GastroEsophageal

Reflux Disease (GERD)

ALAA M ALSER
(R3)

GERD - Definitions
Gsatroesophageal reflux: is a normal physiologic phenomenon
experienced intermittently by most people, particularly after a meal.
Gastro-oesophageal reflux disease (GORD):
Abnormal reflux of gastric juice (acid and bile) into the
oesophagus leading to symptoms
Pathological reflux ranges from simple to erosive to Barretts
Non-erosive reflux disease (NERD):
Reflux disease in which erosion does not occur
Heartburn:
Burning retrosternal pain radiating upward due to exposure of the
oesophagus to acid
Oesophagitis:
Endoscopically demonstrated damage to the oesophageal mucosa

Definition
American College of Gastroenterology (ACG)
Symptoms OR mucosal damage produced by
the abnormal reflux of gastric contents into
the esophagus
Often chronic and relapsing

GERD - New Montreal

GERD is a condition
which develops when the reflux
Definition
of stomach content causes troublesome symptoms
and / or complications

Esophageal
Syndromes

Extra-esophageal
Syndromes

Symptomatic
Syndromes

Syndromes with
Esophageal Injury

Established
Association

Proposed
Association

Typical reflux
syndrome

Reflux esophagitis

Reflux cough

Sinusitis

Reflux stricture

Reflux laryngitis

Reflux chest
pain syndrome

Barrett's
esophagus

Reflux asthma

Adenocarcinoma

Reflux dental
erosions

Pulmonary
fibrosis
Pharyngitis
Recurrent otitis
media

Vakil et al., Am J Gastroenterol 2012

Prevalence
.
Increased prevalence last 10 years.
Accompanied increase in adenocarcinoma lower esophagus.
Obesity associated with increased GERD.

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

Epidemiology
-developed countries
-epidemic
proportions;
present in 40% of
healthy population
-adults: male, over
40

Physiologic vs Pathologic
Physiologic GERD
Postprandial
Short lived
Asymptomatic
No nocturnal sx

Pathologic GERD
Symptoms
Mucosal injury
Nocturnal sx

Anti Reflux Mechanism(ARM)

-This has both:(1) Anatomical.
(2) Functional.
Anatomical:
- The lower esophageal sphincter (LES) at the OG junction consists of tonically contracted smooth
muscle at approx. 8-20 mmHg above the gastric pressure.
- The outside (extrinsic) compression at the OG junction from the crural diaphragm.
- Sharp angle- entry of esophagus into stomach (angle of His).
Functional
-Esophageal peristalsis that serves to clear luminal contents into the stomach.
-Secretion and swallowing of saliva to neutralize the acid and enhance clearance.
-Prompt Gastric emptying.

The 3 mechanisms during

swallowing that keep acid out
of the esophagus include:
Swallowed saliva which helps neutralize
stomach acid.
Sweeping muscles contractions that act to
cleanse the lower esophagus of stomach
acid.
Protective contracture of the LES
(Jackson Gastroenterology - 2005)

TLESR

(Transient Lower Esophageal Sphincter

Relaxations)

A normal phenomenon in healthy

individuals.

Dominant mechanism of
pathological reflux.

Too frequent TLESRs.

Too prolonged TLESRs.

Anatomic radiographic landmarks of the lower esophageal sphincter

(LES).

Pathophysiology of GERD
salivary HCO3
Impaired
mucosal
defence

oesophageal
clearance of acid
(lying flat, alcohol,
coffee)

Impaired LOS
(smoking, fat, alcohol)

Hiatus hernia

transient LOS
relaxations
basal tone

bile reflux

Bile and
pancreatic
enzymes

H+
Pepsin

acid output
(smoking, coffee)
intragastric pressure
(obesity, lying flat)
gastric emptying (fat)

1, impaired lower
esophageal sphincter-low
pressures or frequent
transient lower esophageal
sphincter relaxation
2, hypersecretion of acid
3, decreased acid
clearance resulting
from impaired peristalsis or
abnormal saliva production
4, delayed gastric
emptying or
duodenogastric reflux of
bile
salts and pancreatic
enzymes.

GERD
Pathophysiology
A. Abnormal lower esophageal
sphincter
- Functional (frequent transient LES
relaxation)
- (hypotensive LES)
- Foods (eg, coffee, alcohol),
- Medications (eg, calcium channel
blockers),
- Location ..........
hiatal hernia

or

B. Increase abdominal pressure

The most
common
cause of
(GERD).
decrease the
pressure of
the LES.

obesity
Pregnancy
increased gastric volume

Risk factors

prolonged gastric emptying

obesity
pregnancy
hiatal hernia
trauma
transient LES relaxation - nocturnal,
postprandial

Things that worsen reflux

citrus fruits
chocolate
drinks with caffeine or
alcohol
fatty and fried foods
garlic and onions
mint flavorings
spicy foods
tomato-based foods, like
spaghetti sauce, salsa,
chili, and pizza
Smoking
Posture

Medications that relax

the LES
Benzodiazepines
Theophylline
Narcotics
containing
codeine.
Calcium channel
Blockers
Nitroglycerine

Anticholinergics
Potassium
supplements
Iron supplements
NSAIDS
Erythromycin

Symptoms:
HEARTBURN
- retrosternal burning pain

- may start in
abdomen and
extend up
into the neck

What are the symptoms of

GERD

Persistent heartburn and acid regurgitation.

Waterbrash (sudden excess of saliva)
Sour taste in the mouth
Food stuck in throat
Difficulty or pain when swallowing
Chest pain
Hoarseness
Choking or throat tightness.
Chronic sore throat
Dry cough
Bad breath
Inflammation of the gums
Erosion of tooth enamel (the surface of the
teeth)

Long-term complications of GERD?

-Inflammation of the esophagus
Bleeding or ulcers
strictures
Barrett's esophagus and adenoarcinoma
-Supraesphageal manafestations
Dental
Asthma
chronic cough
pulmonary fibrosis
ENT manafestations

Laryngopharyngeal reflux
81% will have a normal-appearing esophagus
40% may have symptoms of heartburn
Symptoms consistent with this diagnosis
Dysphonia
Globus sensation
Throat clearing
Halitosis
Sore throat
Cough.
Hoarseness is a majer coplaint in 92% of patients with GERDrelated laryngitis
> 50% of patients presenting to ENT specialists with hoarsness
will have a component of GERD contributing to their
symptoms

Severe lingual tonsil

hypertrophy

Arytenoid edema

carinal blunting

Severe postglottic
edema
Tracheal
cobblestoning

Dental erosions in GERD

patients

Ranjitkar S et al, J Gastroenterol

Complications:

chronic esophagitis
erosive changes
strictures
DYSPHAGIA
Barrets esopgagus
dysplasia
adenocarcinoma

Endoscopic pictures of GERD

The Los Angeles Classification System

for the endoscopic assessment of reflux
oesophagitis

GRADE A:
One or more mucosal breaks
no longer than 5 mm, non of
which extends between the
tops of the mucosal folds

The Los Angeles Classification System

for the endoscopic assessment of reflux
oesophagitis
GRADE B:
One or more mucosal
breaks more than 5 mm
long, none of which
extends between the
tops of two mucosal folds

The Los Angeles Classification System

for the endoscopic assessment of reflux
oesophagitis

GRADE C:

Mucosal breaks that extend

between the tops of two or
more mucosal folds, but
which involve less than
75% of the oesophageal
circumference

The Los Angeles Classification System

for the endoscopic assessment of reflux
oesophagitis

GRADE D:

Mucosal breaks which

involve at least 75% of
the oesophageal
circumference

Endoscopic view of GERD

complications

Complications
Esophageal
stricture

Results of
healing of
erosive
esophagitis
May need
dilation

Ulcer
complication

8-15%

Barretts Esophagus

Intestinal metaplasia
of the esophagus
Associated with the
development of
adenocarcinoma

GERD and extraesophageal

manifestations
Its not simple to establish a cause-effect
relationship between GERD and
extraesophageal manifestations !
Regurgitation or pyrosis : 20%-75%
Erosive Esophagitis : < 30%

Irvin,1993; Ours,1999

Ear, nose and throat (ENT) signs in normal volunteers (n = 105)

Hicks DM et al, 2002

Diagnosis:

clinical evaluation of
sypmtoms, excluding
other possible causes
(pectoral angina)
endoscopic procedure:
>esophagogastroscopy
with biopsy
pH metrics: 24-hour
intraluminal monitoring

Endoscopy

pH

24-hour pH monitoring

Accepted standard for establishing or excluding presence of

GERD for those patients who do not have mucosal changes
Trans-nasal catheter or a wireless, capsule shaped device

Transnasal catheter or a wireless capsule shaped device

affixed to distal esophagus
--cather positioned 5cm above manometrically defined upper
limit of les
--capsul attached 6cm proximal to endoscopically defined
squamocolumnar jxn
--if mucosal changeshave dx and do not need 24hph.

24-hour
ambulator
y pHimpedance

None Medical Treatment

Life style changes

If you smoke, stop.

Avoid foods and beverages that worsen
symptoms.
Lose weight if needed.
Eat small, frequent meals.
Wear loose-fitting clothes.
Avoid lying down for 3 hours after a meal.
Raise the head of your bed 6 to 8 inches by
securing wood blocks under the bedposts. Just
using extra pillows will not help.

Treatment - non
medicament:

Lifestyle
modification:

The Step up Approach.

PPI

LOW DOSE PPI.

H2RA +PROKINETIC.

H2RA

OTC ANTACIDS + LIFESTYLE ADVICE.

The Step Down Approach.

PPI

LOW DOSE PPI.

H2RA +PROKINETIC.

H2RA+LIFESTYLE ADVICE.

OTC
ANTACIDS.

Treatment cont.
Medications

Antacids
Foaming agents
H2 blockers
Proton pump inhibitors
Prokinetics

Therapeutic trial of anti-GORD therapy

for asthma patients
Adult asthma patients
Monitor baseline asthma symptom, PEF,
asthma medication use and spirometry
3-month trial with omeprazole 20 mg twice
daily, lansoprazole 30 mg twice daily,
or rabeprazole 20 mg twice daily
Continue monitoring as above
Asthma improved
Begin maintenance anti-GORD
therapy, which may include:
PPIs

H2RAs

Prokinetic agents
Surgery in selected patients

PEF = Peak Expiratory

Flow

Asthma not improved

Perform 24-hour
oesophageal pH test while
on anti-GORD regimen
pH+
Increase antiGORD therapy or
refer to
gastroenterologist

pHAsthma is not
GORD-related

Harding & Sontag, Am J Gastroenterol 2000; 95(Suppl):

S2332.

Criteria for selection of patients

with chronic cough in whom GERD
should be investigated

Galmiche JP et al, APT

Endoscpic management of
GERD:

Endoscopic Baloon dilatation of esophageal

stricture.
Endoscopic photodynamic therapy, laser, or
multipolar electrocoagulation ablasion of
Barret esophagus.
Endoscopic Radiofrequency application to
LES.
Laproscopic funduplication.
Endoscopic antireflux stents.

Treatment cont.
SurgeryFundoplication- is the standard surgical treatment for GERD.
Usually a specific type of this procedure, called Nissen
fundoplication, is performed. This is were the upper part of
the stomach is wrapped around the LES to strengthen the
sphincter, prevent acid reflux, and repair a hiatal hernia.
people can leave the hospital in 1 to 3 days and return to
work in 2 to 3 weeks

Surgery
Nissen
Fundoplication

Nissen Fundoplication

Endoscopic view of Nissen

Fundoplication

Grade I

Grade 2

Grade 3

Grade 4.