Gastroesophageal reflux disease
GERD
Raika Jamali M.D.
Gastroenterologist and hepatologist
Sina Hospital
Tehran University of Medical Sciences
Objectives
• Appreciate the significance of GERD as a
chronic disease
• Identify patients with different
presentations of GERD
• Organize a rationale management plan for
different types of GERD symptoms
• Be familiar with various treatment
modalities of GERD and their appropriate
use
Definitions
GERD: any symptomatic condition
or histopathologic alteration
resulting from episodes of
gastroesophageal reflux
●Erosive: 35%
●Nonerosive (NERD)
Why GERD is so important??
is very common & increasing
Burden and Quality of life
● complications: esophagitis, peptic
stricture, inflammatory polyps ,Barrett's
metaplasia , dysplasia ,adenocarcinoma
●
Epidemiology
●Geographic
● M=F
variation
● Barrett's metaplasia (M/F = 10 /1)
•The prevalence of GERD in
Asian populations is
reported to be lower than
that in the west.
• Population-based data on the
prevalence and symptom profile of
GERD in developing Caucasian
countries is lacking.
Frequency of Endoscopic GERD
Iranian Experience: 1994-1999
100%
80%
60%
40%
20%
0%
94
95
96
97
98
99
GERD
Retrospective study of 4500 UGIE reports (5y): 34.3% E-GERD
Malekzadeh,et al 2000
Prospective evaluation of referring
Dyspeptics in Tehran
• 269 (135 F) participant
• Symptoms recorded, UGIE + Bx from
Z-line was done:
• 77.6% at least one major GERD
symptom
• 76.1% EE (most A & B)
• 5% Specialized intestinal metaplasia
• 3 Dysplasia
• None of the symptoms could predict
the endoscopic or histologic findings
•
Nasseri-Moghaddam, Malekzadeh et al 2002
CONCLUSION
GERD is a common disease among
Iranian general population and its
prevalence is comparable with that
of the western countries .
Pathogenesis
● Transient L E S Relaxation
● Hypotensive L E S
● Anatomic Variables
●Delayed Gastric Emptying
● Esophageal Acid Clearance
- Salivary Function
-Impairments of Esophageal Emptying
‫پاتوفيزيولوژي ‪GERD‬‬
‫اختالل عملكرد‬
‫بزاق‬
‫اختالل مكانيسمهاي‬
‫دفاعي مخاطي‬
‫اختالل پاك‬
‫شدن مري‬
‫هرنيهياتال‬
‫شل شدن گذرا و‬
‫نامناسب ‪LES‬‬
‫ترشح اسيد معده و پپسين‪:‬‬
‫نرمال‪/‬افزايش يافته‬
‫كاهش فشار‬
‫استراحت ‪LES‬‬
‫تأخير تخليه‬
‫بيكفايتي دريچة پيلور؛‬
‫ريفالكس دئودنوگاستريك‬
Case 1
• A 34 y engineer with heart burn for 8 y
comes to your office for evaluation of his
GERD symptoms.
• He asks you about the diagnosis of GERD,
if additional diagnostic work up is needed
and his medical management.
Diagnosis
● History is usually sufficient to confirm
the diagnosis
Indications for Endoscopy
Extra-esophageal or atypical symptoms
Patients > 40 y with new onset GERD symptoms
Dysphagia
Weight Loss
Anemia
Family hx of Cancer
Long(>5 y) or very severe symptoms
GERD-B
The Los Angeles Classification
GERD-A
GERD-C
GERD-D
Avoid:
smoking
stress
Heavy meals
Large quantities of liquid with meals
Fatty foods
Coffee
Choclate
Alcohol
Mint
Orange juice
Tomato catch up
Anticholinergic, calcium channel
blockers, smooth muscle relaxants
Therapeutic regimens for GERD in
order of increasing potency
• Over-the-counter antacids and/or H2
receptor blockers
• Omeprazole (20 mg QD) or
equivalent dose of the other PPIs
• Omeprazole (20 mg BID or 40 mg
BD) or equivalent doses of the other
PPIs
• Step-up approach: with mild symptoms,
no change in QOL
• Step-down approach: with more severe
symptoms affecting QOL or with higher
grades of esophagitis / complications
• Bed time H2B for nocturnal symptoms
Dose of the different H2
blockers
Drug
• Cimetidine
• Ranitidine
• Famotidine
• Nizatidine
Daily dose
800 mg
300 mg
40 mg
300 mg
PPI versus H2 blockers in treatment of erosive
GERD symptoms (right panel) and esophageal
healing (left panel)
PPI side effects
• Pneumonia
• Hypergastrinemia (Carcinoid tumor
in animal model)
• Enteric infections
• Vitamin B12 malabsorption
PROKINETIC DRUGS
• Metoclopramide
• Cisapride
• Tegaserod
Duration of therapy
Maintenance therapy :
lowest dose of PPI or H2 blockers,
especially in severe esophagitis
(grades C & D) and with
complications (BE, stricture)
Intermittent therapy :
on-demand therapy in patients
with mild to moderate heartburn
without severe esophagitis.
Effective initial and long
term mangement
• Decreases amount of drugs used
• Decreases doctor visits
• Decreases the need for repeat UGIE
(Bate et al 1992, Bloom et al 1994, Bardhan et al 1999)
Case 2
• Young woman with chronic cough who is
refractory to treatment with sulbutamol
is referred for evaluation of GERD.
• She complains of morning hoarseness.
• Sulbutamol was in effective and even
aggravated her symptoms.
• Laryngoscopy showed posterior vocal
cord erythema.
• Endoscopy showed esophagitis.
• Symptoms respond to 20 mg of daily
omeprazol.
CLINICAL PRESENTATION
Typical Symptoms
●
Heartburn
●
Regurgitation
●
Dysphagia
Case 3
• Middle age man is visited for evaluation of
dysphagia to solids from 2 months
duration.
• He was a heavy smoker and used
famotidine for heart burn for 14 y.
• Ba swallow was performed.
• Endoscopy and biopsy was done.
Proximal esophageal
stricture
Peptic stricture
Hyperplasia of basal cells and
infiltration of PMN with
erosions in GERD.
Natural History
● Peptic stricture ( 8 to 20 %)
● Ulceration ( 5 %)
● Significant bleeding ( 2 % )
● Perforation extremely rare
Esophageal ulcer in reflux
esophagitis
Case 4
• A 45 y old man with 25 y reflux symptoms
comes to your office for evaluation of
recent weight loss and dysphagia.
• There was a histologic report of “Intestinal
metaplasia” in distal esophagus in his last
endoscopy 2 y ago.
• Ba swallow and endoscopy was
performed.
Adenocarcinoma
Barrett´s Esophagus
Barrett´s Esophagus
Long Segment Barrett’s
Endoscopic mucosal
resection
Case 5
• A 38 y old woman comes to the clinic for
her severe chronic reflux symptoms and
consults about antireflux surgery.
• She is on long term Omeprazole 40 mg
twice a day and ranitidine before bed
time.
• Serum Gastrin level is in upper normal
limits.
• Endoscopy was normal (NERD).
Refractory gastroesophageal
reflux disease
• Failure to control symptoms with full
dose of PPI + life style modification
raises the possibility that symptoms
are due to another disease or
refractory GERD.
• Reduced bioavailability
• Effect of food
• Dosing interval
• Gastric acid hypersecretion
• Drug resistance
• Slow healing
• Esophageal hypersensitivity
(viseral hyperalgesia)
• Eosinophilic esophagitis
• Pill induced esophagitits
TREATMENT
• First confirm the diagnosis then,
• Increase the frequency of dosing
• Increasing the dose (Omeprazole to
80 mg/day)
• Add a second drug
• Switch to another drug
• Check for Gastrinoma
• Surgery
Preoperative evaluation for
gastroesophageal reflux disease
• Detailed clinical history and physical
examination
• Endoscopy to assess degree of
esophagitis
• Esophageal manometry to define LES
pressure and disorders of peristalsis
• Upper gastrointestinal series to assess
esophageal length and hiatal hernia
• 24 hour esophageal pH monitoring
Indications for esophageal
pH recording
• to document abnormal esophageal
acid exposure in an endoscopynegative patient being considered for
surgical antireflux repair
• to evaluate patients after antireflux
surgery who are suspected to have
ongoing abnormal reflux
• to evaluate patients with normal
endoscopic findings and reflux
symptoms that are refractory to
proton pump inhibitor therapy
• to detect refractory reflux in patients
with extraesophageal or atypical
symptoms using symptom
association probability calculation
INDICATIONS FOR OPERATION
AND PREOPERATIVE
EVALUATION
• Persistent or recurrent symptoms
with appropriate response to
medical THX.
• Severe esophagitis by endoscopy
• Benign stricture
• Recurrent pulmonary symptoms
Predictors of successful
surgery
• Response to medical therapy
• Typical reflux symptoms
• Erosive GERD
• Abnormal pH study
Predictors of unsuccessful
surgery
• Lack of response to medical therapy
– (medical failure?)
– It could be something other than GERD
• Non-erosive GERD (NERD)
Helicobacter pylori and GERD
• Eradication of H. pylori is associated
with mild worsening of GERD in
patients with corpus-predominant
gastritis and improvement in those
with antral-predominant gastritis.
• The standard of care is to eradicate
H. pylori in the context of peptic
ulcer disease.