GERD IS A COMMON CLINICAL PRESENTATION. SOME DETAILS ABOUT BASIC UNDERSTANDING OF GERD AND ITS MANAGEMENT

1. Understanding
Essam A.Wahab, MD

2. • This presentation is supported
and supplemented by Tabuk
pharmaceuticals…

3. • Definition of GERD
• Epidemiology
• Pathophysiology
• Clinical Manifestations
• Diagnostic Evaluation
• Complications
• Treatment

4. Definitions

5. Physiologic vs Pathologic
• Physiologic GERD
– Postprandial
– Short lived
– Asymptomatic
– No nocturnal sx
• Pathologic GERD
– Any time
– Symptoms
– Mucosal injury
– Nocturnal sx

6. Definition
• Symptoms OR Mucosal damage produced
by the abnormal reflux of gastric contents into the
esophagus…..
• Often chronic and relapsing

8. • Developed countries:
 Epidemic proportions
 present in 40% of healthy population
• Developing countries ?
Epidemiology

10. Epidemiology
• All ages are affected …..mainly > 40 years.
• 10-20% ….symptomize…… Weekly
• 7%-10%.... Symptomize …… Daily
• Barrett’s esophagus > in white males

11. • LES is the primary barrier to GERD
• LES works in conjunction with the diaphragm
• If this barrier disrupted, reflux occurs.
Pathophysiology

12. Simple Plumbing Circuit

13. GERD

14. LES tone
• Drugs :
CCB
Nitrates, anticholinergic
Contraceptives and estrogen.
• Foods:
Chocolate and fatty foods .
Onions, peppermint, and garlic
• Smoking:

15. Risk factors
• Prolonged gastric emptying
• Obesity
• Pregnancy
• Trauma
• Hiatal hernia
• Nocturnal postprandial
• Transient LES relaxation

16. • 1) Dysfunction of LES;
• Spontaneous transient LES relaxations
• Transient increase in intra abdominal
pressure
• Atonic LES
Pathophysiology

17. 2) DISRUPTION OF ANATOMICAL BARRIERS
3) ESOPHAGEAL CLEARANCE.
4) MUCOSAL RESISTANCE:
5)DELAYED GASTRIC EMPTYING
6)Composition of refluxate:
Pathophysiology

18. Pathophysiology; Summary

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

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

22. • Barrett’s Esophagus:
– Columnar metaplasia.
– Associated with the development of adenocarcinoma
– Have a greater chance (30%) of developing esophageal
stricture
Complications
Barrett’s
Esophagus

24. Clinical Manifestations
• Typical symptoms:
– Heartburn
– Regurgitation
– Water brash
– Belching

27. (2) ATYPICAL SYMPTOMS:
 Non-allergic asthma
 Hoarseness
 Pharyngitis
 Chest pain
 Dental erosions
Clinical Manifestations

29. • (3) ALARMING SIGNS / SYMPTOMS
Dysphagia
Odynophagia
GI bleeding
Iron deficiency anemia
Persistent Vomiting
Unexplained Weight loss
Clinical Manifestations

32. 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

33. 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

34. Endoscopy

35. • 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

39. Management tools

40. • Lifestyle Modification

41. • Antacids:
– OTC acid suppressants.
– Appropriate initial therapy
– More effective than placebo in
relieving GERD symptoms
Treatment

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

43. • 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

44. AGENT DOSAGE/ daily
Esomeprazole 20-40 mg
Omeprazole 20-40 mg
Lansoprazole 15-30 mg
Pantoprazole 40 mg
Rabeprazole 20 mg
Treatment

45. Treatment

47. Rapid change in gastric PH

49. Type of the patient

50. Severity of symptoms

51. H. Pylori co-infection

53. • Antireflux surgery (when?)
– Failed medical management
– Patient preference
– GERD complications
– Large hiatal hernia
– Atypical symptoms with GERD
documented on 24-hour pH monitoring
SURGERY

54. Endoscopic treatment
 Relatively new
 No definite indications
 Select well-informed patients with well-documented
GERD responsive to PPI therapy may benefit
Three categories:
 RF application to increase LES reflux barrier
 Endoscopic sewing devices
 Injection of a non-resorbable polymer into LES area

57. • 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 Next Lecture