GERD is a common disease defined as symptoms or mucosal damage caused by abnormal reflux of gastric contents into the esophagus. It affects all ages and is caused by disruption of the LES and other anatomical barriers that normally prevent reflux. Common symptoms include heartburn, regurgitation, and water brash. Complications can include erosive esophagitis, strictures, and Barrett's esophagus. Treatment involves lifestyle modifications, antacids, H2 blockers, PPIs, and sometimes surgery. Proper diagnosis and management requires consideration of a patient's symptoms, risk factors, and response to therapy.

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