Its an overview about Gastro-Esophageal Reflux Disease, mainly focused on Clinical features, Role of Investigation, Diagnostic Criteria, Management plan. It was mainly prepared for a scientific seminer. It may help others as well.

1. Dr Md Mamunul Abedin Shimul
MBBS, BCS(Health)
Medical Officer (Dept of Medicine)
250 bedded General Hospital, Jamalpur
Scientific Partner:
Organized by:
BMA, Jamalpur

4. Dr Md Mamunul Abedin Shimul
MBBS, BCS(Health)
Medical Officer (Dept of Medicine)
250 bedded General Hospital, Jamalpur
Scientific Partner:
Organized by:
BMA, Jamalpur

5. WHAT IS GASTRO-ESOPHAGEAL REFLUX DISEASES
(GERD) ? (American College of Gastroenterology)
Symptoms OR Mucosal Damage
produced by the abnormal reflux
of gastro-duodenal contents
into the esophagus.

6. A 32 yr old man with a body mass index of 32 kg/m2 consults his family
physician with a long history of heartburn & frequent use of over-the-counter
antacids. The family physician prescribes a 1-month course of omeprazole,
which cures his symptoms but they soon return after stopping the
Omeprazole. The family physician refers him for an upper GIT endoscopy,
which shows evidence of a small hiatus hernia and Barrett’s esophagus.
Which statement is true?
QUIZ
 A. Acid is the only refluxate that causes injury to the lower esophagus
 B. GERD can be reliably diagnosed by symptoms
 C. Most patients who develop esophagitis, Barrett’s Esophagus or
Peptic Strictures have a Hiatus Hernia
 D. Patients are invariably obese
 E. The incidence of GERD is decreasing in most populations

7. PHYSIOLOGY
 LES is tonically contracted under normal
circumstances
 Esophageal Peristaltic Waves - efficiently
clear the gullet
 Alkaline Saliva – neutralizes residual acid

8. PATHOPHYSIOLOGY
 Reduced LES tone
 Diet – Relax LES
 Defective Esophageal
Peristaltic Waves
 Defective Gastric Emptying
 Gastric Contents
 ↑ed Abdominal Pressure
 Hiatus Hernia

9. PATHOPHYSIOLOGY
Gastro-esophageal reflux disease develops when the
esophageal mucosa is exposed to gastro-duodenal
contents for prolonged periods of time – causes
symptoms & some cases causing Esophagitis.
Almost all patients who develop esophagitis, Barrett’s
esophagus or peptic strictures have a hiatus hernia.
Pepsin & Bile also contribute to mucosal injury.
Dietary fat, Chocolate, Alcohol, Tea, Coffee relax LES

10. Most Common: (50%)
 Heartburn (A burning feeling in
the chest)
 Regurgitation
Often occurs after Meals
Provoked by – Bending, Straining, Heavy Lifting, Lying Down

11. Other symptoms:
 Waterbrash
 Atypical Chest Pain
 Odynophagia, Dysphagia
 Choking at night
 Hoarseness (Acid Laryngitis)
 Chronic Cough, Asthma
 Recurrent Chest Infections
 Belching
 Halitosis

12. INVESTIGATIONS
Who Does Not Need This ??

13. INVESTIGATIONS
Young Patients
Who present with Typical Symptoms of GERD
Without Worrying Features
Without Any Complications

14. WORRYING FEATURES
• Dysphagia
• Unexplained Weight loss
• Iron Deficiency Anemia

15. COMPLICATIONs
• Oesophagitis
• Barrett’s Oesophagus
• Iron Deficiency Anemia
• Benign Oesophageal Stricture
• Gastric volvulus
• Recurrent Pneumonia – in old age

16. INVESTIGATIONS
Options:
1. Endoscopy of Upper GIT (Inv of Choice)
2. Twenty-four-hour pH monitoring
3. Esophageal Impedance Testing

17. INVESTIGATIONS
Endoscopy of Upper GIT
-to exclude other GIT diseases
-to identify complications
A normal endoscopy in a patient with
compatible symptoms should not prevent
giving Rx of GERD

18. INVESTIGATIONS
Twenty-four-hour pH monitoring
-if the diagnosis is Unclear
-Surgical intervention is under
consideration
This involves tethering a slim catheter with a
terminal radiotelemetry pH-sensitive probe
above the gastro-oesophageal junction.
A pH of less than 4 for more than 6-7% of the

19. INVESTIGATIONS
Esophageal Impedance Testing
-measures liquid movement from the
stomach into the esophagus.
-can detect weakly Acidic/ Alkaline reflux
that is not revealed by standard pH testing.

20. Physiologic GERD Pathologic GERD
 Postprandial
 Short lived
 Asymptomatic
 No nocturnal Symptoms
 Symptoms
 Mucosal injury
 Nocturnal Symptoms.
Physiologic vs Pathologic

21. Lifestyle
Modification
SurgeryPPI/
H2RA

22. Lifestyle Modifications:
• Reduction of weight
• Change food habit
-avoid eating or drinking chocolate, coffee, peppermint, greasy
or spicy foods, tomato products, and alcohol.
-eat small, frequent meals;
• Stop Smoking
• Elevation of the bed head
-Using extra pillows will not help GERD.
• Avoidance of Late meals
• Avoid bending or stooping positions

23. MEDICAL THERAPY:
• Symptomatic Relief by -
• ANTACIDS & ALGINATES
• DOMPERIDONE
• H2-receptor Antagonist – does not heal Oesophagitis
• Long-Term PPI therapy

24. Long Term PPI therapy is associated with-
-Reduced absorption of Iron, Vit B12, Magnesium
-A small but increased risk of Osteoporosis &
Fractures
-Predispose to Enteric infections with Salmonella,
Campylobacter & Clostridium difficile
-Increased risk of Helicobacter associated Gastric
Mucosal Atrophy

25. SURGERY:
• Failed to respond to Medical Therapy
• Patient unwilling to take long term PPI

27. RABEPRAZOLE
ESOMEPRAZOL
E
OMEPRAZOLE
PANTOPRAZOLE
LANSOPRAZOL
E
DEX-
LANSOPRAZOL
E

28. Which One is the
Best??

30. A 32 yr old man with a body mass index of 32 kg/m2 consults his family
physician with a long history of heartburn & frequent use of over-the-counter
antacids. The family physician prescribes a 1-month course of omeprazole,
which cures his symptoms but they soon return after stopping the
Omeprazole. The family physician refers him for an upper GIT endoscopy,
which shows evidence of a small hiatus hernia and Barrett’s esophagus.
Which statement is true?
QUIZ
 A. Acid is the only refluxate that causes injury to the lower esophagus
 B. GERD can be reliably diagnosed by symptoms
 C. Most patients who develop esophagitis, Barrett’s Esophagus or
Peptic Strictures have a Hiatus Hernia
 D. Patients are invariably obese
 E. The incidence of GERD is decreasing in most populations

31. THANKS
FOR
YOUR PATIENCE HEARING