GERD

SUMARDJO
 Clinical Presentation of GERD
Typical/ Atypical/
Esophageal Supraesophageal
• Heartburn • Chest pain
• Acid regurgitation • Laryngitis
• Asthma
• Sinusitis
• Chronic cough
• Aspiration pneumonia
• Tooth decay
 Patients do not always correctly identif
y the symptom of heartburn
Describing heartburn as “a burning feeling rising
from the stomach or lower chest up towards the n
eck” can help patients recognise this symptom.

Clinician interview/endoscopy
• Functional dyspepsia diagnosed
• Predominant heartburn excluded
42%
Reflux questionnaire
• Identified a burning feeling rising from
the stomach or lower chest
n=196 up towards the neck as their
main symptom

Carlsson R et al. Scand J Gastroenterol 1998;33:1023

 Pathophysiology of GERD
Impaired acid neutralization by
saliva and HCO3

Impaired esophageal motil

ity
LES (inappropriate relaxati
on)
Hiatal hernia
Delayed gastric emptying/
gastroparesis

LES=lower esophageal sphincter

 There is only weak evidence that lifestyle factors aggrava
te GERD symptoms

• Obesity:
– severity of esophagitis correlates with weight only when BMI
>30 kg/m2
– contradictory studies into weight loss indicate no effect/impr
ovement in GERD.
• Smoking:
– lowers LES pressure and the acid-neutralising effect of saliva.
• Physical activity:
– running might provoke GERD by increasing TLESRs.

Meining A et al. Am J Gastroentero 2000;95:2692.

 Medications may aggravate
GERD symptoms
Impairment of LES function: Damage to the esophageal mucosa
• beta-adrenergic agonists :
• theophylline • acetylsalicylic acid and other NS
• anticholinergics AIDs
• tricyclic antidepressants • tetracycline
• progesterone • quinidine
• alpha-adrenergic antagonists • bisphosphates.
• diazepam
• calcium channel blockers.
Cough and GERD: 2 Possible Mechanis
ms
Aspiration to lower Esophageal–bronchial tran
respiratory tree smission via
cough center

Stimulation of va
gus nerve
Cough
response

Gastric refluxate

Gastric refluxate
 Phenotypic Classification of GERD

GERD

Erosive Barrett’s
NERD*
Esophagitis Esophagus
60-70%
20-30% 6-10%

*NERD: Non-Erosive Reflu

x Disease

Fass et al. Alim Pharm Ther 2005

 What are the Symptoms of Symptomat
ic GERD?
• Heartburn
• Regurgitation
• Chest pain
• Impaired QOL
• Others (burning mouth/tongue)
• Atypical (“supraesophageal”) symptoms
• These are the same symptoms as patients with erosive esophagi
tis and Barrett’s esophagus
• The severity of these symptoms CANNOT PREDICT the subtype o
f GERD into which a patient falls prior to endoscopic examinatio
n
 Endoscopic Images

Normal Squamo-c LA Grade A Eso LA Grade D Es

olumnar junction phagitis ophagitis
Esophageal stricture – endoscopic app
earance
Metaplasia of the esophagus: Barrett’s
esophagus
Definition: a change in the esophageal epithelium of
any length that can be recognised at endoscopy and
is confirmed to have intestinal metaplasia by biopsy
of the tubular esophagus and excludes intestinal met
aplasia of the cardia.
Squamous epithelium Columnar epithelium
 Dysplasia in Barrett’s
• Prevalence: LGD: 7.3%; HGD: 3%1
• Dysplasia MUST be confirmed
• HGD: must aggressively look for prevalent canc
ers
• Screening and surveillance intervals?
• Management options for HGD:
– Esophagectomy
– Ablation
– Endoscopic mucosal resection

1Sharma et al. Clin Gastro Hep 2006

 Initial Management of Heartburn
A. Antacids and lifestyle changes
B. H2-receptor antagonists
C. Standard Proton pump inhibitor therapy
D. High-dose Proton pump inhibitor therapy
• Continuous?
• On-Demand?
E. Endoscopy and/or pH testing followed by therap
y based on results
 Proton Pump Inhibitor Test
• Empiric therapy with PPI for heartburn
• Functions as both diagnostic test and thera
peutic trial
• Sensitivity 68-80% as defined by abnormal
pH test or endoscopy
• May be falsely positive (does not actually m
ake a true diagnosis or GERD)

Kahrilas PJ. Am J Gastro 2003;98: S15-23

Indications for additional investigation
s
• Atypical history.
• Symptoms are frequent and long-standing or d
o not respond to therapy.
• Alarm symptoms are present:
– severe dysphagia
– weight loss
– bleeding
– hematemesis
– mass in the upper abdomen
– anemia
Why Do PPI’s Fail to Control Symp
toms?
 Reasons for PPI “Failure”
• Patient non-compliance
• Persistent esophageal acid exposure
– Hypersecretory state
– Large hiatal hernia
– Nocturnal acid breakthrough
• Acid-sensitive esophagus
• Non-acid reflux
• Wrong diagnosis
• Functional heartburn (NOT GERD!!)