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

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


1
Gastroesophageal reflux disease GERD Raika
Jamali M.D. Gastroenterologist and hepatologist
Sina Hospital Tehran University of Medical
Sciences
2
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

3
Definitions GERD any
symptomatic condition or histopathologic
alteration resulting from episodes of
gastroesophageal reflux ?Erosive 35
?Nonerosive (NERD)
4
Why GERD is so important?? ? is very common
increasing Burden and Quality of life ?
complications esophagitis, peptic stricture,
inflammatory polyps ,Barrett's metaplasia ,
dysplasia ,adenocarcinoma
5
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.

8
Frequency of Endoscopic GERD Iranian Experience
1994-1999
Retrospective study of 4500 UGIE reports (5y)
34.3 E-GERD
Malekzadeh,et al 2000
9
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

10
CONCLUSION
  • GERD is a common disease among Iranian general
    population and its prevalence is comparable with
    that
  • of the western countries .

11
Pathogenesis ? Transient L E S
Relaxation ? Hypotensive L E S ? Anatomic
Variables ?Delayed Gastric Emptying ?
Esophageal Acid Clearance - Salivary
Function -Impairments of Esophageal
Emptying



12
????????????? GERD


13
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.

14
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
15
GERD-B
16
The Los Angeles Classification
17
GERD-A
18
GERD-C
19
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

25
  • 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

26
Dose of the different H2 blockers
  • Drug Daily dose
  • Cimetidine 800 mg
  • Ranitidine 300 mg
  • Famotidine 40 mg
  • Nizatidine 300 mg

27
PPI versus H2 blockers in treatment of erosive
GERD symptoms (right panel) and esophageal
healing (left panel)
28
PPI side effects
  • Pneumonia
  • Hypergastrinemia (Carcinoid tumor in animal
    model)
  • Enteric infections
  • Vitamin B12 malabsorption

29
PROKINETIC DRUGS
  • Metoclopramide
  • Cisapride
  • Tegaserod

30
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)

33
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.

34
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.

39
Proximal esophageal stricture
40
Peptic stricture
41
Hyperplasia of basal cells and infiltration of
PMN with erosions in GERD.
42
Natural
History ? Peptic stricture ( 8 to 20 ) ?
Ulceration ( 5 ) ? Significant bleeding ( 2
) ? Perforation extremely rare
43
Esophageal ulcer in reflux esophagitis
44
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
47
Barretts Esophagus
48
Barretts Esophagus
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54
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).

62
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.

63
  • Reduced bioavailability
  • Effect of food
  • Dosing interval
  • Gastric acid hypersecretion
  • Drug resistance
  • Slow healing
  • Esophageal hypersensitivity (viseral
    hyperalgesia)
  • Eosinophilic esophagitis
  • Pill induced esophagitits

64
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

65
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

66
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

67
  • 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

68
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

69
Predictors of successful surgery
  • Response to medical therapy
  • Typical reflux symptoms
  • Erosive GERD
  • Abnormal pH study

70
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.
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