Adam F.

Barrison, MD
Department of Gastroenterology
Summit Medical Group
Typical symptoms of GERD

Heartburn

Regurgitation (an effortless return

of gastric contents into te esopagus and
fre!uently into te mout" often confused #it
$omiting%
&ounes and 'onson. Gastroenterol (lin )ort Am *+++
Atypical symptoms of GERD

(est pain

Hoarseness

(ronic coug

Sore troat

,ee-ing

Dyspagia

.roat clearing

Globus

/aryngospasm

Dental erosion
*
Mu0ica et al. 1ostgrad Med *+++
2
De3ault et al. Am ' Gastroenterol *+++
'onsson et al. Gullet *++2
Symptom patterns in GERD

Reflu45related symptoms occur predominantly

after meals.

Reflu45related symptoms are often triggered by

unusually large meals

bending, stooping, or lying do#n

strenuous acti$ities

.e fre!uency of reflu45related symptoms

$aries #idely
Adapted from (astell Gastroesopageal Reflu4 Disease. Futura 1ublising. *+67
1ersistent symptoms and complications
Fre!uent symptoms
(seen by MD%
8ccasional symptoms
(not seen by MD%
The GERD iceberg
Titanic
1atients presenting
#it reflu4 symptoms (n 9 +:%
;<=
;2=
*2=
Barrett>s
esopagus
)o erosi$e esopagitis
?rosi$e esopagitis
,inters et al. Gastroenterology *+6:
Approximately half of all patients with reflux
symptoms have erosive esophagitis
Severity of heartburn symptoms does not predict
the presence of erosive esophagitis
Heartburn Grade

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.e presence of erosi$e esopagitis sould be diagnostically confirmed.
3enables et al. Scand ' Gastroenterol *++:
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EE ositive EE -egative
Severe
.oderate
.ild
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7@
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)o eartburn Mild eartburn
Moderate eartburn Se$ere eartburn

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Grade A
(n9*;<<%
Grade B
(n9*<A;%
Grade (
(n96<+%
Grade D
(n9A*;%
/e$ine et al. Am ' Gastroenterol *+++
Severity of GERD symptoms does not correlate with
severity of disease
)9;26A
Smout. Aliment 1armacol .er *++:
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?ndoscopy
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Heartburn fre/uency
0re/uency of heartburn does not correlate with
the presence of erosive esophagitis
Erosive Esophagitis
/undell et al. Gut *+++
=

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.ime after cessation of terapy (monts%
)o mucosal breaCs
/A grade A
/A grade B
/A grade (
GERD is a chronic condition that is li1ely to relapse
2-ormal3 Score
GERD has a greater impact on /uality of life
than other common diseases
4orse 5etter
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1sycological General ,ell5being Dnde4 (1G,BD% score
1syciatric patients
G?RD (untreated%
Duodenal ulcer (untreated%
Angina pectoris
Heart failure (mild%
)ormal female
)ormal male
Hypertension (untreated%
*@7
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DimenEs. Scand ' Gastroenterol *++A
.echanisms that cause GERD

.eopylline

Anticolinergics

.(A>s

1rogesterone

(a cannel blocCers

Dia-apam
6omplications of GERD

?sopagealF
5 Barrett>s esopagus
5 Adenocarcinoma
5 Stricture
5 Glceration
5 Bleeding

?4tra5esopagealF
5 Astma
5 (ronic (oug
5 Reflu4 laryngitis
5 Dental enamel loss
5 3ocal cord in0ury
5 Subglottic stenosis
De3ault et al. Am ' Gastroenterol *+++ De3ault et al. Am ' Gastroenterol *+++
Endoscopy

Allo#s direct mucosal $isuali-ation and biopsy

Gold standard for diagnosis of erosi$e esopagitis

8nly metod for reliable detection of Barrett>s

Esophageal stricture
5arrett7s esophagus
/agergren et al. )e# ?ngl ' Med *+++
5arrett7s esophagus 8 clinical significance

1remalignant lesion for esopageal

adenocarcinoma

1atients #it Barrett>s esopagus may be

A@ H <@ times more liCely to de$elop tis
cancer tan te general population

.e reported incidence of adenocarcinoma

of te esopagus is rising
/ieberman et al. Am ' Gastroenterol *++:
@
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*@
*7
2@
27
;
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* to 7
*:
7 to *@
2*
J*@
Duration of symptoms (years%
1
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The prevalence of 5arrett7s esophagus
increases with the duration of reflux symptoms
Esophageal adenocarcinoma
/agergren et al. ) ?ngl ' Med *+++
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Fre!uency of symptoms
The ris1 of esophageal adenocarcinoma
increases with the fre/uency of reflux symptoms
1era et al. Gastroenterology *++A
(onnecticut (ancer Registry
)ational (ancer Dnstitute
Birmingam, ?ngland
(anton 3aud, S#it-erland
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The incidence of esophageal adenocarcinoma
is rising
LGreatest
increase in
#ite males
.anagement options in GERD

/ifestyle measures

Medications

Antireflu4 surgery

)e#er endoscopic tecni!ues

*
Dent et al. Gut *++6
4hat is the role of lifestyle factors in GERD9
/ifestyle factors probably play a lesser role in
te patogenesis of G?RD tan originally
tougt
*
.
:ifestyle measures

Raise te ead of te bed, or lie on left side

Decrease fat intaCeM

A$oid certain foods

A$oid lying do#n for A ours after eating

Stop smoCing

/ose #eigt if appropriate

Dietary factors that may aggravate GERD symptoms

(affeinated products (coffee, tea, cocolate%

1eppermint

Fatty foodsMM

Spicy and tomato5based foods

(itrus foods and 0uices

Alcool
Evolution of pharmacological therapy

Antacids (.ums, Rolaids%

1roCinetics (Reglan, (isapride%

H
2
5receptor antagonists (1epcid, Nantac%

1roton pump inibitors (1rilosec, 1re$acid%

H
2
RAs block the
histamine receptor,
interfering with one of
the stimulation
pathways
PPIs block acid at its
source in the proton
pump
ACh=acetylcholine
.echanisms of Action
of GERD .edications
Antacids neutralize
secreted HCl
HCI
Histamine
ACh
Gastrin
K
+
H
+
1roCinetics
increase
esopageal
clearance and
gastric emptying
Stretta rocedure

Appro$ed by FDA in May, 2@@@

Heat is applied to te deep layer in te lo#er esopagus

Success rate similar to fundoplicationF

(omplete resolution in :@= at * year

1artial resolution in *@ 5*7= at * year

(omplication rate considered lo#F

1ain

1erforation
1ost5procedure appearance
Enteryx

Appro$ed by FDA in April, 2@@A.

Bio5compatible non5biodegradable li!uid polymer

implanted in te #all of lo#er esopagus

Success rate similar to fundoplicationF :;= off

medications at * year

(omplicationF Damage from in0ection outside of te

esopagus

Recalled in 8ctober, 2@@7