differential diagnosis,complication and treatment of gastroesophageal reflux disease

1. DIFFERENTIAL
DIAGNOSIS,COMPLIC
ATION AND
TREATMENT OF GERD
GROUP 403

2. GERD
• Gastroesophageal reflux may be classified into 3 categories, as follows
• :1Physiologic (or functional) gastroesophageal reflux: These patients have no
underlying predisposing factors or conditions; growth and development are normal;
and pharmacologic treatment is typically not necessary, though it may be needed to
relieve symptoms if lifestyle changes are unsuccessful.
• Pathologic gastroesophageal reflux or GERD: Patients frequently experience
complications noted above, requiring careful evaluation and treatment.

3. GERD
• Secondary gastroesophageal reflux: This refers to a case in which an underlying
condition may predispose to gastroesophageal reflux, with examples including
asthma (a condition that may also be, in part, caused by or exacerbated by reflux)
and gastric outlet obstruction.
• The diagnosis of GERD in patients with atypical symptoms can be difficult. When
patients present with atypical complaints, the diagnosis of GERD must be kept in
mind. Patients with recurrent aspiration can have asthma, history of pneumonias,
and progressive pulmonary fibrosis. Additionally, hoarseness can be present due
to chronic laryngeal irritation. Chest pain is another presenting symptom that can
be difficult to evaluate. In these patients, excluding cardiac etiology is important
prior to labeling the pain as noncardiac chest pain secondary to GERD.

4. GERD
• The clinical presentation of GERD in pregnant women is similar to that for the
general population. Heartburn and regurgitation are the cardinal symptoms. The
diagnostic evaluation consists of a thorough history and physical examination.

6. DIFFERENTIAL DIAGNOSIS GERD
• Achalasia
• Acute gastritis
• Antral web cholelithiasis
• Chronic Gastritis
• Coronary artery atherosclerosis
• Esophageal cancer
• Helicobacter pylori infection

7. OESOPHAGEAL MOTOR
DISORDERS: ACHALASIA
Dysphagia for liquids and solids; also may be
associated with chest pain.
Notes-Nutcracker esophagus may be coincident with
GERD; heartburn or chest pain in achalasia not due
to reflux but to fermentation of retained esophageal
contents or esophageal muscle spasm

8. ESOPHAGEAL CANCER
• Presents with dysphagia and weight loss, often in
patients with longstanding GERD.
• Usually incurable by the time of clinical
presentations

9. CORONARY ARTERY DISEASE
• Chest pain that may be clinically indistinguishable
from chest pain associated with GERD.
• In patients at high risk for cardiac disease, should
rule out cardiac disease before evaluating for
GERD

10. • Other causes of chest pain such as heart disease should be ruled out before
making the diagnosis.[24] Another kind of acid reflux, which causes respiratory
and laryngeal signs and symptoms, is called laryngopharyngeal reflux (LPR) or
"extraesophageal reflux disease" (EERD). Unlike GERD, LPR rarely produces
heartburn, and is sometimes called silent reflux.

11. COMPLICATIONS-
ESOPHAGEAL STRICTURE
• Result of healing of erosive esophagitis.
• May need dilation.
• Common in distal esophagus and are generally 1-
2 cm in length.

12. BARRETT'S ESOPHAGUS
• Columnar metaplasia of the esophagus, I.e
replacement of the squamous epithelial lining of
the esophagus by specialized columnar type
epithelium.
• Associated with the development of
adenocarcinoma
• Have a greater chance of developing esophageal
stricture

13. EROSIVE ESOPHAGITIS
• Responsible for 40-60% of GERD symptoms
• Severity of symptoms often fail to match severity
of erosive esophagitis.

14. TREATMENT
• The treatments for GERD include lifestyle modifications, medications, and possibly
surgery. Initial treatment is frequently with a proton-pump inhibitor such as
omeprazole.
• Certain foods and lifestyle are considered to promote gastroesophageal reflux,
but most dietary interventions have little supporting evidence. Avoidance of
specific foods and of eating before lying down should be recommended only to
those in which they are associated with the symptoms. Foods that have been
implicated include coffee, alcohol, chocolate, fatty foods, acidic foods, and spicy
food. Weight loss and elevating the head of the bed are generally useful.
Moderate exercise improves symptoms; however in those with GERD vigorous
exercise may worsen them.Stopping smoking and not drinking alcohol do not
appear to result in significant improvement in symptoms.

15. MEDICATIONS
• medications used for GERD are proton-pump inhibitors, H2 receptor blockers and
antacids with or without alginic acid.
• Proton-pump inhibitors (PPIs), such as omeprazole, are the most effective,
followed by H2 receptor blockers, such as ranitidine. If a once daily PPI is only
partially effective they may be used twice a day. They should be taken one half to
one hour before a meal. There is no significant difference between agents in this
class. When these medications are used long term, the lowest effective dose
should be taken.They may also be taken only when symptoms occur in those with
frequent problems. H2 receptor blockers lead to roughly a 40% improvement.

16. MED.
• The evidence for antacids is weaker with a benefit of about 10% (NNT=13) while a
combination of an antacid and alginic acid (such as Gaviscon) may improve
symptoms 60% (NNT=4). Metoclopramide (a prokinetic) is not recommended
either alone or in combination with other treatments due to concerns around
adverse effects. The benefit of the prokinetic mosapride is modest.
• Sucralfate has a similar effectiveness to H2 receptor blockers; however, sucralfate
needs to be taken multiple times a day, thus limiting its use . Baclofen, an agonist
of the GABA receptor, while effective, has similar issues of needing frequent
dosing in addition to greater adverse effects compared to other medications.

18. SURGERY
• The standard surgical treatment for severe GERD is the Nissen fundoplication. In
this procedure, the upper part of the stomach is wrapped around the lower
esophageal sphincter to strengthen the sphincter and prevent acid reflux and to
repair a hiatal hernia. It is recommended only for those who do not improve with
PPIs.[24] Benefits are equal to medical treatment in those with chronic
symptoms.[24] In addition, in the short and medium term, laparoscopic
fundoplication improves quality of life compared to medical management. When
comparing different fundoplication techniques, partial posterior fundoplication
surgery is more effective than partial anterior fundoplication surgery.

19. THANK YOU.