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Gastroesophageal Reflux Disease GERD

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Gastroesophageal Reflux Disease (GERD) Any symptoms or esophageal mucosal damage ... Regurgitation: bitter, acidic fluid in the mouth when lying down or bending over ... – PowerPoint PPT presentation

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Title: Gastroesophageal Reflux Disease GERD


1
Gastroesophageal Reflux Disease (GERD)
  • Any symptoms or esophageal mucosal damage that
    results from reflux of gastric acid into the
    esophagus
  • Classic GERD symptoms
  • Heartburn (pyrosis) substernal burning
    discomfort
  • Regurgitation bitter, acidic fluid in the mouth
    when lying down or bending over

2
High Prevalence of Gastroesophageal Reflux
Symptoms
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4
Important Reasons to Diagnose and Treat GERD
  • Negative impact on health-related quality of
    life1
  • Risk factor for esophageal adenocarcinoma2
  • Revicki et al. Am J Med 1998104252.
  • Lagergren et al. N Engl J Med 1999340825.

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7
Clinical Presentations of GERD
  • Classic GERD
  • Extraesophageal/Atypical GERD
  • Complicated GERD

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9
Extraesophageal Manifestations of GERD
  • Pulmonary
  • Asthma
  • Aspiration pneumonia
  • Chronic bronchitis
  • Pulmonary fibrosis
  • Other
  • Chest pain
  • Dental erosion
  • ENT
  • Hoarseness
  • Laryngitis
  • Pharyngitis
  • Chronic cough
  • Globus sensation
  • Dysphonia
  • Sinusitis
  • Subglottic stenosis
  • Laryngeal cancer

10
Potential Oral and Laryngopharyngeal Signs
Associated with GERD
  • Edema and hyperemia of larynx
  • Vocal cord erythema, polyps, granulomas, ulcers
  • Hyperemia and lymphoid hyperplasia of posterior
    pharynx
  • Interarytenyoid changes
  • Dental erosion
  • Subglottic stenosis
  • Laryngeal cancer

Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin
Gastro Hep 20031333-344.
11
Pathophysiology of Extraesophageal GERD
12
Symptoms of Complicated GERD
  • Dysphagia
  • Difficulty swallowing food sticks or hangs up
  • Odynophagia
  • Retrosternal pain with swallowing
  • Bleeding

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14
When to Perform Diagnostic Tests
  • Uncertain diagnosis
  • Atypical symptoms
  • Symptoms associated with complications
  • Inadequate response to therapy
  • Recurrent symptoms
  • Prior to anti-reflux surgery

15
Diagnostic Tests for GERD
  • Barium swallow
  • Endoscopy
  • Ambulatory pH monitoring
  • Esophageal manometry

16
Barium Swallow
  • Useful first diagnostic test for patients with
    dysphagia
  • Stricture (location, length)
  • Mass (location, length)
  • Birds beak
  • Hiatal hernia (size, type)
  • Limitations
  • Detailed mucosal exam for erosive esophagitis,
    Barretts esophagus

17
Endoscopy
  • Indications for endoscopy
  • Alarm symptoms
  • Empiric therapy failure
  • Preoperative evaluation
  • Detection of Barretts esophagus

18
Ambulatory 24 hr. pH Monitoring
  • Physiologic study
  • Quantify reflux in proximal/distal esophagus
  • time pH
  • DeMeester score
  • Symptom correlation

19
Ambulatory 24 hr. pH Monitoring
Normal
GERD
20
Wireless, Catheter-Free Esophageal pH Monitoring
Potential Advantages
  • Improved patient comfort and acceptance
  • Continued normal work, activities and diet study
  • Longer reporting periods possible (48 hours)
  • Maintain constant probe position relative to SCJ

21
Esophageal Manometry
Limited role in GERD
  • Assess LES pressure, location and relaxation
  • Assist placement of 24 hr. pH catheter
  • Assess peristalsis
  • Prior to antireflux surgery

22
Treatment Goals for GERD
  • Eliminate symptoms
  • Heal esophagitis
  • Manage or prevent complications
  • Maintain remission

23
Lifestyle Modifications are Cornerstone of GERD
Therapy
  • Elevate head of bed 4-6 inches
  • Avoid eating within 2-3 hours of bedtime
  • Lose weight if overweight
  • Stop smoking
  • Modify diet
  • Eat more frequent but smaller meals
  • Avoid fatty/fried food, peppermint, chocolate,
    alcohol, carbonated beverages, coffee and tea
  • OTC medications prn

24
Acid Suppression Therapy for GERD
  • H2-Receptor Antagonists
  • (H2RAs)
  • Cimetidine (Tagamet)
  • Ranitidine (Zantac)
  • Famotidine (Pepcid)
  • Nizatidine (Axid)
  • Proton Pump Inhibitors
  • (PPIs)
  • Omeprazole (Prilosec)
  • Lansoprazole (Prevacid)
  • Rabeprazole (Aciphex)
  • Pantoprazole (Protonix)
  • Esomeprazole (Nexium )

25
Effectiveness of Medical Therapies for GERD
Treatment Response Lifestyle
modifications/antacids 20 H2-receptor
antagonists 50 Single-dose PPI 80
Increased-dose PPI up to 100
26
Treatment Modifications for Persistent
Symptoms
  • Improve compliance
  • Optimize pharmacokinetics
  • Adjust timing of medication to 15 30 minutes
    before meals (as opposed to bedtime)
  • Allows for high blood level to interact with
    parietal cell proton pump activated by the meal
  • Consider switching to a different PPI

27
GERD is a Chronic Relapsing Condition
  • Esophagitis relapses quickly after cessation of
    therapy
  • 50 relapse within 2 months
  • 80 relapse within 6 months
  • Effective maintenance therapy is imperative

28
Complications of GERD
  • Erosive/ulcerative esophagitis
  • Esophageal (peptic) stricture
  • Barretts esophagus
  • Adenocarcinoma

29
Erosive Esophagitis
30
Peptic Stricture
Barium Swallow
Endoscopy
31
Esophageal Stricture Dilating Devices
32
TTS Balloon Dilation of a Peptic Stricture
33
Barretts Esophagus
34
Esophageal Cancer
Barium Swallow
Endoscopy
35
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36
When to Discuss Anti-Reflux Surgery with Patients
  • Intractable GERD rare
  • Difficult to manage strictures
  • Severe bleeding from esophagitis
  • Non-healing ulcers
  • GERD requiring long-term PPI-BID in a healthy
    young patient
  • Persistent regurgitation/aspiration symptoms
  • Not Barretts esophagus alone

37
Endoscopic GERD Therapy
  • Endoscopic antireflux therapies
  • Radiofrequency energy delivered to the LES
  • Stretta procedure
  • Suture ligation of the cardia
  • Endoscopic plication
  • Submucosal implantation of inert material in the
    region of the lower esophageal sphincter
  • Enteryx
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