Gastro-esophageal reflux disease

( GERD)
 GERD: definition
GERD: Symptoms, mucosal damage or other
complications produced by the abnormal/excessive
reflux of gastric contents into the esophagus

Epidemiology: Affects upto 30% of the general

population
 GERD
Normal physiology:
• Normally the LES is tonically contracted,
relaxing only during swallowing
• However, Some degree of gastroesophageal
reflux is normal, expressed as belching
(physiologically: transient relaxation of the
LES): assymptomatic, gastric by esophageal
peristaltic movements
 GERD: Pathophysiology/etiology
• Several factors are known to be involved:
1. Delayed oesophageal clearance
2. Abnormalities of the lower oesophageal sphincter (LES)
3. Hiatus hernia
4. Excessive acid secretion
5. Delayed gastric emptying
6. Increased intra abdominal pressure
7. Dietary and enviromental factors
 GERD: Pathophysiology
1. Delayed oesophageal clearance: leads to increased
acid exposure time
Defective oesophageal peristaltic activity due to
primary or secondary Esophageal motility disorders
2. Abnormalities of the lower oesophageal sphincter
(LES):
- Reduced lower oesophageal sphincter tone
- Frequent episodes of inappropriate sphincter
relaxation
 GERD: Pathophysiology
3. Hiatus hernia:
• Structural abnormality which results to Herniation of the
stomach through the diaphragm into the chest leading to:
- The pressure gradient between the abdominal and thoracic
cavities is lost
- The oblique angle between the cardia and oesophagus
disappears
• These two factors make it easier for gastric contents to reflux
into the esophagus
• Two types: Roling or paraesophageal hiatus hernia and the
Sliding hiatus hernia
 GERD: Pathophysiology
4. Increased intra-abdominal pressure:
pregenancy, obesity: dysfunction at the GEJ
5. Excessive acid secretion: H.pylori infection
6. Defective/delayed gastric emptying
7. Dietary and environmental factors:
Dietary fat, chocolate, alcohol and coffee relax
the LES
 GERD: Clinical presentation
1. Heartburn (pyrosis):
• A discomfort or burning sensation behind the
sternum
• most commonly experienced after eating,
during exercise, and while lying recumbent.
• Relieved with antacid
 GERD: Clinical presentation
2. Regurgitation:
• Is the effortless return of food or fluid into the pharynx
without nausea or retching
• Usually provoked by Bending, belching, or maneuvers that
increase intraabdominal pressure
• NB: Different from:
- Vomiting: is preceded by nausea and accompanied by
retching
- Rumination: is a behavior in which recently swallowed food is
regurgitated and then reswallowed repetitively for up to an
Hr( psychiatric pts, eating disorders etc)
 GERD: Clinical presentation
3. Water brash: is excessive salivation resulting
from a vagal reflex triggered by presence of acid
in the esophagus
4. Dysphagia: described as a feeling of food
"sticking" or lodging in the chest
5. Odynophagia : is pain either caused by or
exacerbated by swallowing
6. Rarely, Associated Nausea and vomiting ( more
common in cases of delayed gastric emptying)
 GERD
Extraesophageal manifestations

• Coughing, Wheezing, Sore throat,

Hoarseness, Chest pain, Otitis media, Dental
manifestations( enamel erosions)

• Reflux is significantly more common in

asthma patients and asthma is more
common in GERD patients (Evidence for the
direction of causality, however, is lacking)
 GERD: Complications
1. Reflux Oesophagitis:
Range from mild redness to severe bleeding and
ulceration with stricture formation
 GERD: Complications
2. Barrett's oesophagus
• An adaptive response to chronic gastro-oesophageal reflux
(Occurs in 10% of pts with GERD)
• It is a pre-malignant condition in which the normal
squamous lining of the lower oesophagus is replaced by
columnar mucosa containing areas of intestinal metaplasia
• A collumnar lined esophagus is a major risk factor for
oesophageal adenocarcinoma
• The condition is often asymptomatic, discovered when the
patient presents with oesophageal cancer
 GERD: Complications
3. Iron deficiency anaemia: occurs as a
consequence of chronic, insidious blood loss
from long-standing oesophagitis
4. Fibrous esophageal strictures: develop as a
consequence of long-standing oesophagitis
 GERD: Complications
5. Gastric volvulus:
• Occurs when a hiatus hernia twist upon itself, Leading
to complete oesophageal or gastric obstruction
• Symptoms: severe chest pain, vomiting and dysphagia
• The diagnosis is made by:
- chest X-ray: air bubble in the chest
- barium swallow
• Most cases spontaneously resolve but tend to reccur,
requiring surgical correction
 GERD: Investigations
• Young patients who present with typical symptoms
of GERD, can be treated empirically without
investigation
• Investigation is advisable in:
1. Young pts with Alarming features such as
dysphagia, weight loss or anaemia
2. Patients presenting in middle or late age
3. If symptoms are unresponsive to treatment
4. If a complication is suspected
 GERD: Investigations
1. Endoscopy is the investigation of choice: Esophagoscopy ,
biobsy
2. Others:
- Esophageal manometry: Motility testing: Entails positioning a
pressure sensing catheter within the esophagus and then
observing the contractility following test swallows
- Double contrast barium swallow can identify reflux esophagitis
and strictures
- Chest xray: may identify a large hiatus hernia
- Ultra sound, CT scan, MRI = No role in the investigation of
GERD at present
 GERD: Differential diagnosis
• GERD needs to be distinguished from:
1. Infectious esophagitis
2. pill esophagitis
3. eosinophilic esophagitis
4. peptic ulcer disease
5. Biliary tract disease
6. Coronary artery disease( ACS)
8. Esophageal motor disorders
 GERD: Management
Non pharmacologic:
1. Weight loss in obese patients
2. Avoiding foods that reduce the LES pressures; chocolate,
alcohol, coffee
3. Smoking cessation
3. Small frequent meals rather than large meals
4. Waiting 3hrs after a meal/fluid intake to lie down
5. Elevating the head of the bed
6. Avoid bending or stooping positions
8. Avoid tight fitting garments
 GERD: Medical treatment
The most common and effective treatment (GERD) is to
reduce gastric acid secretion: These therapies do not
prevent reflux, but they reduce the acidity of the
refluxate:
1. Anti-acids
2. H2 receptor antagonists: Ranitidine, famotidine,nitazidine
3. Proton pump inhibitors: omeprazole,
lanzoprazole,esomeprazole,pantoprazole
PPIs at a standard ( recommended by the manufactures) are
the most effective of these
 Approach to medical treatment
Mild moderate cases: Repeated courses of Anti
acids and/ H2 blockers/PPIs
Severe cases:
• Prolonged RX with PPI: for at least eight weeks
 Approach to medical treatment
After 8 weeks:
• A trial to step down and stop medications should be
considered in patients who have a good clinical
response:
1. Patients who get Recurrent symptoms in less than
three months are best managed with
continuous/maintenance PPI therapy
2. Recurrences occurring after more than three months
can be managed by repeated courses of PPI therapy
as necessary = intermittent therapy
 GERD: Approach to medical treatment
“Refractory" GERD:
= Patients with (GERD) who continue to have reflux
symptoms or endoscopic evidence of esophagitis
while on standard doses of PPIs
= 10 – 40 % of patients with GERD
1. Consider alternative diagnosis ( differential
diagnosis above)
2. Refer gastroenterologist
3. Candidates for surgical treatment
 H. Pylori and GERD
• H. pylori is an important risk factor for the development
of:
- peptic ulcer disease
- gastric adenocarcinoma
- primary B cell lymphoma of the stomach
• However, the link between GERD and H. pylori is complex
• H. pylori might predispose to GERD is by modifying the
gastric refluxate (increased acid secretion)
• Most authorities advocate testing and eradication of H.
pylori even in the setting of GERD
 GERD: Indications for surgery
1. Poorly controlled on PPIs, A/E of treatments
2. Complications, Barrett’s esophagus, gastric
volvulus
3. hiatus hernia
4. Presence of extraesophageal manifestations
 GERD: Surgical treatment
1. Fundoplication: transthoracic or
transabdominal, open or laparascopic
techniques
2. Placement of device to augment the LES
 Other disorders of the esophagus
1. Motility disorders
- Achalasia
- Diffuse esophageal spasm (DES)
- Secondary causes of motility disorders
2. Eosinophillic esophagitis: mucosal biopsies
demonstrating esophageal squamous
epithelial infiltration with eosinophils.
Associated with drug hypersensitivity,
connective tissue disorders etc
 Other disorders of the esophagus
5. Trauma:
- Perforation
- Foreign bodies
- Mallory-weiss tears: Tears at the gastroesophageal
junction resulting from vigorous Vomiting,
retching, or coughing. presents with hematemesis
Treatment: local epinephrine or cauterization
therapy, endoscopic clipping, or angiographic
embolization. Surgery is rarely needed
 Other disorders of the esophagus
3. Infections of the esophagus: Candinda, HSV,
CMV
4. Tumours of the esophagus
6. Radiation esophagitis
7. Corrosive esophagitis( chemical ingestion)
8. Pill esophagitis: pill gets stuck and causes
chemical injury/dysphagia/odynophagia etc