gastro - esophageal reflux desease ( gerd )

GERD

E-mail: FOWZI_7@HOTMAIL.COM

Dr Aiydarus Ali Ahmed ( Fowzi )MBBS, MD

Gastro-Esophageal,Reflux

Disease (GERDl

Definition

• Reflux of gastric contents into the

esophagus which allows prolonged contact

of these contents with the lower esophageal

mucosa. It is the most common disorder of

the esophagus.

• Alternate names: reflux, acid reflux, reflux

esophagitis, acid regurgitation, and

heartburn

Etiology and pathogenesis

1. The resting lower esophageal sphincter

(LOS) is low and fails to increase when

lying flat.

2. Decrease esophageal clearance of acid due

to poor esophageal peristalsis.

3. Delayed gastric emptying.

4. Hiatus hernia may impair the pinchcock

mechanism of the diaphragm.

5. The lower esophageal sphincter tone fails to

increase when intra abdominal pressure is

increased by tight clothes or pregnancy.

Incidence and Background

• It is one of the most common conditions affecting the gastrointestinal system.

• Anywhere from 36-77% of people have symptoms of GERD (heartburn, regurgitation of acid etc.) spread equally between men and women.

• 7% have daily heartburn

• 14-20% have weekly heartburn

• 15-50% have monthly heartburn

• Even children – especially neurodevelopmental disorders – 90%

Pathophysiology of GERD

• A complex interaction of many

problems can cause reflux:

• Esophageal Dysmotility – weak or

uncoordinated esophageal

contractions (movement)

• Inadequate saliva production – seen

in smokers, in certain diseases and

normally seen during sleep.

• Saliva normally “buffers” any acid

which is found in the esophagus.

Pathophysiology, cont’d

• Impaired resistance of esophageal lining.

• LES dysfunction – poorly functioning sphincter muscle allowing acid to wash up into the esophagus

• Delayed emptying of the stomach – poor motor function of the stomach (not draining into the intestine) allowing acid to “pool” in the stomach.

• Hiatal hernia – allows acid to wash up into the esophagus due to pressure differences between the abdomen and chest.

• Loose hiatus muscle fibers causes reflux even without a hiatal hernia.

Factors associated with increase

reflux

• - Obesity

• - Fat, peppermint

• - Coffee (Caffeine)

• - Anticholinergics

• - Nitrates

• - Pregnancy

• - Chocolate

• - Smoking

• - Ca Ch blockers

• - Hiatus hernia

•Heartburn – burning or tightness behind the sternum or in the

epigastric area.

•Acid regurgitation – sour or bitter taste in the throat or mouth.

•Water brash – a hot sensation in the stomach followed by a large

amount of watery liquid in the mouth.

•Dysphagia - difficulty swallowing or painful swallowing

(odynophagia). The sensation of a lump in the throat or food getting

“stuck” after swallowing.

•Asthma, laryngitis and chronic cough are unusual symptoms, but

can be caused by GERD.

Symptoms

Symptoms

• Symptoms typically occur after eating a

meal and…

• can be especially noticeable with a large meal

or spicy foods.

• Symptoms may be relieved by antacids.

• Symptoms often are worse when lying flat,

straining or sleeping.

Symptoms made worse…

• Fatty foods, chocolate, coffee, peppermint as

well as alcohol and use of tobacco products

can cause or worsen symptoms.

• Theophylline, Albuterol, and Calcium channel

blockers can also cause symptoms of GERD.

Investigations

• GERD is a clinical diagnosis & many

patients can be treated without

investigations:-

1. Endoscopy. to confirm the presence of

esophagitis.

2. 24 hour intraluminal pH monitoring of the

esophagus.

3. Esophageal manometry.

4. Barium study: It may show a hiatus hernia.

Barium swallow

Upper endoscopy

24-hr pH Monitoring

Esophageal Manometry

Complications of GERD

• Reflux esophagitis

• Injury and inflammation of the inner lining of the esophagus from prolonged exposure to acid and digestive enzymes.

• This produces pain as well as sometimes painful swallowing (odynophagia) or a “sticking” sensation (dysphagia)

Complications of GERD

• Reflux esophagitis can progress to complications:

• Long-standing inflammation and scarring can progress

to Barrett’s esophagus which is a premalignant

condition.

• Severe scarring and narrowing of the esophagus can

occur called strictures. These can cause food to become

“stuck” or can cause pain when swallowing.

• Advanced cases can lead to outpouchings of the walls

of the esophagus called a diverticula.

Complications of GERD

• Barrett’s Esophagus

• This is the replacement of the

cells lining the esophagus

with cells more typical of the

stomach or intestines

(metaplasia) due to the long-

term damage caused by

GERD and acid.

• Occurs in approx 10% of

patients with GERD.

Barrett’s Esophagus

• Barrett’s esophagus• Represents one of the

more serious complications of GERD. It is a precancerous condition associated with cancer of the esophagus. It is thought to be caused by ongoing injury, inflammation and damage to the lining of the esophagus.

• Anemia

• Iron deficiency anemia occurs as a

consequence of chronic insidious blood loss

from long standing esophagitis

Treament

•Treatment of GERD is primarily medical,

the mainstays being lifestyle modifications

(see Table below) and drug therapy

Treatment, Cont…

• The goals of treatment are to provide

symptom relief, heal erosive esophagitis,

and prevent complications.

Treatment, Cont…

I. Simple life style measures

50% of patients can be treated by:o Cessation'et smoking, loss of weight and simple

antacids.

o Avoid alcohol, fatty meals & drugs e.g. nitrates.

o Avoid heavy meals especially before sleep.

o Raising the head of the bed at night.

o Avoid any other precipitating factor.

Treatment, Cont…

II. Pharmacological Therapy

I. Drugs reduce gastric acidity: (Prolonged therapy is

usually needed)

• Antacids: Mg trisilicate and aluminium hydroxide, also

alginate containing antacids forming a gel with gastric

contents reducing reflux.

• H2blockers: Ranitidine (Zantac(ID)(300mg at bed

time)

• Proton pump inhibitors: Omeprazole (20-40mg/day),

Lanzoprazole (30mg/day) or pantoprazole (20-

40mg/day). They inhibit the gastric hydrogen-

potassium ATPase .

Treatment , Cont…

• Drugs increase esophageal peristalsis

and LOS pressure (Prokinetic)

• - Cisapride (Prepulsid): not available now!?

It leads to arrythmia.

• - Metoclopramide or Domperidone.

والسالم عليكم و رحمة هللا