Medical Management of

Gastroesophageal Reflux
Disease

by
Dr. Vidyasagar Abbagani
 GERD IN U.S.A

• 20% of adults have symptoms of GERD

• 50% of these have mild symptoms(O.C.M)

• 20- 30% of these have frequent symptoms and consult

primary care physician

• 10-15% of patients have persistent symptoms with or without

complications and consult gastroenterologist.
 GERD IN INDIA
• 10% of adults have GERD symptoms .
• 80% of patients have mild disease .
• 5-10% of patients have frequent symptoms .
• Severe esophagitis & complications are less common .
•REASO,S FOR LOW PREVALE,CE & LESS
SEVERE DISEASE :
l. Low dietary fat .
2. Low body mass index .
3. Low acid output .
4. Genetically determined:( Chromose 13 q 14 .
 EVALUATION
1. Young patient with typical GERD
Symptoms no further evaluation -
Medical treatment.
2. Indications for investigations.
investigations.
A. Patients not responding to treatment.
B. Age group > 50 years.
C. Patients presenting with
1. Dysphagia
2. Odynophagia
3. G.I. Bleed
4. Resp. Symptoms.
 EVALUATION

Upper GI endoscopy & histology

24 hour pH monitoring

Oesophageal manometry with

measurement of LES pressure
A. Erosion B. Ulcer
C. Stricture D. Barrets
Assessment of severity of GERD

Symptoms Score

Endoscopic Grading
 SYMPTOMS SCORE OF GERD - Tefera, 1997
Symptom Score Severity
0 ,one
Heart burn
1 Mild: Occasional Episode
2 Moderate:primary reason for visit
3 severe: Disables for daily activities
Regurgitation 0 ,one
1 Mild: occasional, after staining
2 Moderate: Predictable
3 Severe: associated with pul. aspiration

Dysphagia 0 ,one
1 mild: occasional with coarse food.
2 Moderate: requires liquid to clear
3 severe: needs semisolid diet.
 SAVARY MILLER
CLASSIFICATION OF GERD
GRADE E,DOSCOPIC FI,DI,GS

Grade I One or more non confluent mucosal lesions.

Grade II Confluent mucosal lesions which do not cover
entire circumference.

Grade III Circumferential mucosal lesions.

Grade IV Chronic mucosal lesions such as deep ulceration

and / stricture.
 MANAGEMENT GOALS
1.Relief of symptoms 2. Prevention of relapses
3.Acceleration of healing 4. Prevention of complications

THERAPEUTIC STATEGIES
1. Acute(short term) treatment
2. Long term treatment.
3.Treatment of complications
 GORD : MANAGEMENT
Traditional step - wise treatment of G.E.R.D.

Step I : Non Pharmacological interventions.

Step II : Prokinetic agent or H2RB.
Step III : Proton Pump inhibitors.
Step IV : Surgery in less than 5% of cases
 Non Pharmacological Treatment

Lifestyle modifications

Avoid
– Smoking
– Alcohol
– Choc olates
– Eating before retiring to bed.
– Tight fitting garments

Small Frequent meals

Head end of bed propped up while sleeping

Weight reduction
DRUGS AND GERD :
Potentially harmful medicines
1. Anticholinergics.
2. Sedatives and tranquilizers.
3. Theophylline.
4. Ca++ channel blockers.
5. Nitrates.
6. Prostaglandins.
 PHAMACOLOGICAL TREATMENT
Treatment Dosage
1) H2 antagonist
Ranitidine 150 mg 2 times a day
Famotidine 20 mg 2 times a day

2) Prokinetic agents
Cisapride 10 mg 3 times a day
Metaclopramide 10 mg 3 times a day
Mosapride 5 mg 3 times a day
Domperidone 10 mg 3 times a day

3) Proton Pump inibitors:

Omeprazole 20 mg a day
Lansoprazole 30 mg a day

4) Antacids & mucosal protective agents

 Which Prokinetic?

Efficacy Safety
 GERD: MANAGEMENT
100
% Endoscopic Relief of
o Healing Symptoms
80
f
60
p
a
t 40
i
e 20
n
t
s 0
PLA CIS H2-Ra PPI PLA CIS H2-Ra PPI
Overall summary of reports on the efficacy of cisapride (CIS) H2 re ceptor antagonists (H2-RA) and
proton pump inhibitors (PPI) as compared to placebo (Pla). Healing of esophagitis was proven by
endoscopy (left panel); GERD symptoms were assessed by various scoring systems (right panel)
 STEP UP/STEP DOWN

Mild to moderate.
Moderate to severe.

– Non pharmacological – High dose P.P.I.

– H2 RB/ Prokinetics. – Low dose P.P.I

– P.P.I. – H2 RB/ Prokinetics.

LONG TERMTREATMENT OF
GERD
• GERD is chromic disease characterised by recurrent
relapses

• Severe GERD: 36-82% relapse within one year after

stopping treatment

• Mild Disease : 50% spontaneous remission

20% lifestyle modifications / antacids
30% on demand therapy
 PREDICTORS FOR DELAYED HEALING
AND FOR RELAPSE OF ESOPHAGITIS

• Risk factors for delayed healing-Endoscopic severity of

esophagitis.
•Risk factors for relapse.
-Persistent symptoms at time of Endoscopic healing .
-Endoscopic severity of esophagitis .
-Severe pre-treatment symptoms.
-,eed / use of P.P.I for healing .
 Endoscopic Remission Free of Symptoms
% 100
o
f 80

p
a 60
t
i 40
e
n
20
t
s
0 RA, CIS OME RA, OME RA, CIS OME RA, OME
+CIS +CIS +CIS +CIS
MAINTENANCE THERAPY
Comparison of different maintenance therapies (1 year) for patients with reflux esophagitis. All patients were treated with omeprazole until the esophagitits
had healed and then randomly assigned to a 1 year treatment regimen with ranitidine, 3 x 150 mg/ day (Ran); cisapride, 3 x 10 mg/ day (Cis); omeprazole, 20
mg/ day (Ome); ranitidine plus cisapride (Ran +Cis); and omeprazole plus cisappride (Ome + Cis). Healing of esophagitis (remission) was assessed by
endoscopy (left panel); GERD symptoms were determined by a scoring system (right panel). Omeprazole was better than ranitidine (p<0.05) and cisapride
(p<0.01), and both combination treatments were more effective than each drug alone. There were 35 patients in each group
 LONG TERM P.P.I. TREATMENT
Efficacy, Safety and Influence on Gastric mucosa
Gastroenterology March 2000

•230 Pts mean age 63 yrs. Omeprazole > 20mg /day for mean period
6. 5 yrs.
•Annual Endoscopy for relapse and histological changes in the
gastric mucosa .
•Relapse rate : 1/9.4 yrs.
•Carcinoid tumors : ,one .
• Atrophic gastritis : Incidence was 4.7 % and 0.7 % in H. pylori +ve
& -ve patients .
• Corpus metaplasia was rare and no dysplacias / neoplasms
observed .
 Comparison of long term Drug treatment
with Antireflux Surgery

* Two Prospective R.C.T:

Open Fundoplication/ antacids + Life style modifications

Surgery more effective

P.PI / Lap surgery were not included
* Recent study: (Gastroenterology 1998)

OME / ARS in long term management of GERD.
Open Fundoplication

310 PTS
OME

Followed for 3 years

No significant difference in outcome
TREATMENT OF COMPLICATIONS
Peptic Stricture
1. Proton Pump Inhibitors

Degree of dysphagia

Requirement of dilation

2. Endoscopic Dilation

3. Rarely requires Surgical Intervention

 TREATMENT OF
COMPLICATIONS
• Barrets Esophagus with:
,o dysplasia : P.P.I+ Surveillance
Mild dysplasia : P.P.I+ Surveillance
Photo dynamic therapy
Severe dysplasia:
Young : Surgery
Elderly,Unfit : P.P.I+ Surveillance
Photo dynamic therapy
 G.E.R.D New Endoscopic treatments
2001))
(Digestive Disease week May, 2001

Endoscopic Gastroplasty.
– Endoscopic sewing machine (Dr. Paul Swain)

Radio Frequency Ablation (Stretta Procedure)
– Radio frequency energy is delivered via
special device

Endoscopic Implantation
– Sub mucosal Injection of Plexiglas
microspheres
– Ethinyl - vinyl - alcohol (E.V.A) Injection
– Cyano - acrylate glue Injection.
 CONCLUSIONS
• GERD is a common G.I problem.Its natural course
is milder in Asian patients
• Proton Pump inhibitors are highly effective in Acute
and long term treatment.
• P.P.I s have an excellent long term safety profile.
• New Endoscopic treatment for GERD have
tremendous promise