Gastroesophageal reflux disease GERD Raika Jamali M.D. Gastroenterologist and hepatologist Sina Hospital Tehran University of Medical Sciences

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Gastroesophageal reflux disease GERDRaika
Jamali M.D.Gastroenterologist and hepatologist
Sina Hospital Tehran University of Medical
Sciences
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Objectives

• Appreciate the significance of GERD as a chronic
  disease
• Identify patients with different presentations of
  GERD
• Organize a rationale management plan for
  different types of GERD symptoms
• Be familiar with various treatment modalities of
  GERD and their appropriate use

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DefinitionsGERD any
symptomatic condition or histopathologic
alteration resulting from episodes of
gastroesophageal reflux ?Erosive 35
?Nonerosive (NERD)
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Why GERD is so important?? ? is very common
increasingBurden and Quality of life?
complications esophagitis, peptic stricture,
inflammatory polyps ,Barrett's metaplasia ,
dysplasia ,adenocarcinoma
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Epidemiology ?Geographic variation
? MF ? Barrett's metaplasia (M/F 10 /1)
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• The prevalence of GERD in Asian populations is
  reported to be lower than that in the west.
• Population-based data on the prevalence and
  symptom profile of GERD in developing Caucasian
  countries is lacking.

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Frequency of Endoscopic GERD Iranian Experience
1994-1999
Retrospective study of 4500 UGIE reports (5y)
34.3 E-GERD
Malekzadeh,et al 2000
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Prospective evaluation of referring Dyspeptics in
Tehran

• 269 (135 F) participant
• Symptoms recorded, UGIE Bx from Z-line was
  done
• 77.6 at least one major GERD symptom
• 76.1 EE (most A B)
• 5 Specialized intestinal metaplasia
• 3 Dysplasia
• None of the symptoms could predict the endoscopic
  or histologic findings
• Nasseri-Moghaddam, Malekzadeh et al
  2002

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CONCLUSION

• GERD is a common disease among Iranian general
  population and its prevalence is comparable with
  that
• of the western countries .

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Pathogenesis ? Transient L E S
Relaxation ? Hypotensive L E S ? Anatomic
Variables ?Delayed Gastric Emptying ?
Esophageal Acid Clearance - Salivary
Function -Impairments of Esophageal
Emptying



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????????????? GERD


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Case 1

• A 34 y engineer with heart burn for 8 y comes to
  your office for evaluation of his GERD symptoms.
• He asks you about the diagnosis of GERD, if
  additional diagnostic work up is needed and his
  medical management.

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Diagnosis ? History is usually
sufficient to confirm the diagnosis
Indications for Endoscopy
Extra-esophageal or atypical symptoms Patients gt
40 y with new onset GERD symptoms
Dysphagia Weight Loss Anemia Family hx of
Cancer Long(gt5 y) or very severe symptoms
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GERD-B
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The Los Angeles Classification
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GERD-A
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GERD-C
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GERD-D
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• Avoid
• smoking
• stress
• Heavy meals
• Large quantities of liquid with meals
• Fatty foods
• Coffee
• Choclate
• Alcohol
• Mint
• Orange juice
• Tomato catch up
• Anticholinergic, calcium channel blockers, smooth
  muscle relaxants

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Therapeutic regimens for GERD in order of
increasing potency

• Over-the-counter antacids and/or H2 receptor
  blockers
• Omeprazole (20 mg QD) or equivalent dose of the
  other PPIs
• Omeprazole (20 mg BID or 40 mg BD) or equivalent
  doses of the other PPIs

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• Step-up approach with mild symptoms, no change
  in QOL
• Step-down approach with more severe symptoms
  affecting QOL or with higher grades of
  esophagitis / complications
• Bed time H2B for nocturnal symptoms

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Dose of the different H2 blockers

• Drug Daily dose
• Cimetidine 800 mg
• Ranitidine 300 mg
• Famotidine 40 mg
• Nizatidine 300 mg

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PPI versus H2 blockers in treatment of erosive
GERD symptoms (right panel) and esophageal
healing (left panel)
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PPI side effects

• Pneumonia
• Hypergastrinemia (Carcinoid tumor in animal
  model)
• Enteric infections
• Vitamin B12 malabsorption

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PROKINETIC DRUGS

• Metoclopramide
• Cisapride
• Tegaserod

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Duration of therapy

• Maintenance therapy
• lowest dose of PPI or H2 blockers, especially in
  severe esophagitis (grades C D) and with
  complications (BE, stricture)
• Intermittent therapy
• on-demand therapy in patients with mild to
  moderate heartburn without severe esophagitis.

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Effective initial and long term mangement

• Decreases amount of drugs used
• Decreases doctor visits
• Decreases the need for repeat UGIE
• (Bate et al 1992, Bloom et al 1994,
  Bardhan et al 1999)

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Case 2

• Young woman with chronic cough who is refractory
  to treatment with sulbutamol is referred for
  evaluation of GERD.
• She complains of morning hoarseness.
• Sulbutamol was in effective and even aggravated
  her symptoms.
• Laryngoscopy showed posterior vocal cord
  erythema.
• Endoscopy showed esophagitis.
• Symptoms respond to 20 mg of daily omeprazol.

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CLINICAL PRESENTATION
Typical Symptoms ? Heartburn ?
Regurgitation ? Dysphagia
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Case 3

• Middle age man is visited for evaluation of
  dysphagia to solids from 2 months duration.
• He was a heavy smoker and used famotidine for
  heart burn for 14 y.
• Ba swallow was performed.
• Endoscopy and biopsy was done.

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Proximal esophageal stricture
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Peptic stricture
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Hyperplasia of basal cells and infiltration of
PMN with erosions in GERD.
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Natural
History ? Peptic stricture ( 8 to 20 ) ?
Ulceration ( 5 ) ? Significant bleeding ( 2
) ? Perforation extremely rare
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Esophageal ulcer in reflux esophagitis
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Case 4

• A 45 y old man with 25 y reflux symptoms comes to
  your office for evaluation of recent weight loss
  and dysphagia.
• There was a histologic report of Intestinal
  metaplasia in distal esophagus in his last
  endoscopy 2 y ago.
• Ba swallow and endoscopy was performed.

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Adenocarcinoma
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Barretts Esophagus
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Barretts Esophagus
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Long Segment Barretts
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Endoscopic mucosal resection
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Case 5

• A 38 y old woman comes to the clinic for her
  severe chronic reflux symptoms and consults about
  antireflux surgery.
• She is on long term Omeprazole 40 mg twice a day
  and ranitidine before bed time.
• Serum Gastrin level is in upper normal limits.
• Endoscopy was normal (NERD).

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Refractory gastroesophageal reflux disease

• Failure to control symptoms with full dose of PPI
  life style modification raises the possibility
  that symptoms are due to another disease or
  refractory GERD.

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• Reduced bioavailability
• Effect of food
• Dosing interval
• Gastric acid hypersecretion
• Drug resistance
• Slow healing
• Esophageal hypersensitivity (viseral
  hyperalgesia)
• Eosinophilic esophagitis
• Pill induced esophagitits

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TREATMENT

• First confirm the diagnosis then,
• Increase the frequency of dosing
• Increasing the dose (Omeprazole to 80 mg/day)
• Add a second drug
• Switch to another drug
• Check for Gastrinoma
• Surgery

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Preoperative evaluation for gastroesophageal
reflux disease

• Detailed clinical history and physical
  examination
• Endoscopy to assess degree of esophagitis
• Esophageal manometry to define LES pressure and
  disorders of peristalsis
• Upper gastrointestinal series to assess
  esophageal length and hiatal hernia
  
• 24 hour esophageal pH monitoring

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Indications for esophageal pH recording

• to document abnormal esophageal acid exposure in
  an endoscopy-negative patient being considered
  for surgical antireflux repair
• to evaluate patients after antireflux surgery who
  are suspected to have ongoing abnormal reflux

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• to evaluate patients with normal endoscopic
  findings and reflux symptoms that are refractory
  to proton pump inhibitor therapy
• to detect refractory reflux in patients with
  extraesophageal or atypical symptoms using
  symptom association probability calculation

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INDICATIONS FOR OPERATION AND PREOPERATIVE
EVALUATION

• Persistent or recurrent symptoms with appropriate
  response to medical THX.
• Severe esophagitis by endoscopy
• Benign stricture
• Recurrent pulmonary symptoms

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Predictors of successful surgery

• Response to medical therapy
• Typical reflux symptoms
• Erosive GERD
• Abnormal pH study

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Predictors of unsuccessful surgery

• Lack of response to medical therapy
• (medical failure?)
• It could be something other than GERD
• Non-erosive GERD (NERD)

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Helicobacter pylori and GERD

• Eradication of H. pylori is associated with mild
  worsening of GERD in patients with
  corpus-predominant gastritis and improvement in
  those with antral-predominant gastritis.
• The standard of care is to eradicate H. pylori in
  the context of peptic ulcer disease.