Gastroesophageal reflux

disease

GERD
Raika Jamali M.D.
Gastroenterologist and hepatologist
Sina Hospital
Tehran University of Medical Sciences

Objectives
Appreciate the significance of GERD as a
chronic disease
Identify patients with different
presentations of GERD
Organize a rationale management plan for
different types of GERD symptoms
Be familiar with various treatment
modalities of GERD and their appropriate
use

Definitions
GERD: any symptomatic
condition or histopathologic
alteration resulting from
episodes of gastroesophageal
reflux
Erosive: 35%
Nonerosive (NERD)

Why GERD is so important??

is

very common & increasing

Burden and Quality of life
complications: esophagitis,
peptic stricture, inflammatory
polyps ,Barrett's metaplasia ,
dysplasia ,adenocarcinoma

Epidemiology
Geographic
M=F

variation

Barrett's metaplasia (M/F =

10 /1)

The prevalence of GERD in

Asian populations is
reported to be lower than
that in the west.

Population-based data on the

prevalence and symptom profile of
GERD in developing Caucasian
countries is lacking.

Frequency of Endoscopic GERD

Iranian Experience: 1994-1999

Retrospective study of 4500 UGIE reports (5y): 34.3% E-GERD

Malekzadeh,et al 2000

Prospective evaluation of referring

Dyspeptics in Tehran
269 (135 F) participant
Symptoms recorded, UGIE + Bx from
Z-line was done:
77.6% at least one major GERD
symptom
76.1% EE (most A & B)
5% Specialized intestinal metaplasia
3 Dysplasia
None of the symptoms could predict
the endoscopic or histologic findings

Nasseri-Moghaddam, Malekzadeh et al 2002

CONCLUSION
GERD is a common disease among
Iranian general population and its
prevalence is comparable with that
of the western countries .

Pathogenesis
Transient L E S Relaxation
Hypotensive L E S
Anatomic Variables

Delayed Gastric Emptying

Esophageal Acid Clearance
- Salivary Function

-Impairments of Esophageal Emptying

 GERD

LES

LES

:
/

Case 1
A 34 y engineer with heart burn for 8
y comes to your office for evaluation
of his GERD symptoms.
He asks you about the diagnosis of
GERD, if additional diagnostic work
up is needed and his medical
management.

Diagnosis

History is usually sufficient to

confirm the diagnosis

Indications for Endoscopy

Extra-esophageal or atypical symptoms

Patients > 40 y with new onset GERD symptoms
Dysphagia
Weight Loss
Anemia
Family hx of Cancer
Long(>5 y) or very severe symptoms

GERD-B

The Los Angeles Classification

GERDA

GERD-C

GERD-D

Avoid:
smoking
stress
Heavy meals
Large quantities of liquid with meals
Fatty foods
Coffee
Choclate
Alcohol
Mint
Orange juice
Tomato catch up
Anticholinergic, calcium channel
blockers, smooth muscle relaxants

Therapeutic regimens for GERD in

order of increasing potency
Over-the-counter antacids and/or H2
receptor blockers
Omeprazole (20 mg QD) or
equivalent dose of the other PPIs
Omeprazole (20 mg BID or 40 mg
BD) or equivalent doses of the other
PPIs

 Step-up approach: with mild symptoms,

no change in QOL
Step-down approach: with more severe
symptoms affecting QOL or with higher
grades of esophagitis / complications
Bed time H2B for nocturnal symptoms

Dose of the different H2

blockers
Drug
Cimetidine
Ranitidine
Famotidine
Nizatidine

Daily dose
800 mg
300 mg
40 mg
300 mg

PPI versus H2 blockers in treatment of erosive

GERD symptoms (right panel) and esophageal
healing (left panel)

PPI side effects

Pneumonia
Hypergastrinemia (Carcinoid tumor
in animal model)
Enteric infections
Vitamin B12 malabsorption

PROKINETIC DRUGS
Metoclopramide
Cisapride
Tegaserod

Duration of therapy
Maintenance therapy :
lowest dose of PPI or H2 blockers,
especially in severe esophagitis

(grades C & D) and with

complications (BE, stricture)

Intermittent therapy :
on-demand therapy in patients
with mild to moderate heartburn
without severe esophagitis.

Effective initial and long

term mangement
Decreases amount of drugs used
Decreases doctor visits
Decreases the need for repeat UGIE
(Bate et al 1992, Bloom et al 1994, Bardhan et al 1999)

Case 2

Young woman with chronic cough who is

refractory to treatment with sulbutamol
is referred for evaluation of GERD.
She complains of morning hoarseness.
Sulbutamol was in effective and even
aggravated her symptoms.
Laryngoscopy showed posterior vocal
cord erythema.
Endoscopy showed esophagitis.
Symptoms respond to 20 mg of daily
omeprazol.

CLINICAL PRESENTATION
Typical Symptoms

Heartburn

Regurgitation

Dysphagia

Case 3

Middle age man is visited for

evaluation of dysphagia to solids
from 2 months duration.
He was a heavy smoker and used
famotidine for heart burn for 14 y.
Ba swallow was performed.
Endoscopy and biopsy was done.

Proximal esophageal
stricture

Peptic stricture

Hyperplasia of basal cells and

infiltration of PMN with
erosions in GERD.

Natural History

Peptic stricture ( 8 to 20 %)
Ulceration ( 5 %)
Significant bleeding ( 2 % )

Perforation extremely rare

Esophageal ulcer in reflux

esophagitis

Case 4
A 45 y old man with 25 y reflux
symptoms comes to your office for
evaluation of recent weight loss and
dysphagia.
There was a histologic report of
Intestinal metaplasia in distal
esophagus in his last endoscopy 2 y
ago.
Ba swallow and endoscopy was
performed.

Adenocarcinoma

Barretts Esophagus

Barretts Esophagus

Long Segment Barretts

Endoscopic mucosal
resection

Case 5
A 38 y old woman comes to the clinic
for her severe chronic reflux
symptoms and consults about
antireflux surgery.
She is on long term Omeprazole 40
mg twice a day and ranitidine before
bed time.
Serum Gastrin level is in upper
normal limits.
Endoscopy was normal (NERD).

Refractory gastroesophageal
reflux disease
Failure to control symptoms with full
dose of PPI + life style modification
raises the possibility that symptoms
are due to another disease or
refractory GERD.

 Reduced bioavailability
Effect of food
Dosing interval
Gastric acid hypersecretion
Drug resistance
Slow healing
Esophageal hypersensitivity
(viseral hyperalgesia)
Eosinophilic esophagitis
Pill induced esophagitits

TREATMENT
First confirm the diagnosis then,
Increase the frequency of dosing
Increasing the dose (Omeprazole to
80 mg/day)
Add a second drug
Switch to another drug
Check for Gastrinoma
Surgery

Preoperative evaluation for

gastroesophageal reflux disease
Detailed clinical history and physical
examination
Endoscopy to assess degree of
esophagitis
Esophageal manometry to define LES
pressure and disorders of peristalsis
Upper gastrointestinal series to assess
esophageal length and hiatal hernia
24 hour esophageal pH monitoring

Indications for esophageal

pH recording
to document abnormal esophageal
acid exposure in an endoscopynegative patient being considered for
surgical antireflux repair
to evaluate patients after antireflux
surgery who are suspected to have
ongoing abnormal reflux

 to evaluate patients with normal

endoscopic findings and reflux
symptoms that are refractory to
proton pump inhibitor therapy
to detect refractory reflux in patients
with extraesophageal or atypical
symptoms using symptom
association probability calculation

INDICATIONS FOR OPERATION

AND PREOPERATIVE
EVALUATION
Persistent or recurrent symptoms
with appropriate response to
medical THX.
Severe esophagitis by endoscopy
Benign stricture
Recurrent pulmonary symptoms

Predictors of successful
surgery
Response to medical therapy
Typical reflux symptoms
Erosive GERD
Abnormal pH study

Predictors of unsuccessful
surgery

Lack of response to medical therapy

(medical failure?)
It could be something other than GERD

Non-erosive GERD (NERD)

Helicobacter pylori and GERD

Eradication of H. pylori is associated
with mild worsening of GERD in
patients with corpus-predominant
gastritis and improvement in those
with antral-predominant gastritis.
The standard of care is to eradicate
H. pylori in the context of peptic
ulcer disease.