GASTRO ESOPHAGEAL
REFLUX DISEASE
(GERD)
Dr FONJE AHMED
Today’s Talk
• Definition of GERD
• Epidemiology of GERD
• Pathophysiology of GERD
• Clinical Manisfestations
• Complications
• Diagnostic Evaluation
• Treatment
DEFINITION OF GERD
• American College of
Gastroenterology (ACG)
– Symptoms OR mucosal
damage produced by the
abnormal reflux of gastric
contents into the esophagus
– Often chronic and relapsing
– May see complications of
GERD in patients who lack
typical symptoms
EPIDEMIOLOGY
• GERD occurs in all ages but, most common in those older than 40
years of age.
• About 10-20% of people in western countries suffer from GERD
symptoms on a weekly basis
• About 7% have symptoms daily.
• Except for NERD and pregnancy , no much difference in incidence
between men and women.
• But for Barrett’s esophagus, prevalence is more in males
particularly white adult males.
PATHOPHYSIOLOGY OF GERD
• Primary barrier to gastro esophageal reflux is the lower
esophageal sphincter
• LES normally works in conjunction with the diaphragm
• If barrier disrupted, acid goes from stomach to esophagus
• May be due to
• Spontaneous transient LES relaxations
• Transient increase in intra abdominal pressure
• An atonic LES
Drugs that reduce LES tone include calcium channel
antagonists (e.g., nifedipine, verapamil, diltiazem),
nitrates, anticholinergic agents(e.g.,tricyclic
antidepressants , antihistamines), and oral contraceptives
and estrogen.
Foods that reduce LES tone include chocolate, fatty foods ,
onions, peppermint, and garlic
Smoking(nicotine) reduces LES tone
2)DISRUPTION OF ANATOMICAL BARRIERS
• Associated with hiatal hernia
• The size of hiatal hernia is proportional to the frequency of LES
relaxations
• Hypotensive LES pressures and large hiatal hernia- more chance
of GERD following abrupt increase in intra abdominal pressure
3) ESOPHAGEAL CLEARANCE
• The GI acid produced spent too much time in contact with the
esophageal mucosa
• Normally swallowing contributes to esophageal clearance by
increasing salivary flow
• Saliva decreases with increasing age, so more often seen with
elderly.
4)MUCOSAL RESISTANCE
• The mucus secreated by the mucus secreting glands involves
in the protection of esophagus
• The bicarbonate s moving from the blood to the lumen can
neutralize acidic refluxate in the esophagus. On repeated
exposure to the refluxate or due to some defect in normal
mucosal defenses hydrogen ions diffuse into the mucosa,
leading to cellular acidification and necrosis leading to
esophagitis.
5)DELAYED GASTRIC EMPTYING
• An increase in gastric volume may increase both the
frequency of reflux and the amount of gastric fluid available to
be refluxed
• Physiologic Postprandial Gastro esophageal reflux occurs
CLASSIFICATION OF GERD
• Physiological – asymptomatic.
post prandial.
no abnormality.
• Functional – asymptomatic.
+ve pH study.
• Pathological – local symptoms.
secondary manisfestation.
• Secondary – underlying condition ( asthma &
gastric outlet obstruction).
CLINICAL MANIFESTATONS
• 3 CLASSES OF SYMPTOMS (TYPICAL)
• May be aggravated by activities that worsen
gastroesophageal reflux such as recumbent position,
bending over, or eating a meal high in fat.
Heartburn—retrosternal burning discomfort
Regurgitation—effortless return of gastric contents into the
pharynx without nausea, retching, or abdominal
contractions
Water brash (hyper salivation)
Belching
GERD IN CHILDREN
• NEONATES/ INFANTS OLDER CHILDREN/ADOLESCENT
Regurgitation – post Early morning nausea
Prandially Abdominal discomfort
• Signs of esophagitis – Substernal pain.
irritability, arching , Recurrent vomiting
gagging , chocking , Heartburn
feeding aversion.
• Failure to thrive.
Poor weight gain.
EXTRA ESOPHAGEAL SYMPTOMS
• 2 mechanisms - microaspiration of gastric contents.
Vagally mediated events
Pulmonary manifestations
1) Chronic cough – GERD 1 of 3 most common
cause along with PND & asthma.
Predominantly day time & standing position.
Non productive & long standing nature.
> 50 % cases sole manifestation.
Chest xray – normal.
No evidence of asthma.
2) asthma :- GERD is a potential trigger in many
cases of asthma.
ENT manifestations
1) Reflux laryngitis :- gastric contents in larynx , pharynx and upper
aerodigestive tract.
2) Mucosal damage.
3) Direct effect on mucocilliary cleareance.
4) Vagally mediated reflex.
4 – 10 % GERD.
SYMPTOMS :- hoarsness, Globus sensation, Chronic throat clearing,
Vocal fatigue , break
Sore throat
Neck pain
Excessive throat mucus
PND
• Signs:- edema , erythema , increase vascularity .
• Red , inflammed larynx.( posterior larynx).
• Thickening of posterior laryngeal mucosa with hyperkeratosis
• (pachyderma laryngeus).
• Increase mucosal thickening with increase granularity & rough
• cobbelstone appeareance – granular mucositis.
• Increase mucus formation.
• Pseudosulcus vocalis
2) Recurrent otitis media ( pepsin & pepsinogen
effusion).
• GERD nasopharyngeal inflammation
obstruction of eustachian tube
3) chronic sinusitis – direct effect on mucociliary
cleareance.
4) dental erosions :- oral ulcers , halitosis.
ALARM SIGNS/SYMPTOMS
These symptoms may be indicative of complications of GERD such
as Barrett’s esophagus, esophageal strictures, or esophageal
cancer
• Dysphagia
• Early satiety
• GI bleeding
• Odynophagia
• Vomiting
• Unexplained Weight loss
• Iron deficiency anemia
• Choking
• Continual pain
COMPLICATIONS
• Erosive Esophagitis
Responsible for 40-60% of GERD symptoms
Severity of symptoms often fail to match severity of
erosive esophagitis
COMPLICATION
• Esophageal stricture
– Result of healing of erosive esophagitis
– Common in the distal esophagus and are generally 1 to 2 cm
in length.
– May need dilation
Barrett’s Esophagus
• Acid damages lining of esophagus and causes chronic esophagitis
• Damaged area heals in a metaplastic process and abnormal columnar
cells replace squamous cells
• This specialized intestinal metaplasia can progress to dysplasia and
adenocarcinoma
DIAGNOSTIC EVALUATION
• According to guidelines patient with
symptoms & h/o suggestive of uncomplicated
GERD , the diagnosis of GERD must be
assumed & empirical therapy should begin.
• Patient showing signs of GERD complications
& not responding to therapy should undergo
further diagnostic testing.
Fig. 1. Infant with suspicion of [Link]: gastro-esophageal reflux disease, GI: gastrointestinal.
Pediatr Gastroenterol Hepatol Nutr. 2019 Mar;22(2):107-121.
[Link]
Fig. 2. Older children with suspicion of [Link]: gastro-esophageal reflux disease, NERD: Non-erosive reflux disease.
Pediatr Gastroenterol Hepatol Nutr. 2019 Mar;22(2):107-121.
[Link]
INVESTIGATIONS
• Barium swallow
• Endoscopy
• Ambulatory pH monitoring
• Impedance-pH monitoring
• Esophageal manometry
BARIUM SWALLOW
• Useful first diagnostic test for patients with dysphagia
– Stricture (location, length)
– Mass (location, length)
– Hiatal hernia (size, type)
• Limitations
– Detailed mucosal exam for
erosive esophagitis, Barrett’s
esophagus
ENDOSCOPY
• Endoscopy (with biopsy if needed)
– In patients with alarm signs/symptoms
– Those who fail a medication trial
– Those who require long-term tx
• Absence of endoscopic features
does not exclude a GERD diagnosis
• Allows for
detection, stratification, and
management of esophageal
manisfestations or complications of
GERD
24-HOUR PH MONITORING
Physiologic study
– Accepted standard for establishing or excluding
presence of GERD for those patients who do not have
mucosal changes
– Trans-nasal catheter or a wireless, capsule shaped device
NORMAL
GERD
ESOPHAGEAL MANOMETRY
• Measures amplitude & duration of
contraction & relaxation pressure
in pharynx , UOS, esophagus & LES.
• The equipment & methodology are
inadequate for pharyngeal & upper
esophageal manometry , where
catheters with miniature strain
gauge pressure transducer sensors
required.
• Difference in anatomy & physiology
& frequency of recordings.
MANAGEMENT
Treatment goals
• Eliminate symptoms.
• Heal esophagitis.
• Manage or prevent complications.
• Maintain remission.
MANAGEMENT
LIFESTYLE MODIFICATIONS
• Weight reduction if overweight
• Avoid clothing that is tight around the waist
• Modify diet
• Eat more frequent but smaller meals
• Avoid fatty/fried food, peppermint, chocolate, alcohol,
carbonated beverages, coffee and tea, onions, garlic.
• Stop smoking
• Elevate head of bed 4-6 inches
• Avoid eating within 2-3 hours of bedtime
• Avoid meds that may potentiate GERD (CCB, alpha agonists,
theophylline, nitrates, sedatives, NSAIDS)
PHARMACOLOGICAL TREATMENT
1) Antacids
Quick but short-lived relief
Neutralize HCl acid
– Approx 1/3 of patients with heartburn-related
symptoms use at least twice weekly
– More effective than placebo in relieving GERD
symptoms
Examples: Maalox, Gaviscon, Pepsane, Almax
PHARMACOLOGICAL TREATMENT
2) Histamine H2-Receptor Antagonists
Competitively block the histamine receptors in
gastric parietal cells, thereby preventing acid
secretion
More effective than antacids for relieving heartburn
in patients with GERD
Faster healing of erosive esophagitis
Can be used regularly or on-demand
AGENT DOSAGE
• Cimetadine 400-800mg twice daily
Cimetidine(tab)
• Ranitidine 150mg twice daily
Azantac(tab)
• Famotidine 20-40mg twice daily
Ulcetrax(tab)
• Nizatidine 150mg twice daily
Axid
PROTON PUMP INHIBITOR(PPI)
• If symptoms doesn’t respond to H2
receptor blocker then change to PPI
once daily
• Irreversible blockage of gastric acid
secretion.
• Faster healing rates for erosive
esophagitis.
• Drug maintenance therapy may be
needed depending on the severityof
disease & recurrence of symptoms
after initial drug therapy is stopped.
AGENT DOSAGE
• Esomeprazole 20-40mg daily
Inexium(tab)
• Omeprazole 20mg daily
Omicap(cap)
• Lansoprazole 15mg daily
Ozapral(Cap)
• Pantoprazole 40mg daily
Pandom(tab
• Rabeprazole 20mg daily
Rabeloc(tab)
H2RAs v/s PPIs
– 12 week freedom from symptoms
• 48% vs 77%
– 12 week healing rate
• 52% vs 84%
– Speed of healing
• 6%/wk vs 12%/wk
EFFECTIVENESS OF MEDICAL THERAPIES
FOR GERD
Treatment Response
• Lifestyle modifications/antacids 20 %
• H2-receptor antagonists 50 %
• Single-dose PPI 80 %
• Increased-dose PPI up to 100 %
INDICATIONS FOR SURGERY
• Antireflux surgery
– Failed medical management
– Patient preference
– GERD complications
– Medical complications attributable to a large hiatal hernia
– Atypical symptoms with reflux documented on 24-hour
pH monitoring
– OGD proven esophagitis
– Normal esophageal motility
– Partial or complete response to acid suppression
Principles of Anti-Reflux Surgery
Nissen Fundoplication
PROGNOSIS
• Postsurgery
10% have solid food dysphagia
2-3% have permanent symptoms
7-10% have gas, bloating, diarrhea, nausea, early
satiety
Within 3-5 years 52% of patients back on
antireflux medications
OTHER TREATMENTS
• Endoscopic treatment
– Relatively new
– No definite indications
– Select well-informed patients with well-documented GERD
responsive to PPI therapy may benefit
• Three categories
– Radiofrequency application to increase LES reflux
barrier
– Endoscopic sewing devices
– Injection of a nonresorbable polymer into LES
area
RECOMMENDED TREATMENT IN CLIBO
• INEXIUM 40mg: 1 tab BD
• MOTILIUM 10mg: 1 tab TID
• GAVISCON: 1 sachet TID (mostly when pains)
SUMMARY
• Definition of GERD
• Epidemiology of GERD
• Pathophysiology of GERD
• Clinical Manisfestations
• Diagnostic Evaluation
• Treatment
• Complications
