GASTROESOPHAGEAL

REFLUX
DISEASE
Tutor 2
Definition
• Gastroesophageal reflux disease (GERD) as “a condition
which develops when the reflux of stomach contents causes
troublesome symptoms and/or complications” (Yamada’s
Textbook of Gastroenterology).
• Gastroesophageal reflux resulting
in either troublesome symptoms
or an array of potential
esophageal and extraesophageal
manifestations. (Harrison)
 EPIDEMIOLOGI
• Population-based studies show that up to 15% of individuals have
heartburn and/or regurgitation at least once a week, and 7% have
symptoms daily.
• chronic oesophagitis occurring in 30% of the general population.
• Based on the self-reported prevalence of heartburn, 10%–20% of
individuals in Western countries have GERD
• Gender: GERD is equally prevalent among males and females but there is a male
preponderance of esophagitis (2 : 1 to 3 : 1).
• Age: The incidence of GERD increases with age; GERD was greatest in the 60–69-year
range.
• Pregnancy : half to two-thirds of pregnant women complain of typical GERD symptoms
• Geographic variation: GERD prevalence is greater in Western countries (10%–20%) than
in Asia (5%–7%).
• Lifestyle, environmental factors, and genetic predisposition may influence GERD
prevalence
• Obesity: In western countries, the increased prevalence of GERD has occurred in
parallel with the dramatic increase in obesity.
• Medications: Several medications (nitrates, calcium channel blockers, anticholinergics,
α-adrenergic agonists, theophylline, morphine, benzodiazepines, and sumatriptan) have
been reported to promote GERD occurrence.
• H. pylori: prevalence of H. pylori has decreased, the prevalence of GERD has increased.
 ETIOLOGI
Harrison
• Symptoms are caused by backflow
of gastric acid and other gastric
contents into the esophagus due to
incompetent barriers at the
gastroesophageal junction.
• Incompetence of the diaphragmatic
crural muscle also predisposes to
GERD.
RISK FACTOR :
• Obesity
Crash Course
Factors associated with GORD are:
1. Pregnancy or obesity
2. Fat, chocolate, coffee or alcohol
ingestion
3. Large meals
4. Cigarette smoking
5. Anticholinergic drugs, calcium
channel antagonists and nitrate
drugs
6. Hiatus hernia
 PATHOPHYSIOLOGY
• Reflux occurs only when the gradient of pressure between the LES and the
stomach is lost.
• caused by a sustained or transient decrease in LES tone.
• sustained hypotension of the LES may be due to muscle weakness that is
often without apparent cause.
• Increased episodes of tLESR are associated with GERD.
 PATHOPHYSIOLOGY
1. The resting LOS tone is low or absent
2. The LOS tone fails to increase when lying flat, or when the intra-
abdominal pressure has increased, e.g. during pregnancy or while
wearing tight clothing.
3. Poor oesophageal peristalsis leads to reduced clearance of acid in the
oesophagus
4. Hiatus hernia can impair the function of the LOS and the diaphragm
closure mechanism, as the pressure gradient between the abdominal
and thoracic cavities is diminished
5. Delayed gastric emptying increases the chance of reflux.
 Gastric contents are most likely to reflux :
1. gastric volume is increased
2. gastric contents are near the gastroesophageal junction
3. gastric pressure is increased
 Esophageal exposure to refluxed gastric contents
depends on :
1. amount of refluxed material per episode
2. frequency of reflux episodes
3. rate of clearing of the esophagus by gravity and peristaltic
contractions

• Acid refluxed into the esophagus is neutralized by saliva.

• If the refluxed material extends to the cervical esophagus and crosses
the upper sphincter, it can enter the pharynx, larynx, and trachea.
 Complication of reflux
1. Reflux esophagitis, most common esophageal
mucosal injury (erosions).
2. Mild esophagitis
3. Erosive esophagitis
4. Peptic stricture
• These may haemorrhage, perforate, or heal by fibrosis
(sometimes forming a stricture) and epithelial
regeneration.
• Barrett’s oesophagus
• Esophageal adenocarcinoma.
 CLINICAL FEATURES
• Heartburn
• Regurgitation of sour material into the mouth
• Angina-like or atypical chest pain
• dysphagia
• woken up at night if refluxed fluid irritates the larynx
• Bleeding
• Extraesophageal manifestations : chronic cough, laryngitis, and
pharyngitis, morning hoarseness, chronic sinusitis .
• Recurrent pulmonary aspiration : chronic bronchitis, asthma, pulmonary
fibrosis, chronic obstructive pulmonary disease, or pneumonia.
 DIAGNOSIS
• In most cases, the diagnosis can be made clinically and no
investigation is required. In atypical cases, diagnostic approach to
GERD can be divided into three categories :

 Documentation of mucosal injury

 Documentation and quantitation of reflux
 Definition of the pathophysiology
Documentation of mucosal injury
• Barium swallow (reveal an ulcer or a stricture),
• Esophagoscopy (reveal the presence of erosions,ulcers, peptic
strictures, or Barrett’s metaplasia with or without ulcer, peptic
stricture, or adenocarcinoma
• Mucosal biopsy, show early changes of esophagitis, including dilation
of intracellular spaces.
Documentation and quantitation of reflux

• can be done by long-term esophageal pH recording, using a pH-

sensitive capsule are helpful only in the evaluation of pharyngeal acid
reflux.
• Reflux of nonacid contents can be documented by the use of an
impedance test.
Treatment
• The goals : symptom relief, heal erosive esophagitis, and prevent
complications.
• management of mild cases :
1. weight reduction,
2. sleeping with the head of the bed elevated by about 4–6 in. with
blocks
3. elimination of factors that increase abdominal pressure.

Prevention :
• not smoke
• avoid consuming fatty foods,
coffee, chocolate, alcohol, mint,
orange juice, and certain
medications (such as
anticholinergic drugs, calcium
channel blockers, and other
smooth-muscle relaxants)
• Avoid ingesting large quantities
of fluids with meals
• lifestyle change and over-the-
counter antisecretory agents.
Non Pharmacology :
Antireflux surgery
Pharmacology
SYMPTOM RELIEF
• H2 receptor antagonists (cimetidine,
300 mg qid; ranitidine, 150 mg bid;
famotidine, 20 mg bid; nizatidine, 150
mg bid).
HEAL EROSIVE ESOPHAGITIS
• PPIs : omeprazole (20 mg/d),
lansoprazole (30 mg/d), pantoprazole
(40 mg/d), esomeprazole (40 mg/d),
or rabeprazole (20 mg/d) for 8 weeks.
taken 30 min before breakfast.
Reference :
• Harison’s Gastroenterology and Hepatology 3 ed
• Crash Course Gastrointestinal system 4 ed
• Yamada’s Textbook Gastroenterology 6 ed