Gastroesophageal Reflux

Disease
(GERD)

Dr. Agus Mulyadi Sp.BKBD

RSU BANYUMAS
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hat Is Gastroesophageal Reflu

Gastroesophageal refers to the
stomach and esophagus.
Reflux means to flow back or
return.
Therefore, gastroesophageal
reflux is the return of the
stomach's contents back up into
the esophagus
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The Digestive System

In normal digestion, the LES opens to

allow food to pass into the stomach
and closes to prevent food and acidic
stomach juices from flowing back
into the esophagus.
Gastroesophageal reflux occurs
when the LES is weak or relaxes
inappropriately, allowing the
stomach's contents to flow up into
the esophagus.

Acid reflux involves inflammation

and irritation of the lower
oesophagus due to the reflux of
food and gastric acid. This reflux
of gastric contents is spontaneous
and
involuntary.
Below
is an endoscopic image
showing ulceration of the lower
end of the oesophagus caused
by the
refluxed gastric acid.

5 GO
Inflamed oesophagus due to

Epidemiology
About 44% of the adult population
have heartburn at least once a
month
14% of adults have symptomps
weekly
7% have symptoms daily

Pathophysiology
Primary barrier to
gastroesophageal
reflux is the lower
esophageal sphincter
LES normally works
in conjunction with
the diaphragm
If barrier disrupted,
acid goes from
stomach to
esophagus
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Gastroesophageal Reflux Disease

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Gastroesophageal Reflux Disease

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Gastroesophageal Reflux Disease

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hat Are the Symptoms of Heartbu

Heartburn, also called acid
indigestion, is the most common
symptom of GERD and usually feels
like a burning chest pain beginning
behind the breastbone and moving
upward to the neck and throat.
Many people say it feels like food is
coming back into the mouth leaving
an acid or bitter taste.
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Heartburn is Classic Symptom of

GERD
Substernal
burning and/or
regurgitation
Postprandial
Aggravated by
change in
position
Prompt relief by
antacids
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Heartburn is Classic Symptom of

GERD

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 The burning, pressure, or pain of

heartburn can last as long as 2
hours and is often worse after
eating.
Lying down or bending over can
also result in heartburn.
Many people obtain relief by
standing upright or by taking an
antacid that clears acid out of
the esophagus.
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 Heartburn pain can be mistaken

for the pain associated with heart
disease or a heart attack, but
there are differences.
Exercise may aggravate pain
resulting from heart disease, and
rest may relieve the pain.
Heartburn pain is less likely to be
associated with physical activity.
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How Common Is Heartburn

and GERD?
More than 60 million American
adults experience heartburn at least
once a month, and about 25 million
adults suffer daily from heartburn.
Twenty-five percent of pregnant
women experience daily heartburn.
Recent studies show that GERD in
infants and children is more common
than previously recognized and may
produce recurrent vomiting,
coughing, and other respiratory
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Predisposing Factors

Obesity
Cigarette smoking
High caffeine intake (e.g. coffee, tea or chocolate);
Excess alcohol ingestion;
Eating large meals (especially late at night) or
meals high in fat;
Pregnancy;
Hiatus hernia;
Family history: There is some genetic
predisposition to reflux, and
Some drugs (particularly those used to treat high
blood pressure and angina)
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What Is the Treatment for GERD?

Doctors recommend lifestyle and
dietary changes for most people
needing treatment for GERD.
Treatment aims at decreasing the
amount of reflux or reducing
damage to the lining of the
esophagus from refluxed materials.

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Treatment
Goals of therapy
Symptomatic relief
Heal esophagitis
Avoid complications

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 Avoiding foods and beverages that

can weaken the LES is
recommended.
These foods include chocolate,
peppermint, fatty foods, coffee,
and alcoholic beverages.
Foods and beverages that can
irritate a damaged esophageal
lining, such as citrus fruits and
juices, tomato products, and
pepper, should also be avoided.
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 Decreasing the size of portions at

mealtime may also help control
symptoms.
Eating meals at least 2 to 3 hours
before bedtime may lessen reflux
by allowing the acid in the
stomach to decrease and the
stomach to empty partially.
Being overweight often worsens
symptoms. Many overweight
people find relief when they lose
weight.

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 Cigarette smoking weakens the

LES. Stopping smoking is
important to reduce GERD
symptoms.
Elevating the head of the bed
on 6-inch blocks or sleeping
on a specially designed
wedge reduces heartburn by
allowing gravity to minimize
reflux of stomach contents
into the esophagus.
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 Antacids taken can help neutralize

acid in the esophagus and
stomach and stop heartburn. An
antacid combined with a foaming
agent helps some people.
These compounds are believed to
form a foam barrier on top of the
stomach that prevents acid reflux
from occurring.

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Long-term use of antacids, however,

can result in side effects, including
diarrhea, altered calcium
metabolism (a change in the way
the body breaks down and uses
calcium), and buildup of magnesium
in the body. Too much magnesium
can be serious for patients with
kidney disease.
If antacids are needed for more than
3 weeks, a doctor should be
consulted.

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For chronic reflux and heartburn,

the doctor may recommend
medications to reduce acid in the
stomach. These medicines include
H2 blockers, which inhibit acid
secretion in the stomach.
H2 blockers include: cimetidine,
famotidine, and ranitidine.

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Another type of drug, the proton

pump (or acid pump) inhibitor inhibits
an enzyme (a protein in the acidproducing cells of the stomach)
necessary for acid secretion.
Some proton pump inhibitors include
Esomeprazole
Lansoprazole
Omeprazole
Pantoprazole
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Other approaches to therapy will

increase the strength of the LES and
quicken emptying of stomach
contents with motility drugs that act
on the upper gastrointestinal (GI)
tract. These drugs metoclopramide .

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Treatment
Antireflux surgery
Failed medical management
Patient preference
GERD complications
Medical complications attribute to a
large hiatal hernia
Atypical symptomps with reflux
documented on 24-houe pH monitioring

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Principles of Anti-Reflux
Surgery

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Complications
Erosive esophagitis
Stricture
Barretts esophagus

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Complications
Erosive esophagitis
Responsible for 40-60% of GERD
symptoms
Severity of symptoms often fail to match
severity of erosive esophagitis

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Complications
Esophageal stricture
Result of healing of erosive esophagitis
May need dilation

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Peptic Stricture
Barium Swallow

Endoscopy

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Esophageal Stricture: Dilating

Devices

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TTS Ballon Dilation of a Peptic

Stricture

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Complications
Barretts
Esophagus
Columnar
metaplasia of the
esophagus
Associated with
the development
of
adenocarcinoma
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Barretts Esophagus

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Complications
Barretts Esophagus
Acid damages lining of
esophagus and causes
chronic esophagitis
Damaged area heals in a
metaplastic process and
abnormal columnar cells
replace squamous cells
This specialized
intestinal metaplasia can
progress to dysplasia
and adenocarcinoma

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Complications
Barretts Esophagus
Manage in same manner as GERD
EGD every 3 years in patients without
dysplasia
In patient with dysplasia annual to
shorter interval surveillance

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Complications
Patients who need EGD
Alarm symptoms
Poor therapeutic response
Long symptom duration

Once in a lifetime EGD for patients

with chronic GERD becoming
accepted practice
Many patients with Barretts are
asymptomatic
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Esophageal Cancer
Barium Swallow

Endoscopy

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T
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For UMY 546

- 2013