GERD is most common gastric problem in community affecting large number of people. Diagnosis and management is very simple with understanding. http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/ https://drdhavalmangukiya.com/

1. Gastroesophageal
Reflux Disease
Dr.Dhaval O.Mangukiya

2. Objectives
 Definition of GERD
 Epidemiology of GERD
 Pathophysiology of GERD
 Clinical Manisfestations
 Diagnostic Evaluation
 Treatment
 Complications

3. Definition
 American College of
Gastroenterology (ACG)
• Symptoms OR mucosal
damage produced by the
abnormal reflux of gastric
contents into the esophagus
• Often chronic and relapsing
• May see complications of
GERD in patients who lack
typical symptoms

4. Physiologic vs Pathologic
 Physiologic GERD
• Postprandial
• Short lived
• Asymptomatic
• No nocturnal sx
 Pathologic GERD
• Symptoms
• Mucosal injury
• Nocturnal sx

5. Epidemiology
 About 44% of the US adult
population have heartburn at least
once a month
 14% of have symptoms weekly
 7% have symptoms daily

6. Pathophysiology
 Primary barrier to
gastroesophageal
reflux is the lower
esophageal sphincter
 LES normally works in
conjunction with the
diaphragm
 If barrier disrupted,
acid goes from
stomach to esophagus

7. Clinical Manisfestations
 Most common symptoms
• Heartburn—retrosternal burning
discomfort
• Regurgitation—effortless return of
gastric contents into the pharynx
without nausea, retching, or
abdominal contractions

8. Clinical Manisfestations
• Dysphagia—difficulty swallowing
• Other symptoms include:
 Chest pain, water brash, globus sensation,
odynophagia, nausea
• Extraesophageal manifestations
 Asthma, laryngitis (hoarseness), chronic
cough, aspiration

9. Diagnostic Evaluation
• If classic symptoms of heartburn and
regurgitation exist in the absence of
“alarm symptoms” the diagnosis of
GERD can be made clinically and
treatment can be initiated

10. Alarms
• Alarm Signs/Symptoms
 Dysphagia
 Early satiety
 GI bleeding
 Odynophagia
 Vomiting
 Weight loss
 Iron deficiency anemia

11. Trial of Medications
 H2RA or PPI
• Expect response in 2-4 weeks
• If no response
 Change from H2RA to PPI
 Maximize dose of PPI

12. Trial of Medications
 If PPI response inadequate despite
maximal dosage
• Confirm diagnosis
 EGD
 24 hour pH monitor

13. Esophagogastrodudenoscopy
 Endoscopy (with biopsy if
needed)
• In patients with alarm
signs/symptoms
• Those who fail a medication
trial
• Those who require long-term tx
 Lacks sensitivity for
identifying pathologic reflux
 Absence of endoscopic
features does not exclude a
GERD diagnosis
 Allows for detection,
stratification, and
management of esophageal
manisfestations or
complications of GERD

14. pH
 24-hour pH monitoring
• Accepted standard for establishing or
excluding presence of GERD for those
patients who do not have mucosal
changes
• Trans-nasal catheter or a wireless,
capsule shaped device

15. Ambulatory 24 hr. pH Monitoring
 Physiologic study
 Quantify reflux in
proximal/distal
esophagus
• % time pH < 4
• Symptom
correlation

16. Wireless, Catheter-Free Esophageal pH
Monitoring
• Improved patient
comfort and acceptance
• Continued normal work,
activities and diet study
• Longer reporting periods
possible (48 hours)
• Maintain constant probe
position relative to SCJ
Potential Advantages

17. Esophageal Manometry
 Assess LES
pressure, location
and relaxation
• Assist placement of
24 hr. pH catheter
 Assess peristalsis
• Prior to antireflux
surgery
Limited role in GERD

18. Patient with heartburn
Iniate tx with H2RA or PPI
H2RA taken
BID
Good response
Frequent relapses
On demand tx
PPI taken QD
Good response
Maintenance therapy
with lowest effective dose
Symptoms persist
Consider EGD if
risk factors present
(> 45, white, male
and > 5 yrs of sx)
Increase to
max dose QD
or BID
Good response
Confirm diagnosis
EGD, ph monitor
No
Yes Yes
No
Yes
Yes
No
No

19. Treatment
 Goals of therapy
• Symptomatic relief
• Heal esophagitis
• Avoid complications

20. Better Living
 Lifestyle modifications
• Avoid large meals
• Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate,
onions, garlic, peppermint
• Decrease fat intake
• Avoid lying down within 3-4 hours after a meal
• Elevate head of bed 4-8 inches
• Avoid meds that may potentiate GERD (CCB, alpha agonists,
theophylline, nitrates, sedatives, NSAIDS)
• Avoid clothing that is tight around the waist
• Lose weight
• Stop smoking

21. Treatment
 Antacids
• Over the counter acid
suppressants and
antacids appropriate
initial therapy
• Approx 1/3 of patients
with heartburn-related
symptoms use at least
twice weekly
• More effective than
placebo in relieving
GERD symptoms

22. Treatment
 Histamine H2-Receptor Antagonists
• More effective than placebo and
antacids for relieving heartburn in
patients with GERD
• Faster healing of erosive esophagitis
when compared with placebo
• Can use regularly or on-demand

23. Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Cimetadine 400mg twice daily 400-800mg twice daily
Famotidine 20mg twice daily 20-40mg twice daily
Nizatidine 150mg twice daily 150mg twice daily
Ranitidine 150mg twice daily 150mg twice daily

24. Treatment
 Proton Pump Inhibitors
• Better control of symptoms with PPIs vs
H2RAs and better remission rates
• Faster healing of erosive esophagitis
with PPIs vs H2RAs

25. Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Esomeprazole 40mg daily 20-40mg daily
Omeprazole 20mg daily 20mg daily
Lansoprazole 30mg daily 15-10md daily
Pantoprazole 40mg daily 40mg daily
Rabeprazole 20mg daily 20mg daily

26. Treatment
 H2RAs vs PPIs
• 12 week freedom from symptoms
 48% vs 77%
• 12 week healing rate
 52% vs 84%
• Speed of healing
 6%/wk vs 12%/wk

27. Treatment
 Antireflux surgery
• Failed medical management
• Patient preference
• GERD complications
• Medical complications attributable to a
large hiatal hernia
• Atypical symptoms with reflux
documented on 24-hour pH monitoring

28. Treatment
 Antireflux surgery candidates
• EGD proven esophagitis
• Normal esophageal motility
• Partial response to acid suppression

29. Treatment
 Antireflux surgery
• Tenets of surgery
 Reduce hiatal hernia
 Repair diaphragm
 Strengthen GE junction
 Strengthen antireflux barrier via gastric
wrap
 75-90% effective at alleviating symptoms of
heartburn and regurgitation

31. Treatment
 Postsurgery
• 10% have solid food dysphagia
• 2-3% have permanent symptoms
• 7-10% have gas, bloating, diarrhea,
nausea, early satiety
• Within 3-5 years 52% of patients back
on antireflux medications

32. Treatment
 Endoscopic treatment
• Relatively new
• No definite indications
• Select well-informed patients with well-
documented GERD responsive to PPI therapy
may benefit
 Three categories
• Radiofrequency application to increase LES
reflux barrier
• Endoscopic sewing devices
• Injection of a nonresorbable polymer into LES
area

33. Complications
 Erosive esophagitis
 Stricture
 Barrett’s esophagus

34. Complications
 Erosive esophagitis
• Responsible for 40-60% of GERD
symptoms
• Severity of symptoms often fail to
match severity of erosive esophagitis

35. Complications
 Esophageal
stricture
• Result of healing
of erosive
esophagitis
• May need
dilation

36. Complications
 Barrett’s Esophagus
• Columnar metaplasia
of the esophagus
• Associated with the
development of
adenocarcinoma

37. Complications
 Barrett’s Esophagus
• Acid damages lining of
esophagus and causes
chronic esophagitis
• Damaged area heals in
a metaplastic process
and abnormal columnar
cells replace squamous
cells
• This specialized
intestinal metaplasia
can progress to
dysplasia and
adenocarcinoma

38. Complications
 Barrett’s Esophagus
• Manage in same manner as GERD
• EGD every 3 years in patient’s without
dysplasia
• In patients with dysplasia annual to
shorter interval surveillance

39. ?QUESTIONS?