Understanding

Essam A.Wahab, MD

• This presentation is supported and supplemented by Tabuk pharmaceuticals…

• Definition of GERD

• Epidemiology

• Pathophysiology

• Clinical Manifestations

• Diagnostic Evaluation

• Complications

• Treatment

Definitions

Physiologic vs Pathologic

• Physiologic GERD– Postprandial– Short lived– Asymptomatic– No nocturnal sx

• Pathologic GERD– Any time – Symptoms– Mucosal injury– Nocturnal sx

Definition• Symptoms OR Mucosal damage produced

by the abnormal reflux of gastric contents into the esophagus…..

• Often chronic and relapsing

• Developed countries: Epidemic proportions present in 40% of healthy population• Developing countries ?

Epidemiology

Epidemiology

• All ages are affected …..mainly > 40 years.

• 10-20% ….symptomize…… Weekly

• 7%-10%.... Symptomize …… Daily

• Barrett’s esophagus > in white males

• LES is the primary barrier to GERD

• LES works in conjunction with the diaphragm

• If this barrier disrupted, reflux occurs.

Pathophysiology

Simple Plumbing Circuit

GERD

LES tone• Drugs :

CCBNitrates, anticholinergic Contraceptives and estrogen.

• Foods:Chocolate and fatty foods .Onions, peppermint, and garlic

• Smoking:

Risk factors

• Prolonged gastric emptying• Obesity• Pregnancy• Trauma• Hiatal hernia• Nocturnal postprandial• Transient LES relaxation

• 1) Dysfunction of LES;• Spontaneous transient LES relaxations

• Transient increase in intra abdominal

pressure

• Atonic LES

Pathophysiology

2) DISRUPTION OF ANATOMICAL BARRIERS

3) ESOPHAGEAL CLEARANCE.

4) MUCOSAL RESISTANCE:

5)DELAYED GASTRIC EMPTYING

6)Composition of refluxate:

Pathophysiology

Pathophysiology; Summary

Complications

• Erosive esophagitis:– Responsible for 40-60% of GERD symptoms– Severity of symptoms often fail to match

severity of erosive esophagitis.

• Esophageal stricture:– Healing of erosive esophagitis– May need balloon dilation– Common in the distal esophagus – generally 1 to 2 cm in length.

• Barrett’s Esophagus:

– Columnar metaplasia.

– Associated with the development of adenocarcinoma

– Have a greater chance (30%) of developing esophageal

stricture

Complications

Barrett’s Esophagus

Clinical Manifestations

• Typical symptoms:– Heartburn

– Regurgitation

– Water brash

– Belching Atypica

l

Alarm

Typical

(2) ATYPICAL SYMPTOMS:

Non-allergic asthma

Hoarseness

Pharyngitis

Chest pain

Dental erosions

Clinical Manifestations

• (3) ALARMING SIGNS / SYMPTOMSDysphagia

Odynophagia

GI bleeding

Iron deficiency anemia

Persistent Vomiting

Unexplained Weight loss

Clinical Manifestations

Diagnostic Evaluation

– If classic/typical symptoms like heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated

Trial of Medications

• H2RA or PPI:??– Expect response in 2-4 weeks– If no response :– Change from H2RA to PPIs– Maximize dose of PPI

• If inadequate despite max dose,• Confirm diagnosis of GERD by :

– UGIE– 24 hour pH monitor

Endoscopy

• UGIE (with biopsy if needed):– With alarm signs/symptoms– failed a medication trial– Require long-term THERAPY

– Distinguishing between esophagitis and Barret’s

• Absence of endoscopic features does not

exclude a GERD diagnosis !

• Confirmation by (Bernstein test) is rarely

DONE

NERD

24 hour pH monitoring is now the gold standard

Endoscopy

Management tools Lifestyle Modification

Pharmacological TTT

Antireflux surgery

• Lifestyle Modification

• Antacids:– OTC acid suppressants.– Appropriate initial therapy– More effective than placebo in

relieving GERD symptoms

Treatment

• Histamine H2-Receptor Antagonists:– Competitively block H2 receptors– More effective than antacids – Faster healing of erosive esophagitis– OTC drugs

Treatment

• Proton Pump Inhibitors :– Effective for all type and form of GERD – Decreasing basal and stimulated gastric acid

secretion.– Inhibition the H+/K+ ATPase proton pump– Better control of symptoms– Faster healing of erosive esophagitis with RA

PPI

Treatment

AGENT DOSAGE/ daily

Esomeprazole 20-40 mg

Omeprazole 20-40 mg

Lansoprazole 15-30 mg

Pantoprazole 40 mg

Rabeprazole 20 mg

Treatment

Treatment

Rapid change in gastric PH

Type of the patient

Severity of symptoms

H. Pylori co-infection

• Antireflux surgery (when?)– Failed medical management– Patient preference– GERD complications– Large hiatal hernia– Atypical symptoms with GERD

documented on 24-hour pH monitoring

SURGERY

Endoscopic treatmentRelatively newNo definite indicationsSelect well-informed patients with well-documented

GERD responsive to PPI therapy may benefit

Three categories:RF application to increase LES reflux barrierEndoscopic sewing devices Injection of a non-resorbable polymer into LES area

• GERD is a common disease • All ages and both sex are effaced • Be careful about proper endoscopic timing ! • Be aware about GERD complications• Do not hesitate to refer your pt to GI

specialist• Be familial with refractory GERD

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