux (GER), also have no visible damage in the mucosal lining (non- called acid regurgitation or acid reflux. Here digestive erosive GERD/NERD), whereas others have reflux juices – called acids –go up along with the food esophagitis, stricture formation or Barrett's change in commonly. It occurs when the LES relax to open the esophagus. Severe esophageal mucosal disease spontaneously, for variable period of time, or does not almost guarantees presence of hiatushernia and may close properly and contents from the stomach rise up results in melena, vomiting blood or coffee ground into the esophagus. GER occurs when there is failure looking material, dysphagia, anemia (low blood count), Pakistan J. of Gastroenterology, Vol. 29, Biannual Mar., 2014 38 MUHAMMAD ARIF NADEEM un-explained weight loss. Patients with GERD and its changes or medications, then additional testing may be complications should be checked carefully by a required, where barium swallow radiograph can detect gastroenterologist. GERD may deteriorate or initiate abnormalities like hiatal hernia and other anatomical the chronic cough, asthma, and pulmonary fibrosis. or physical problems of the esophagus but will not Anatomical anti - reflux barrier is a fortress, perceive mild irritation, although strictures or ulcers of composed of LES, crural diaphragm and the esophagus can be detected. Upper