MARJAN G.
CAMZAR
RD
BS PHARMACY 3 YEAR
CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 2
GASTROESOPHAGEAL REFLUX DISEASE
ACID REFLUX
 Occurs when the sphincter muscle at the lower
end of your esophagus relaxes at the wrong
time, allowing stomach acid to back up into the
esophagus.
GERD
 Gastroesophageal reflux disease or chronic acid
reflux is a condition caused by frequent acid
reflux.
 A weak or damaged lower esophageal
sphincter is the main cause of GERD
 More intense and more regular (occurs twice
a week or more)
 Longer - lasting
Normal With GERD
Swallow food Swallow food
Food squeezed down the Food squeezed down the
esophagus esophagus
LES relaxes LES doesn’t relax as it
should and weakens
Les closes LES doesn’t close properly
TYPES:
 Stage 1 Mild GERD- Symptoms can usually be
managed by dietary and lifestyle changes plus over-
the-counter acid reflux medication if needed. Minimal
acid reflux occurs once or twice a month.
 Stage 2 Moderate GERD- Symptoms are frequent
enough to require prescription acid reflux
medication, which is typically taken daily. GERD
symptoms may affect daily activities.
 Stage 3 Severe GERD- Symptoms are painful and
may not be improved even with the help of
prescription medication. Quality of life is impaired,
and doctors may recommend surgical GED
correction
 Stage 4 Precancer or Cancer- Esophagus can
develop a precancerous condition known as Barrett's
esophagus. Precancerous lesions can progress into
esophageal cancer without treatment.
CLASSIFICATION OF GERD
Symptom-based
- May exist with or without esophageal injury and
most commonly presents as heartburn,
regurgitation, or dysphagia.
- Nonerosive Reflux Disease (NERD)
Tissue injury-based
- May exist with or without symptoms. The
spectrum of injury includes esophigitis, barrett's
esophagus, strictures and esophageal
adenocarcinoma
EPIDEMIOLOGY
In a narrative review of the prevalence of
gastroesophageal reflux disease (GERD) of Boulton and
Dettmar, 2022
 The incidence of GERD is high in the general
population, it is estimated to affect up to 20% of
the population worldwide
 The prevalence of GERD at 10–20% in Europe
and the USA, but less than 5% in Asia
 It occurs most commonly in those older than age
40 years.
 Obese patients are 2.5 times more likely to
experience GERD symptoms
 About 50% of pregnant women will experience
GERD
 Prevalence depends on geographic region but is
highest in Western countries
 Incidence in similar between men and women
 Heartburn is the most frequent clinical complaint
ETIOLOGY
It is caused by weakness or relaxation of the lower
esophageal sphincter.
Factors that can lead to this include:
 Obesity
 Particular types of food (Ex. dairy, spicy, fried,
greasy, and fatty foods) and eating habits
 Too much pressure on the abdomen (Ex.
Pregnant women)
 Medications (ex. medicines for asthma, high
blood pressure, and allergies; painkillers,
sedatives, and antidepressants)
 Toxins and chemicals (ex. smoking)
 Hiatal hernia
PATHOPHYSIOLOGY
Lower Esophageal Sphincter Pressure
1. Reflux may occur following transient LES
relaxation that are not associated with
swallowing.
2. Reflux may occur following transient increase in
intraabdominal pressure (stress reflux)
MARJAN G. CAMZAR
RD
BS PHARMACY 3 YEAR
CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 2

3. The LES may be atonic, thus permitting free

reflux as seen in patients with sclerodema
Tissue Injury-Based GERD syndromes
Anatomic Factors
 Esophigitis
1. Hiatal Hernia Occurs when the upper part of  Strictures
your stomach bulges through the large muscle  Barrett's esophagus
separating your abdomen and chest  Esophageal adenocarcinoma
(diaphragm).
Extraesophageal GERD Syndromes
Esophageal Clearance
 Chronic cough
- The acid spends too much time in contact with  Laryngitis
the esophageal mucosa. Contact time is  Wheezing
dependent on the rate at which the esophagus  Asthma (50% with asthma have GERD)
clears the noxious material, as well as the
frequency of reflux. DIAGNOSTIC TEST

Mucosal Resistance 1. Upper endoscopy

2. Ambulatory Acid (pH) probe test
- Mucus-secreting glands - Contributes to the 3. X-ray of the upper digestive system
protection of the esophagus. 4. Esophageal manometry
- Cellular Acidification and necrosis may ultimately 5. Transnasal esophagoscopy
cause esophagitis
TREATMENT
Gastric Emptying/Increased Intra-abdominal
Pressure NON PCOL with Lifestyle Modifications

- Delayed gastric emptying can contribute to a) Maintain a healthy weight

gastroesophageal reflux. b) Stop smoking and alcohol consumption
- An increase in gastric volume may increase both c) Elevate the head of your bed
frequency of reflux and the amount of gastric d) Don't lie down after a meal
fluid available to be refluxed. e) Eat food slowly and chew thoroughly
f) Avoid foods and drinks that trigger reflux
COMPLICATIONS g) Avoid tight-fitting clothing

1. Esophigitis PCOL
2. Esophageal Strictures
3. Barrett's esophagus
4. Esophageal adenocarcinoma

CLINICAL MANIFESTATIONS / SYMPTOMS

Symptom-Bases GERD Syndromes

 Heartburn
 Regurgitation/belching
 Reflux chest pain
 Acid brash

Alarm symptoms:

 Dysphagia
 Odynophagia
 Bleeding
 Weight loss
MARJAN G. CAMZAR
RD
BS PHARMACY 3 YEAR
CLINICAL PHARMACY & PHARMACOTHERAPEUTICS 2

Monitoring

 Reflux monitoring

Surgery to treat GERD

 Esophageal pH monitoring

CASE STUDY

A male Chronic Alcoholic obese patient came to the

OPD with complaints of Retrosternal Chest pain 1/2 hour
after eating and sour brash since 6 months. For 2
weeks, he observed teeth discoloration.

Findings

 Gender: Male
 Symptoms:
- Retrosternal Chest Pain
- Sour Brash
- Teeth discoloration

Laboratory Test Results:

 Endoscopy - showing the epithelial changes in

the lower esophagus
 Biopsy - replacement of stratified squamus Non
Keratinised Epithelium with the resistant
intestinal columnar epithelium
 Manometry - Loss of tone of LES

Assessment

 Gastroesophageal reflux disease or chronic acid

reflux

Resolution

 Non-pharmacologic
- Lifestyle modifications
 Pharmacologic
- Proton pump inhibitors - to decrease acidic
content of the stomach
- Prokinetic Drugs - to increase motility