Gastro-Esophageal
Reflux Disease
GERD
Gastro-esophageal reflux
• Physiological retrograde movement of gastric content into
the esophagus
Gastro-Esophageal Reflux Disease (GERD)
• Esophageal inflammation caused by refluxed gastric
content and acid
Definitions
Non-Erosive Reflux Disease (NERD)
• Reflux symptoms without reflux esophagi tis or abnormal
esophageal acid exposure (previously named functional
heartburn)
Refractory GERD
• Failure of GERO to respond symptomatically (partially or
completely) to standard dose PPI ( double dose at least 8
weeks)
Etiology &
Pathogenesis
Transient lower esophageal
sphincter relaxations (t-LESRs)
Account for most reflux events in individuals with a normal LES pressure.
It differs from swallow-induced LES relaxation in the following : Occur without an associated pharyngeal contraction
Unaccompanied by esophageal peristalsis
Persist for longer periods (> 10 sec)
Also, t-LESRs are responsible for belching.
GABA-B agonists (Baclofen) can inhabit t-LESRs
Hvpotensive lower
esophageal sphincter (LES)
Factors that decrease LES tone
Chocolate (xanthines)
Caffeine & Smoking & Ethanol
Fatty meals & Carminatives (spearmint, peppermint)
Drugs : CCBs, Nitrates, Diazepam, Theophylline, Morphine
Hormones : Secretin, CCK, Glucagon, VIP, Progesterone (CCP)
Anatomic disruption of GEJ:
Hiatus Hernia
The severity of esophagitis correlates with the size
of the hiatus hernia.
Alone hiatus hernia or hypotensive LES can't
results in severe incompetence;
the two conditions interact with each other
Delayed
gastric
emptying
exacerbate
GERD by
01
02
03
Increasing the
gastroesophageal
pressure gradient
Increasing gastric
volume & hence
the volume of
potential
refluxate
Increasing T-LESR
frequency
Impaired esophageal clearance
Esophageal clearance time :
the duration of time that the esophageal mucosa
remains in contact with the refluxed materials
Clearance occurs by esophageal peristalsis (lry &
2ry) & swallowed saliva.
Epidemiology
Age : GERD incidence increases with age
Gender : males = females (males are more liable for esophagitis &
Barrett's)
Obesity : GERD increased in high BMI
Pregnancy : GERD l in pregnant than non-pregnant
Lifestyle : environmental factors may influence GERO prevalence
Zollinger-Ellison syndrome
Duodeno-Gastric reflux : bile reflux
Clinical picture of
GERD
Esophageal features
Non Esophageal features
Typical presentations
o
Heart bum
o
Regurgitation
Atypical presentations
o
Cheat pain (angina like)
o
Dysphagia
o
Odynophagia
Respiratory presentations
o
Chronic cough & Wheezes
o
Aspirated pneumonia
Non Respiratory presentations
o
Dental erosions & Sore throat &
Hoarseness of voice
o
Water brash : sudden mouth filling
with clear, slightly salty fluid which
o
comes in large amounts from the
salivary glands in response to
GERD
Esophageal strictures
Barrett's esophagus (20%)
Complications
of GERD
Esophageal ulcers and bleeding
Laryngeal carcinoma (due to prolonged
irritation of the larynx by repeated aspiration)
Pulmonary manifestations
Eosinophilic esophagitis
Differential
Diagnosis of
GERD
Pill induced esophagitis
Functional Heartburn
Esophageal Motor Disorder
Rumination Syndrome
Gastroparesis
GERD VS. IHD
GERD
Burning pain
Pain not radiates to arm
Pain precipitated by
hot liquids or alcohol
Relieved by antacid
Increased by nitrates
No dyspnea
Myocardial ischemia
Compression or Crushing pain
Pain radiates back,
shoulder,neck, and Lt arms
Pain precipitated by exercise
Relieved by rest and nitrates
Dyspnea may present
Invesigations
Therapeutic Trial
Most patients with classic symptoms of GERD can be started with
empiric trial of medical ttt after exclusion of other extra-esophageal
symptoms
Complete resolution with ttt and relapse after stop it confirm diagnosis
Upper GI Endoscopy (UGIE) +
Mucosal biopsy
Indication
Patients with Alarm symptoms (pain, vomiting, anemia, bleeding, Wt loss)
Patients with Atypical symptoms Or Refractory GERD
Patients with GERD symptoms > 5 years>>>>> suspicious for Barrett's
Before Endoscopic and Surgical therapy for GERD
Ambulatory pH monitoring
The gold standard for measurement of acid GERD
Indicated if endoscopy is -ve or atypical symptoms
It monitors esophageal pH for 12-24 hours
Acid reflux if pH < 4 and last longer than 5 sec
Total duration of all reflux episodes should > 5% of the total monitoring
time to diagnose GERD
Esophageal manometry
Indicated in atypical symptoms of chest
pain and before anti-reflux surgery
Poor test in predicting GE[ unless the LES
pressure < 6 mmHg
Others
Barium swallow
Wireless pH monitoring (Bravo dewice)
Multichannel intraluminal impedance (MIl)
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