The document discusses Gastroesophageal Reflux Disease (GERD), including its pathophysiology caused by lower esophageal sphincter abnormalities, hiatal hernias, and delayed esophageal clearance. It covers the clinical features, complications like esophagitis and Barrett's esophagus, investigations using endoscopy and pH monitoring, and management through lifestyle changes, medications like PPIs, and sometimes surgery.

1. Gastroesophageal Reflux
Disease
CHRISTA MARIA JOEL
MODERATOR: DR. AKSHATHA RAO

2. DEFINITION
• GERD is a consequence of the failure of the normal anti reflux
barrier to protect against frequent and abnormal amounts of
gastroesophageal reflux
• Spectrum of injury to the oesophagus:
- Esophagitis
- Stricture
- Barrett’s oesophagus
- Adenocarcinoma

3. PATHOPHYSIOLOGY
• GERD develops
when oesophageal
mucosa is exposed to
gastroduodenal
contents for
prolonged period of
time, resulting in
symptoms and, in
proportion of cases,
oesophagitis.

4. ABNORMALITIES OF LOWER
ESOPHAGEAL SPHINCTER
• Some patients with GERD- have
reduced tone of lower
oesophageal sphincter,
permitting reflux when
intrabdominal pressure rises.
• Some others- basal sphincter
tone is normal but reflux occurs
in response to frequent episodes
of inappropriate sphincter
relaxation.

5. HIATUS HERNIA
• Herniation of the stomach through
the diaphragm into the chest.
• Causes reflux because the pressure
gradient between abdominal and
thoracic cavities which normally
pinches the hiatus is lost.

6. TYPES OF HIATUS HERNIA

7. DELAYED ESOPHAGEAL
CLEARANCE
• Defective oesophageal
peristaltic activity commonly
found in patients who have
oesophagitis.
• Poor oesophageal clearance
leads to increased acid
exposure time.
GASTRIC CONTENTS
• Gastric acid- most important
oesophageal irritant.
• There is a close relationship
between acid exposure time and
symptoms.
• Pepsin and bile also contribute
to mucosal injury.

8. • DEFECTIVE GASTRIC EMPTYING: Delayed in patients with
GERD. Reason is unknown.
• INCREASED INTRA-ABDOMINAL PRESSURE: Pregnancy
and obesity are predisposing causes.
• DIETARY AND ENVIRONMENTAL FACTORS
• PATIENT FACTORS

9. CLINICAL FEATURES
• Heartburn and regurgitation provoked by bending, straining or lying down.
• Waterbrash
• Patient is often overweight.
• Some patients wake up at night by choking as refluxed fluid irritates larynx.
• Odynophagia or dysphagia
• Atypical chest pain which may be severe and can mimic angina and may be due
to reflux induced oesophageal spasm.
• Hoarseness, recurrent chest infections, chronic cough and asthma.

10. COMPLICATIONS - OESOPHAGITIS
• On endoscopy:
- Mild redness
- Severe bleeding ulceration
- With stricture formation
Poor correlation between
symptoms and histological and
endoscopic findings.

11. BARRETT’S OESOPHAGUS
• Premalignant condition in
which the normal squamous
lining of the lower oesophagus
is replaced by columnar
mucosa that may contain areas
of intestinal metaplasia.
• Adaptive response to chronic
gastro oesophageal reflux.

12. • Risk of cancer seems to relate to the severity and duration of
reflux.
• Dudenogastroesophageal reflux of bile, pancreatic enzymes and
pepsin as well as gastric acid may be important in the
pathogenesis.
• Diagnosis: multiple systematic biopsies to maximise the chance of
detecting intestinal metaplasia and/or dysplasia.

13. • Management of Barrett’s oesophagus:
- Regular endoscopic surveillance- detect dysplasia at early stage and
may improve survival.
- Patients with columnar lined oesophagus without dysplasia
- Patients with low grade dysplasia
- Patients with high grade dysplasia or intramucosal carcinoma.

14. ANAEMIA
• Iron deficiency anaemia as a consequence of occult blood loss
from long standing oesophagitis.
• Most patients have large hiatus hernia and bleeding can stem from
subtle erosions in the neck of the sac- Cameron lesions.

15. BENIGN OESOPHAGEAL STRICTURE
• Fibrous strictures can develop as
a consequence of long standing
oesophagitis especially in the
elderly and those with poor
oesophageal peristaltic activity.
• Dysphagia that is worse for solids
than liquids.

16. • Diagnosis: endoscopy.
• Endoscopic balloon dilatation is helpful.
• Long term therapy with a PPI drug at full
dose should be started.
• Patient is advised to chew food
thoroughly and is important to ensure
adequate dentition.

17. GASTRIC VOLVULUS
• Occasionally a massive
intrathoracic hiatus hernia may
twist upon itself leading to a gastric
volvulus.
• Gives rise to complete oesophageal
or gastric obstruction.
• Patient presents with severe chest
pain, vomiting and dysphagia.

18. INVESTIGATIONS
• Young patients with typical symptoms of gastroesophageal reflux,
without worrying features such as dysphagia, weight loss or
anaemia can be treated empirically without investigation.
• Investigation is advisable if patient presents over the age of 50-55
years if symptoms are atypical or if a complication is suspected.
• Endoscopy- investigation of choice.

19. • 24 hour pH monitoring indicated if diagnosis
is unclear or surgical intervention is under
consideration.
• pH < 4 for more than 6-7 % of the study time
is diagnostic of reflux disease.
• In a few patients with difficult reflux,
impedance testing can detect weakly acidic or
alkaline reflux that is not revealed by
standard pH testing.

20. MANAGEMENT
• Lifestyle advice:
- weight loss
- avoid fatty food, alcohol, mint, tomato based foods, spicy foods,
coffee, tea and acidic foods.
- elevation of bed head in those who experience nocturnal
symptoms
- avoid late night meals before retiring.
- give up smoking.
- avoid weight lifting, stooping and bending at waist.
- Frequent feeds and small volume.

21. • Medical treatment:
• Antacids: Used in the dose of 10-15
ml, 1 and 3 hours after meal and at
bed time or as needed.
• Histamine (H2) receptor antagonists:
Drugs include cimetidine 800 mg
bid, 400 mg qid or ranitidine 150 mg
qid or famotidine 20-40 mg bid daily
to be given with meals and before
bed time for at least 6 weeks.

22. • Proton pump inhibitors Include
omeprazole 20-40 mg/day, lansoprazole
15-30 mg/day, pantoprazole 40 mg/day,
esmoprazole 20-40 mg/day and
rabeprazole 10-20 mg/day.
• Drugs are useful in moderate to severe
cases and are usually given for 6-8 weeks
in higher doses.
• Maintenance dose- 6-8 months.

23. • The common practice of using metoclopramide or domperidone 10
mg thrice daily is not supported because of its adverse effects.
• H. pylori eradication does not have any therapeutic value.
• Dilatation of esophageal strictures.
• Anaemia is treated with oral iron or blood transfusion.

24. • Surgical treatment:
- Surgical resection of
oesophageal strictures.
- Anti reflux surgery-
laparoscopic fundoplication.