gastro - esophageal reflux desease ( gerd )
TRANSCRIPT
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.
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