GERD is a common condition where stomach acid refluxes into the esophagus. It affects around 13% of the global population. Risk factors include advancing age, obesity, hiatal hernia, smoking, and certain foods. GERD occurs when there is an imbalance between protective factors in the esophagus and aggressive factors like acid and pepsin from the stomach. Symptoms range from heartburn to complications like esophagitis, stricture, and Barrett's esophagus. Treatment involves lifestyle modifications, antacids, H2 blockers, and PPIs. For severe cases, surgery may be considered to reinforce the lower esophageal sphincter. Endoscopic surveillance is important for monitoring Barrett

2. Gastroesophageal reflux disease
(GERD)
Dr. Md. Shariful Hasan
Resident, phase B
Gastroenterology, BSMMU

3. GERD

5. Epidemiology
• Pooled prevalence – 13%
• prevalence of GERD is highest in South Asia and Southeast Europe
(more than 25%)
• 20% - heartburn/week
• 10% - daily symptoms

6. • No gender difference in Europe
• Complication more in male
• Advancing age (40-60 yrs)
• Obese> non obese
• Race
• H. Pylori associated gastritis

7. Pathogenesis
Imbalance between-
a) Defensive factors protecting the Esophagus
b) Aggressive factors refluxing from the Stomach

8. 1) Antireflux barriers-
• Hypertensive LES
• Diaphragmatic crura
• Intra-abdominal LES
• Phrenoesophageal ligaments
• Acute angle of His.

9. 2) Esophageal acid clearance
3) Tissue resistance –
- Tight junction & lipid rich glycoconjugates

10. Aggressive factors
1) Gastric -Acid & pepsin
2) Gastric volume
3) Delayed gastric emptying
4) Duodeno-gastric reflux-bile

11. Mechanisms of reflux
• Transient LES relaxation
• Swallow induced LES relaxation
• Hypotensive LES
• Hiatal Hernia

12. Fig: Effect of Hiatal hernia on anti-reflux barrier

13. Precipitating factors
Foods
• Caffeine
• Chocolate
• Fats
• Peppermint
• Alcohol
• Carbonated beverages
• Citrus fruits
• Tomato-based products (tomato juice pH = 3.25)
• Vinegar (pH = 3.00)

14. Lifestyle factors
• Weight gain
• Smoking
• Eating prior to recumbency
• Sleep deprivation
• Psychological stress

15. Medication
• Decrease LES pressure
• Causes mucosal damage

18. Pathophysiology

19. Clinical Features

25. Alarm symptoms

26. Associated condition
• Pregnancy- 30%-80%
• Scleroderma- 90%
• ZES
• Heller myotomy- 10%-30%
• Prolong NG intubation

27. Diagnosis
• Classic symptoms
• Response to acid suppression (68%-83%)/ PPI trial/ PPI test
• Investigations

28. Investigations
• Barium Esophagogram
• Endoscopy
• Histology
• 24 H ambulatory Intra-esophageal pH monitoring
• Esophageal manometry
• Multi channel intraluminal impedence testing

29. Barium esophagogram
• Anatomic narrowing
• Hiatal hernia
•Esophagitis (moderate-severe)
- thickening of mucosal folds
- Erosions, ulcers and stricture

30. Barium esophagogram
Fig: Peptic esophageal stricture with Hiatal
hernia.

31. Endoscopy
• Sensitivity is low
• Document complication
• Exclude other diagnosis

33. Los Angeles classification for esophagitis

34. 24 H Ambulatory Intra-Esophageal
pH monitoring :

35. Wireless capsule pH monitoring:

36. Multi-channel impedance testing:

37. Others..
• Esophageal manometry has limited value
• Preoperative evaluation
• Other tests- ECG and ETT
• Screening for H. pylori

38. Complications
• Hemorrhage -7% to 18%
• Ulcers and Perforations
• Peptic Esophageal Stricture
• Barrett’s Esophagus
• Adenocarcinoma

39. Treatment
Goals are to-
• Resolve symptoms
• Heal esophagitis
• Prevent complications
• Maintain remission

40. Stepwise Management

41. Step-I: General anti reflux measures:
Lifestyle modifications:
Avoidance/ Restriction of-
-Alcohol, smoking
-Foods & bevarages
-Tight dressing, bending, straining
-Sleep within 2-3 hrs of meal
-Drugs

42. Lifestyle modifications:
• Elevation of head end of bed
• Weight reduction in obese

43. Medical measures
Mild to moderate GERD:
• H2RA for 8-12 weeks –if no response
PPI 40mg/day- 8- 12 wks
• Alginate/ Antacid
Severe GERD:
•H2RA in double doses for 8-12wks
PPI – 40 mg/day for 8-12wks

44. Maintenance therpay
PPI in optimum doses- sccessful in >85%
Recurrence within 6 months
• Severe esophagitis-80%
• Milder esophagitis- 15-30%
Maintenance at standard/half doses needed

45. • Mild to Moderate GERD: Step up
General measures + Antacids/ alginate
H2RA in standard doses for 8-12 weeks
PPI in standard doses for 8-12 weeks

46. • Step down therapy :
PPI in standard doses ( 40mg/day)
Maintenance in half doses
if possible

47. Step-III: Surgical treatment:
Indications:
• Failure/ poor response to Mx
• Peptic sricture- frequent dilatation (>3/yr)
• Younger pt with Barrett esophagus (BE)
• Pt with BE having dysplastic changes
• Respiratory complications
• Persistant volume reflux
• Patients desire

48. Treatment Algorithm

53. PPI Vs H2RA

56. Anti reflux surgery :
Fig : Nissen 360-degree Fundoplication B. An anterior wrap
C. Toupet partial fundoplication

57. Magnetic sphincter

58. Electric stimulation to LES

59. Barrett esophagus
• Columnar metaplasia of squamous epithelium at lower end of
esophagus
• More common in white male
• Pre-malignant condition

60. Criteria for Barrett esophagus
• Columnar epithelium lines 1 cm or greater of the distal esophagus.
• biopsy specimens shows columnar epithelium

62. It can be categorized
Long segment
Short segment
Prague C and M classification
Circumference
Maximum extent

63. • long-segment Barrett esophagus is found in 3% to 5%
• 10% to 20% have short-segment Barrett esophagus.

64. • The overall incidence of cancer development in patients with non-
dysplastic Barrett esophagus is approximately 0.25% per year.
• Low grade dysplasia to cancer-0 .4%/ year
• High grade dysplasia to cancer- 6%/year

65. Presentation
• Asymptomatic
• Symptom of underlying GERD

66. Management
• Treatment of GERD
• Maintenance therpay despite asymptomatic
• Endoscopic surveilance for dysplasia

67. Endoscopic eradication therapy
Endoscopic ablative therapy
 Laser, electocoagulation, radio-frequency ablation
cryotherapy
Photodynamic therapy
• EMR/ESD

68. Follow-up
• high-grade dysplasia or intramucosal carcinoma in Barrett esophagus,
endoscopic surveillance is performed every 3 months for the first
year, every 6 months in the second year, and annually thereafter.
• Low-grade dysplasia, endoscopic surveillance is performed every 6
months for the first year, and annually thereafter.

69. References
• Sleisenger and Fordtran's Gastrointestinal and Liver Disease
• CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy
• 2013 American College of Gastroenterology guidelines for diagnosis and
management: Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and
management of gastroesophageal reflux disease. Am J Gastroenterol.
2013;108:308–328; quiz 329. Doi: 10.1038/ ajg.2012.444. National Guideline
Clearinghouse NGC 009639.
• World Gastroenterology Organigation guideline
• Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group. The
Montreal definition and classification of gastroesophageal reflux disease: a
global evidence-based consensus. Am J Gastroenterol 2006;101:1900–20; quiz
1943.
• Moayyedi P, Talley NJ. Gastro-oesophageal reflux disease. Lancet
2006;367:2086–100.