Etiology and pathogenesis
1. The resting lower esophageal sphincter
(LOS) is low and fails to increase when
2. Decrease esophageal clearance of acid due
to poor esophageal peristalsis.
3. Delayed gastric emptying.
4. Hiatus hernia may impair the pinchcock
mechanism of the diaphragm.
5. The lower esophageal sphincter tone fails to
increase when intra abdominal pressure is
increased by tight clothes or pregnancy.
Incidence and Background
• It is one of the most common conditions affecting
the gastrointestinal system.
• Anywhere from 36-77% of people have symptoms of
GERD (heartburn, regurgitation of acid etc.) spread
equally between men and women.
• 7% have daily heartburn
• 14-20% have weekly heartburn
• 15-50% have monthly heartburn
• Even children – especially neurodevelopmental
disorders – 90%
Pathophysiology of GERD
• A complex interaction of many
problems can cause reflux:
• Esophageal Dysmotility – weak or
• Inadequate saliva production – seen
in smokers, in certain diseases and
normally seen during sleep.
• Saliva normally “buffers” any acid
which is found in the esophagus.
• Impaired resistance of esophageal lining.
• LES dysfunction – poorly functioning
sphincter muscle allowing acid to wash
up into the esophagus
• Delayed emptying of the stomach – poor
motor function of the stomach (not
draining into the intestine) allowing acid
to “pool” in the stomach.
• Hiatal hernia – allows acid to wash up
into the esophagus due to pressure
differences between the abdomen and
• Loose hiatus muscle fibers causes reflux
even without a hiatal hernia.
•Heartburn – burning or tightness behind the sternum or in the
•Acid regurgitation – sour or bitter taste in the throat or mouth.
•Water brash – a hot sensation in the stomach followed by a large
amount of watery liquid in the mouth.
•Dysphagia - difficulty swallowing or painful swallowing
(odynophagia). The sensation of a lump in the throat or food getting
“stuck” after swallowing.
•Asthma, laryngitis and chronic cough are unusual symptoms, but
can be caused by GERD.
• Symptoms typically occur after eating a
• can be especially noticeable with a large meal
or spicy foods.
• Symptoms may be relieved by antacids.
• Symptoms often are worse when lying flat,
straining or sleeping.
Symptoms made worse…
• Fatty foods, chocolate, coffee, peppermint as
well as alcohol and use of tobacco products
can cause or worsen symptoms.
• Theophylline, Albuterol, and Calcium channel
blockers can also cause symptoms of GERD.
• GERD is a clinical diagnosis & many
patients can be treated without
1. Endoscopy. to confirm the presence of
2. 24 hour intraluminal pH monitoring of the
3. Esophageal manometry.
4. Barium study: It may show a hiatus hernia.
Complications of GERD
• Reflux esophagitis
• Injury and inflammation of
the inner lining of the
esophagus from prolonged
exposure to acid and digestive
• This produces pain as well
as sometimes painful
or a “sticking” sensation
Complications of GERD
• Reflux esophagitis can progress to complications:
• Long-standing inflammation and scarring can progress
to Barrett’s esophagus which is a premalignant
• Severe scarring and narrowing of the esophagus can
occur called strictures. These can cause food to become
“stuck” or can cause pain when swallowing.
• Advanced cases can lead to outpouchings of the walls
of the esophagus called a diverticula.
Complications of GERD
• Barrett’s Esophagus
• This is the replacement of the
cells lining the esophagus
with cells more typical of the
stomach or intestines
(metaplasia) due to the long-term
damage caused by
GERD and acid.
• Occurs in approx 10% of
patients with GERD.
• Barrett’s esophagus
• Represents one of the
complications of GERD.
It is a precancerous
with cancer of the
esophagus. It is thought
to be caused by ongoing
injury, inflammation and
damage to the lining of
• Iron deficiency anemia occurs as a
consequence of chronic insidious blood loss
from long standing esophagitis
•Treatment of GERD is primarily medical,
the mainstays being lifestyle modifications
(see Table below) and drug therapy
• The goals of treatment are to provide
symptom relief, heal erosive esophagitis,
and prevent complications.
I. Simple life style measures
50% of patients can be treated by:
o Cessation'et smoking, loss of weight and simple
o Avoid alcohol, fatty meals & drugs e.g. nitrates.
o Avoid heavy meals especially before sleep.
o Raising the head of the bed at night.
o Avoid any other precipitating factor.
II. Pharmacological Therapy
I. Drugs reduce gastric acidity: (Prolonged therapy is
• Antacids: Mg trisilicate and aluminium hydroxide, also
alginate containing antacids forming a gel with gastric
contents reducing reflux.
• H2blockers: Ranitidine (Zantac(ID)(300mg at bed
• Proton pump inhibitors: Omeprazole (20-40mg/day),
Lanzoprazole (30mg/day) or pantoprazole (20-
40mg/day). They inhibit the gastric hydrogen-potassium
Treatment , Cont…
• Drugs increase esophageal peristalsis
and LOS pressure (Prokinetic)
• - Cisapride (Prepulsid): not available now!?
It leads to arrythmia.
• - Metoclopramide or Domperidone.