GERD, presentation on gastro esophageal reflux disease

1. Gastroesophageal Reflux Disease
(GERD)

2. Introduction
When reflux of gastric contents in the food pipe causes troublesome symptoms or
complications the condition is termed as Gastroesophageal reflux disease (GERD)
Montreal definition of GERD
Am J Gastroenterol. 2006, 101:1900-20
Reflux of gastric contents into the esophagus or
oropharynx and produce symptoms

3. Prevalence
North America: 18.1%-27.8%
Europe: 8.8%-25.9%
East Asia: 2.5%-7.8%
India: 7.6% to 30%
Internat J Basic Clin Pharmacol 2016; 6:194-202; J
Neurogastroenterol Motil. 2018 Oct; 24(4): 559–569
J Assoc Physicians India. 2019;67:88.

4. mage to the esophagus lining caused by reflux (coming
back) of acid from stomach
GERD Symptoms
• Heartburn: Substernal burning discomfort
• Regurgitation: Bitter, acidic fluid in the mouth
• Dysphagia: Difficulty swallowing
• Odynophagia: Pain with swallowing
• Bleeding: In severe cases
Am J Gastroenterol 2006;101:1900–20

5. No mucosal damage
(endoscopy-negative reflux disease or NERD)
Patients who do not respond (functional heartburn-Rome III )
GERD Classification
Gut. 1999 Apr; 44(Suppl 2): S1–S16. Am J Gastroenterol. 2001 Feb;96(2):303-14.
On the basis of endoscopy findings
Esophageal mucosal damage
(erosive esophagitis and Barrett’s esophagus)
Type 1: Patients who demonstrate an abnormal acid exposure time
Type 2: Patients with a normal acid exposure time, but with symptoms & reflux events that are significantly correlated,
Type 3: Patients with typical reflux symptoms, but normal pH studies, & no correlation between symptoms & acid exposure
Patients responding to proton pump inhibitor therapy

6. Clinical Manifestations of GERD
Aliment Pharmacol Ther 2005; 22: 79–94

7. Pathogenesis
Aliment Pharmacol Ther. 2004; 20 (Suppl 9): 14

8. Pathogenesis
• LES in a resting stats remains at high pressure (10-30mmHg) to prevent the gastric contents from entering
into the esophagus
• Pressures are lowest during the day & with meals & highest at night
• Transient relaxations of the LES are short periods of sphincter relaxation that are different from those that
occur with swallowing or peristalsis
• Occur due to vagal stimulation in response to gastric distension from meals, gas, stress, vomiting or
coughing
• Can persist > 10 seconds
• These account for 50-89% of occurrences in patients with pathogenic GERD
Transient Relaxations of the Lower Esophageal Sphincter

9. Practical Gastroenterology; 2004; 5, 44-55
Anatomical Defect: Hiatus Hernia
Pathogenesis
• Upper part of the stomach moves up into the chest through a small opening called hiatus, which disrupts
the normal anatomy and physiology of the lower esophageal sphincter

10. • Functional defect: Frequent transient lower esophageal sphincter relaxation
• Mechanical defect due to hypotensive lower esophageal sphincter :Lower esophageal sphincter pressure
(<10 mmHg)
• Inherent abnormality of the lower esophageal sphincter tone
• Foods e.g: Tea, coffee, alcohol, spicy food, fatty food
• Medications: Anticholinergics, Barbiturates, Ca++ Channel blockers NSAID’s Nicotine
• Patient factors e.g: Age, lifestyle and disease states
Physiological Defect
Pathogenesis

11. Factors That May Worsen GERD Symptoms

12. GERD Complications
World J Gastrointest Endosc 2010; 16; 2(12): 388-39
• Erosive esophagitis: Due to prolonged exposure to gastric acids
• Esophageal hemorrhage: Bleeding in the gastrointestinal tract through esophageal
membrane, in severe cases of GERD
• Esophageal stricture: Severe scarring of the esophagus causes narrowing of the esophagus
• Barrett’s esophagus: In 10-15 % patients leads to a premalignant condition called Barrett’s
esophagus

13. Extraesophageal Manifestations of GERD

14. http://www.ascentxmedical.com/technology-platform/G125-for-GERD/ Last accessed on 26/05/2016

16. When to Perform Diagnostic Tests?
• Uncertain diagnosis
• Atypical symptoms
• Symptoms associated with complications
• Inadequate response to therapy
• Recurrent symptoms
• Prior to anti-reflux surgery

17. • Empiric PPI therapy (a PPI trial) is a reasonable approach to confirm GERD when it is
suspected in patients with typical symptoms.
• A response to therapy would ideally confirm the diagnosis
• Limitation: Negative trial does not rule out GERD
• Test is valid only if the patient is suffering from erosive reflux disease
Diagnostic Tests: Empirical Therapy

18. • Gold standard test for GERD
• Passage of small tube through nose till LES
• pH sensor at the tip of the tube
• Measure exposure of gastric acids into lower part
of esophagus
• Test performed for 24 hours after which tube is
removed
• Composite pH Score or DeMeester Score is
calculated. Score > 14.72 indicates reflux
Diagnostic Tests: Ambulatory pH Monitoring

19. • During endoscopy, a thin, flexible tube equipped
with a light and camera (endoscope) is inserted
down the throat
• Useful in looking for complications of reflux, such
as Barrett's esophagus
• Endoscopy appears normal in 40-60 % of the
GERD patients and recommended only when
patient showing clinically alarming symptoms
Diagnostic Tests: Endoscopy

20. Diagnostic Tests: Barium Swallow & Esophageal Manometry

21. Management of
GERD
Lifestyle
modification
Pharmacotherapeutic Surgical management
Management of GERD

22. Treatment Goals for GERD
• Relief of symptoms
• Prevention of symptom relapse
• Healing of erosive esophagitis
• Prevention of complications of esophagitis
Am Fam Physician. 2003; 68(7):1311-8
Management of GERD

23. 1. Acid suppression therapy
• GERD is not due to excessive acid produced, it is due to the damage caused due to the existing acid
• Hence acid suppression therapy, helps prevent further damage due to acid reflux
• It helps heal damaged acid attacked esophageal mucosa
• The ability to maintain gastric pH above 4 throughout most of the 24 hr period causes healing of the
mucosa
2. Modification of the lower esophageal sphincter (LES) tone
• Aid in reducing relaxation or aid in contraction of the lower esophageal sphincter
Pharmaco-therapeutic Approaches

24. Pharmacotherapeutic Approaches
Antacids
• Over the counter acid suppressants and antacids- Appropriate for initial therapy
• Antacids work within 5-15 min. Duration of relief-1-3 hrs.
• Sodium bicarbonate, Calcium carbonate, Aluminium Hydroxide, Magnesium Hydroxide

25. Pharmacotherapeutic Approaches
Aim:
A Comparison of the Efficacy of the Alginate Preparation with Placebo in the Treatment of GERD
Method:
• Double-blind, randomised, multicentre, parallel-group study
• Doses of the alginate preparation (10 ml containing 1 g sodium alginate, 0.2 g calcium carbonate and 0.2 g potassium
bicarbonate; Gaviscon Advance) or placebo (10 ml fruit cordial)were taken four times daily (30-60 min after each main meal
and at bedtime)
• Duration: 4 weeks
• N=100
Curr Med Res Opin. 1999;15(3):152-9.
Antacids

26. H2-Receptor Antagonists
(H2RAs)
1. Cimetidine
2. Ranitidine
3. Famotidine
4. Nizatidine
Proton Pump Inhibitors
(PPIs)
1. Omeprazole
2. Lansoprazole
3. Rabeprazole
4. Pantoprazole
5. Esomeprazole
Pharmaco-therapeutic Approaches

27. • Used for symptomatic relief
• Control both basal and food-stimulated acid secretion
• Long lasting level of acid suppression
• Rapid relief and damage reverses in 4-8 weeks of
treatment
• Treated for all complications of GERD
• Relapse of symptoms after discontinuation and
ineffectiveness in nocturnal acid reflux
• Relatively short duration of action
• Produce incomplete inhibition of postprandial
gastric acid secretion
• Inhibit acid secretion by up to 70% over a 24-h
period
• Development of tolerance to standard H2RAs
within 2 weeks of repeated administration
• Usually not used for monotherapy
• Healing occurs only in 50-70 % of the patients
Acid Suppression Therapy
Proton pump inhibitors Histamine receptor antagonists
Pharmaco-therapeutic Approaches

28. Food /Smell of food
Stimulates the vagus
nerve in the brain
Food
Proton pump
inhibitors
Pharmaco-therapeutic Approaches
Proton Pump Inhibitors

29. Pharmaco-therapeutic Approaches
Proton Pump Inhibitors: Omeprazole
Aim:
• To study the Effects of Omeprazole Versus Placebo in Treatment of Non-cardiac Chest Pain and Gastroesophageal Reflux
Methods:
• Double -blind, randomize d trial of patients with NCCP and GER
• 36 consecutive patients with NCCP and GER documented by 24-hr ambulatory pH testing entered this study
• Omeprazole , 20 mg by mouth twice a day (17 patients), or placebo (19 patients) for eight weeks
• Diagnosis of GERÐ: 24-Hr Ambulatory pH Studies
• Esophageal Motility: Manometry
• Chest Pain Assessment: 0 =none, to 10=worst possible
Dig Dis Sci (1997) 42: 2138.

30. Aliment Pharmacol Ther 1996; 10: 757-763
Pharmaco-therapeutic Approaches
Proton Pump Inhibitors: Lansoprazole
Aim:
To Assess the efficacy of lansoprazole vs. omeprazole in healing esophagitis
Study Design:
• Double blind, randomized, multicentre, comparative study
• 565 patients with esophagitis were randomized to receive lansoprazole or omeprazole for 4-8 weeks
• Lansoprazole group: n= 282
• Omeprazole group: n= 283

31. Pharmaco-therapeutic Approaches
Proton Pump Inhibitors: Lansoprazole
Aliment Pharmacol Ther 1996; 10: 757-763
Lansoprazole is better at healing esophagitis than omeprazole

32. Lifestyle Modifications
• Elevating the head of the bed
• Reducing fat intake
• Quitting smoking and alcohol
• Remaining upright for three hours after meals.
• Foods such as chocolate, alcohol, peppermint, coffee, onions, and garlic are reported to decrease
lower esophageal sphincter pressure
Am Fam Physician 2005; 71: 2376-2382

33. Treatment of Non Erosive Reflux Disease

34. Endoluminalplication
Laparoscopic Nissen fundoplication
Radiofrequency energy delivery Lynx implanation device
Surgical
Procedures

35. • Medications: PPIs are safe and effective in most patients
• Need to be taken long term, treat only the symptoms and not the cause and long term use might have adverse effects
• Long term use may develop tolerance and reduce patient compliance
• Surgery: Alternative for patients who fail medical therapy, suffer primarily from regurgitation, do not want to take
medications, or have large hiatal hernias
• Some patients prefer one time surgery than long term treatment
• Also, PPIs are only effective against refluxing acid, not effective against refluxing bile which has a potential to cause
equal damage
Conclusion
Treatment for GERD is highly individualized, with a large number of factors dictating the choice and course of
treatment

36. Use in specific populations