Gastro-Esophageal Reflux Disease (GERD)

FM

Gastro-esophageal Reflux Disease (GERD)

Overview

• A condition in which the stomach contents leak backwards from the stomach into the esophagus.
• Common, affecting approximately 30% of the general population.

Symptoms of GERD

• Presents with:
  • Heartburn, Sharp stabbing sub-sternal pain (probability: 89%)
  • Regurgitation (probability: 95%)
  • At night or after heavy meal
  • Chronic cough, asthma-like wheezing
  • MI ??

Risk Factors

• Pregnancy
• Smoking
• Drugs
• Fat
• Chocolate
• Coffee
• Alcohol ingestion
• Large meals

Defective Oesophageal Clearance

• Abnormal lower oesophageal sphincter
  • Reduced tone
  • Inappropriate relaxation

Other Contributing Factors

• Hiatus hernia
• Delayed gastric emptying
• Increased intra-abdominal pressure

Drugs – antimuscarinic, calcium-channel blockers, nitrates

Diagnosis of GERD

Young Patients

• Young patients who present with typical symptoms of gastro-oesophageal reflux
• Without worrying features such as dysphagia, weight loss, or anaemia
• Can be treated empirically without investigation

Middle or Late Age Patients

• If patients present in middle or late age
• If symptoms are atypical, or
• If a complication is suspected
  1. Endoscopy is the investigation of choice
  2. Esophageal manometry
  3. 24-h pH monitoring

Assess oesophagitis and hiatal hernia by endoscopy. If there is oesophagitis or Barrett’s oesophagus reflux is confirmed esophageal manometry : (study of esophageal motility) diagnose abnormal peristalsis and/or decreased LES tone 24-h pH monitoring: most accurate test, but rarely required or performed

Diagnosis & Management of GERD

• Diagnosis: History, PPI test, Endoscopy
• Lifestyle Modification: ??
• Medication:
  • Antacid
  • Antisecretory drug:
    • H₂ receptor blocker
      • Proton pump inhibitor (2 months)
  • Prokinetics
• Surgery: Laparoscopic fundoplication or open?

GERD Complications

• Weakness or incompetence of lower esophageal sphincter
• Esophagitis
• Esophageal stricture
• Barret’s esophagus

---

---

---

Therapeutics

occurs when the amount gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury.

Prevalence:

• Affect all ages and both sexes.
• Very common, 10% of population have daily symptoms and 33% of population have intermittent symptoms

Pathophysiology:

The following factors protect against occurrence of GERD. impairment of one or more of these factors may lead to GERD:

• I. Competent gastroesophageal junction. e.g Impairment can occur in the form of decrease lower esophageal sphincter (LES) tone.

• II. Effective esophageal clearing through esophageal peristalsis.

• III. Neutralization of refluxed fluid by saliva.

Presentation of GERD:

I. Typical Symptoms: Heart burn and/or regurgitation and halitosis.

II. Extra- esophageal manifestations:

• -Non cardiac chest pain which may be typical to angina however never diagnosed except after exclusion of coronary heart disease.
• -Asthma.
• -Chronic cough
• -Pneumonia and pneumonitis
• -Laryngitis
• -Hoarseness of voice

Ill. Manifestations of complications:

1. Erosive esophagitis causing hematemesis.
2. Peptic stricture causing dysphagia.
3. Barrett’s esophagitis (columnar metaplasia): a condition in which specialized intestinal type columnar mucosa replaces the normal squamous mucosa in response to chronic gastro esophageal reflux disease with increased risk of adenocarcinoma. Endoscopy with biopsy is recommended for Barrett’s esophagus but not chronic gastroesophageal reflux disease.

Diagnosis of GERD:

1. Presence of typical symptoms.
2. Endoscopy: showing inflammation and/or complications in lower esophagus.
3. 24-hour Ambulatory pH monitoring: detecting abnormal acid reflux.

Treatment:

1. Active Disease: by acid suppression:

• H-2 receptor blockcers for mild disease. Options include ranitidine, cimetidine, famotidine and nizatidine

• Proton pump inhibitors for moderate or severe disease e.g. omeprazole, lansoprazole and esmoprazole.

2. Long term therapy: to avoid recurrence:

• Life style modification: reduce weight, stop smoking, small frequent diet, raise bed head and avoid late meals.

• Infrequent symptoms: intermittent acid suppression therapy.

• Frequent symptoms: long term therapy or surgery (fundoplication).