A case of

GERD
DEFINITION

Occurs when the amount of gastric juice that

refluxes into the esophagus exceeds the
normal limit; there by causing symptoms with
or without associated esophageal mucosal
injury
DEFINITION

 MONTREAL DEFINITION
 GERD is a condition which develops when
thereflux of the stomach contents causes
troublesome symptoms and/or
complications
EPIDEMIOLOGY

 Eastern Asia, the prevalence of GERD has risen from 2.5–

4.8% before 2005 to 5.2–8.5% from 2005 to 2010.
 In Asia, time trend studies during the last two decades reveal
that the prevalence of erosive esophagitis (EE) has increased
from 1.8% in 1995 to 12.6% in 2002
 In the Philippines, the prevalence of EE increased from 2.9%
to 6.3% between two time periods, 1994–1997 and 2000–
2003, respectively.

From : Philippine Journal of Internal Medicine : Clinical Practice Guidelines on the Diagnosis and
Treatment of Gastroesophageal Reflux Disease (GERD) 2015
CLNICAL MANIFESTATIONS
Classic symptoms :
 Heartburn
 Regurgitation
 Other symptoms of GERD include :
 dysphagia
 chest pain
 odynophagia
 extraesophageal symptoms (eg, chronic cough,
hoarseness, wheezing)
 nausea
SIGNS AND SYMPTOMS

From Vakil N et al. Am J Gastroenterol 2006;101:1900-1920

PATHOPHYSIOLOGY

1 2 3
Poor Dysfunctional Delayed
Esophageal Gastric
LES Emptying
Motility
POOR ESOPHAGEAL MOTILITY

 Proper esophageal clearance is an extremely important

factor in preventing mucosal injury.
 Esophageal clearance must be able to neutralize the acid
refluxed through the lower esophageal sphincter.
 Normal clearance limits the amount of time the esophagus
is exposed to refluxed acid or bile and gastric acid mixtures.
 Abnormal peristalsis can cause inefficient and delayed acid
clearance.
DYSFUNCTIONAL LES

 (LES) is defined by manometry as a zone of elevated

intraluminal pressure at the esophagogastric junction.
 LES dysfunction occurs via one of several mechanisms
 Transient relaxation of the LES (most common
mechanism)
 Permanent LES relaxation
 Transient increase of intra-abdominal pressure that
overcomes the LES pressure.
DELAYED GASTRIC EMPTYING

Occurs when there is an increase in gastric

contents resulting in increased intragastric
pressure and, ultimately, increased pressure
against the lower esophageal sphincter.
DIAGNOSIS

 According from the World Gastroenterology

Organisation Global Guidelines GERD Global
Perspective on Gastroesophageal Reflux Disease:
 The presence of heartburn and/or regurgitation
symptoms 2 or more times a week is
suggestive of GERD.
RECOMMENDATION NO.5

Locally-validated standardized questionnaires

may be utilized to reinforce the clinical
diagnosis of GERD, as well as, to assess
response to PPI treatment

From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
DIAGNOSTICS

From the World Gastroenterology Organisation Global Guidelines GERD Global Perspective
on Gastroesophageal Reflux Disease 2017
ALARM FEATURES
RECOMMENDATION NO.24

From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
MANAGEMENT

 The core principles of GERD management

are lifestyle interventions and reduction of
esophageal luminal acid either by local acid
neutralization or by suppression of gastric
acid secretion using medical treatment; or,
rarely, antireflux surgery.

From the World Gastroenterology Organisation Global Guidelines GERD Global Perspective
on Gastroesophageal Reflux Disease 2017
 The primary goals of treatment are to :
 relieve symptoms
 improve the patient’s health-related quality of life,
 heal esophagitis
 prevent symptom recurrence
 prevent or treat GERD-associated complicationsin the
most cost-effective manner.

From the World Gastroenterology Organisation Global Guidelines GERD Global Perspective
on Gastroesophageal Reflux Disease 2017
LIFESTYLE MODIFICATION
DIETARY FACTORS TO
AVOID (RELAXES LES)
 Alcohol – absolute
 contraindication
 Spicy foods
 Caffeine. Coffee
 Citrus, fruit juices
 Fatty foods – delays gastric
 emptying
 Chocolate
 Peppermint
 Carbonated beverages
LIFESTYLE
 Smoking/ tobacco cessation
 Weight loss – for obese patients
 Avoid LES-relaxingmedications –
calcium antagonists, ISDN,
nitroglycerin
 Sleeping in left-lateral decubitus
position
 Elevate head of the bed at least 30
degrees)
 Eat meals earlier
 Do not lie down immediately after
ameal; stay upright or sitting down 1-
2 hours before lying down/sleeping
MEDICAL MANAGEMENT

 The dominant pharmacologic approach to GERD

management is with inhibitors of gastric acid
secretion, and abundant data support the
effectiveness of this approach.
From the World Gastroenterology Organisation Global Guidelines GERD Global Perspective
on Gastroesophageal Reflux Disease 2017
STEPWISE THERAPY
RECOMMENDATION NO.7

 Recommendation #7: Standard dose PPI once daily for eight

weeks, taken 30 minutes before morning meal, is the cornerstone
of therapy for erosive esophagitis.
 Proton pump inhibitors (PPIs) have consistently shown
better results over Histamine 2 receptor antagonist
(H2RA), antacids, prokinetics and sucralfate in healing
rates and symptom relief in both erosive and non-
erosive reflux disease.

From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
RECOMMENDATION NO.7

 During the consensus deliberations, a four-week

duration of PPI therapy for EE was discussed
because it may have economic implications to the
GERD patients in the Philippines.
 Observations from unpublished cohort studies also
claim good symptom relief achieved with a short
duration of PPI treatment.
 It was suggested that a well-designed, multicentre study be
done among our Filipino patients before a proper
recommendation can be made on this regard.
From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
RECOMMENDATION NO.9

 Recommendation #9:
 If eight weeks of standard once daily PPI treatment
achieved only a partial relief of symptoms, administer
the same PPI twice daily or switch to a different PPI.

From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
RECOMMENDATION NO.9

 A meta-analysis of 10 studies showed overall

benefit, albeit modest, in relief of symptoms
and healing of erosive esophagitis among
patients who shifted from once-daily
omeprazole (20 mg), lansoprazole (30 mg) or
pantoprazole (40 mg) to esomeprazole 40 mg
for eight weeks.

From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
RECOMMENDATION NO.10

 Recommendation #10:
 When symptoms relapse after standard GERD
treatment, on demand or intermittent PPI therapy is
suggested for NERD while, continuous PPI treatment is
recommended for moderate to severe erosive
esophagitis. During maintenance therapy, prescribe the
lowest effective dose of PPI

From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
RECOMMENDATION NO.10

 On-demand therapy - PPI consumption when

GERD symptoms occur and for as long as the
bothersome symptoms persist.

 Intermittent therapy - is administration of PPI

for a pre-defined period of time, usually lasting for
five to seven days, even after symptoms have abated.

From the Philippine Journal of Internal Medicine Clinical Practice Guidelines on the
Diagnosis and Treatment of Gastroesophageal Reflux Disease (GERD)2015
SURGICAL MANAGEMENT

 Recommendation #25 from Philippine Journal of Internal Medicine

Clinical Practice Guidelines on the Diagnosis and Treatment of
Gastroesophageal Reflux Disease (GERD)2015 :
 Surgery, preferably laparoscopic fundoplication done in high-volume,
expert centers, is an option only among patients with GERD whose
symptoms respond to PPI therapy but not amenable to long-term medical
treatment
 Other indications :
 Presence of a large hiatal hernia,
 Severe GERD complications
 Refractory GERD
 Recommendation #26 from Philippine Journal of Internal Medicine
Clinical Practice Guidelines on the Diagnosis and Treatment of
Gastroesophageal Reflux Disease (GERD)2015 :

 Esophageal manometry and ambulatory reflux studies should be

performed prior to surgery to exclude disorders other than GERD.
From the World Gastroenterology Organisation Global Guidelines GERD Global Perspective
on Gastroesophageal Reflux Disease 2017
From the World Gastroenterology Organisation Global Guidelines GERD Global Perspective
on Gastroesophageal Reflux Disease 2017
From the World Gastroenterology Organisation Global Guidelines GERD Global Perspective
on Gastroesophageal Reflux Disease 2017
COMPLICATIONS

EROSIVE ESOPHAGEAL BARRETT’S

ESOPHAGITIS STRICTURE ESOPHAGUS
Erosive esophagitis Result of the healing A condition in which
occurs when excessive process of ulcerative metaplastic columnar
reflux of acid and pepsin esophagitis. Collagen is epithelium replaces the
results in necrosis of deposited during this stratified squamous
surface layers of phase and, with time, the epithelium that normally
esophageal mucosa, collagen fibers contract, lines the distal esophagus.
causing erosions and narrowing the esophageal
ulcers. lumen.
COMPLICATIONS

Erosive Esophageal Barret’s

Esophagitis Stricture Esophagus