GASTROESOPHAGEAL REFLUX DISEASE (GERD)

DEFINITION: GERD is a disease which occurs by reflux of the stomach content in the esophagus,
causes unpleasant symptoms and/or complications and worsens quality of life. The term endoscopic negative
reflux disease is used for patients who have symptoms of GERD but do not have mucosal eruptions by
endoscopy.
ETIOPATHOGENESIS: the reflux of salt acid and pepsin from the stomach into the esophagus is the
main cause for the occurrence of the clinical symptoms. By most of the patients with GERD the time of contact
of the stomach acid with the esophageal mucosa is longer. By endoscopic negative reflux disease the time of
contact of the stomach acid with the esophageal mucosa is shorter, but longer in comparison to the one by
healthy people. The hiatal hernia has a particular role for development of GERD. The way of life and type of
eating are not the determining factors in the pathogenesis of GERD.
CLINICAL PICTURE:
Esophageal symptoms/ syndromes
 Heartburn-means burning sensation behind the chestbone and irradiating in the throat.
 Syndromes with esophageal damage: reflux esophagitis, reflux stricture, Barrett’s esophagus.
 Adenocarcinoma.
Typical reflux syndrome (regurgitation). Heartburn sensation without endoscopic changes, characteristic
for GERD means endoscopic negative reflux disease. The typical symptoms-heartburn and regurgitation occur
after eating. Night symptoms occur only in patients with diaphragmal hernia. Complains, showing advanced
GERD are dysphagia, odynophagia, iron deficiency anemia, weight loss.
Extraesophageal symptoms are reflux-pharingitis and sinusitis, idiopathic pulmonary fibrosis, recidivating
medial otitis.
The diagnose GERD is set up when the typical symptoms occur 2 or more times weekly throughout 3-
6 months. The intensity and frequency of symptoms have no correlation with the presense or heaviness of the
mucosal lesions of the esophagus. The clinical symptoms by GERD disturb many aspects of quality of life of
the patients. They worsen the physical, social and emotional comfort of the patients in comparison to the total
population. GERD influences the quality of life of the patients in a way, compared to other heavy chronic
diseases like bronchial asthma, chronic cardiac insufficiency and psychiatric diseases. Burning in the night and
related with the reflux, sleep disturbances are significant problems for the patients. Diminished work capacity,
connected with GERD is comparable to the one by other chronic diseases like arthritis, arterial hypertony,
allergies, headache.
The symptoms by GERD are almost the same by patients with and without reflux esophagitis.
DIAGNOSE
 GERD can be diagnosed only on the basis of the anamnestical data by carefully taken anamnesis.
 Physical examination is of no great importance.
 Endoscopy is the major diagnostical method for GERD and its complications, especially for finding out
the Barretts esophagus (intestinal metaplasia of the flat epithelium in the distal part of the esophagus,
which is a result of longlasting reflux). By suspicion for Barretts esophagus the circular biopsy in
different levels of the esophagus is obligatory.
The endoscopy is imperative by patients with atypical history:
 Symptoms of reflux which are not influenced by the therapy;
 Alarming symptoms like: heavy dysphagia, weight loss, bleeding(hematemesis), palpation of
formation in the abdominal area, anemia.
Modified classification of the esophagitis by Savary-Miller
Grade Description
I Solitary/isolated linear or oval erosions, which damage one mucosal fold
II Multiple erosions, which damage more than one mucosal fold with por confluation,
but not circumferential erosions
III Circumferential erosions
IV Chronic lesions: ulcers or strictures and/or short esophagus or in combination with
 changes from the stadium I-III.
V Cylindrical epithelium above the Z-line-alone or in tcombination with changes from
stadium I-IV.

Classification of the reflux esophagitis from Los Angeles

Stadium Description
A One or more mucosal eruptions <5 mm, found on a single mucosal esophageal fold
B One or more mucosal eruptions >5 mm, found on a single mucosal esophageal fold, which
do not spread to other mucosal folds.
C One or more mucosal eruptions, spreading on two or more mucosal esophageal folds, but
not taking more than 75 % of the esophageal circumference.
D Mucosal damages, taking more than 75 % of the esophageal circumference.
Measurement of the pH of esophageal content is not used in the routine practice.

TREATMENT
Its main aims are:
1. mastering the symptoms;
2. maintaining symptomatic and endoscopic remission;
3. prophylaxis of the complications;
The end goal is achieving significant improvement of patients’ quality of life. The control over the acid
secretion is the main factor for achievement of all aims. If the pH of the stomach juice increases above 4, the
pepsin activity diminishes.
Common measures-pulling up of the bed, dietetic restrictions, stopping the alcohol intake, stopping
smoking do not have proved therapeutical effect.
Medicamentous treatment has the major role by treatment of GERD. It includes:
1. Active initial treatment;
2. maintaining treatment;
3. treatment of the relapses;
Major principle of the initiating treatment is using drugs from the group of the proton pump inhibitors. By not
endoscopied patients, patients with endoscopic negative GERD, reflux esophagitis I-II gr. Full dose PPI are
prescribed for 4-6 weeks. Over 95 % of the patients with these forms of GERD show rapid improvement from
this treatment.
By overwhelming of the symptoms maintaining treatment is performed. In rare cases of persistence of
the symptoms the course with PPI lasts longer-8 weeks. By persistence of the symptoms after longer course(8
weeks) control FGS should be performed and reestimation of the symptoms and the endoscopic finding.
After effective initial treatment and no clinical symptoms maintaining treatment is performed with PPI-
once daily 1 hour before eating. The lack of symptoms by maintaining treatment is of great importance as it
shows lack of relapse.
On demand therapy is indicated by endoscopic negative GERD and healthy patient.
The treatment by heavy forms-III-IV gr. is done for 8-12 weeks with frequent controls. In the end of the
third month FGS should be performed.
Maintaining treatment by III-IV gr. esophagitis is performed with full dose PPI to avopid the relapses
and forming of strictures, and the patients are monitored 1 monthly and endoscopically-1 in 2-3 months.