Gastroesophageal reflux disease

GERDRaika Jamali M.D.

Gastroenterologist and hepatologist Sina Hospital

Tehran University of Medical Sciences

Objectives

• Appreciate the significance of GERD as a chronic disease

• Identify patients with different presentations of GERD

• Organize a rationale management plan for different types of GERD symptoms

• Be familiar with various treatment modalities of GERD and their appropriate use

DefinitionsDefinitions

GERD: any symptomatic GERD: any symptomatic condition or histopathologic condition or histopathologic alteration resulting from alteration resulting from episodes of gastroesophageal episodes of gastroesophageal refluxreflux

●●Erosive: 35% Erosive: 35%

●●Nonerosive (NERD) Nonerosive (NERD)

Why GERD is so important??Why GERD is so important??

● ● is very common & increasingis very common & increasingBurden and Quality of lifeBurden and Quality of life

●● complications: esophagitis, complications: esophagitis, peptic stricture, inflammatory peptic stricture, inflammatory polyps ,Barrett's metaplasia , polyps ,Barrett's metaplasia , dysplasia ,adenocarcinomadysplasia ,adenocarcinoma

EpidemiologyEpidemiology

●●Geographic variationGeographic variation ●● M=F M=F

●● Barrett's metaplasia (M/F = Barrett's metaplasia (M/F =

10 /1)10 /1)

•The prevalence of GERD in Asian populations is reported to be lower than that in the west.

• Population-based data on the prevalence and symptom profile of GERD in developing Caucasian countries is lacking.

Frequency of Endoscopic GERD Frequency of Endoscopic GERD Iranian Experience: 1994-1999Iranian Experience: 1994-1999

GERD

0%

20%

40%

60%

80%

100%

94 95 96 97 98 99

Retrospective study of 4500 UGIE reports (5y): 34.3% E-GERD Malekzadeh,et al 2000

Prospective evaluation of referring Prospective evaluation of referring Dyspeptics in TehranDyspeptics in Tehran

• 269 (135 F) participant• Symptoms recorded, UGIE + Bx from

Z-line was done:

• 77.6% at least one major GERD symptom

• 76.1% EE (most A & B)• 5% Specialized intestinal metaplasia • 3 Dysplasia

• None of the symptoms could predict the endoscopic or histologic findings

• Nasseri-Moghaddam, Malekzadeh et al 2002

CONCLUSIONCONCLUSION

GERD is a common disease among Iranian general population and its

prevalence is comparable with that of the western countries .

PathogenesisPathogenesis

●● Transient L E S RelaxationTransient L E S Relaxation

●● Hypotensive L E SHypotensive L E S

●● Anatomic Variables Anatomic Variables

●●Delayed Gastric Emptying Delayed Gastric Emptying

●● Esophageal Acid ClearanceEsophageal Acid Clearance - - Salivary FunctionSalivary Function

--Impairments of Esophageal EmptyingImpairments of Esophageal Emptying

GERDپاتوفيزيولوژي

اختالل پاك شدن مري

هرني هياتال

شل شدن گذرا و LESنامناسب

ترشح اسيد معده و پپسين:

نرمال/افزايش يافتهبي كفايتي دريچة پيلور؛

ريفالكس دئودنوگاستريك

اختالل عملكرد

بزاقاختالل مكانيسم

هاي دفاعي

مخاطي

كاهش فشار استراحت

LES

تأخير تخليه معده

Case 1Case 1• A 34 y engineer with heart burn for 8

y comes to your office for evaluation of his GERD symptoms.

• He asks you about the diagnosis of GERD, if additional diagnostic work up is needed and his medical management.

Diagnosis Diagnosis ●● History is usually sufficient to History is usually sufficient to confirm the diagnosisconfirm the diagnosis

Indications for EndoscopyIndications for EndoscopyExtra-esophageal or atypical symptoms Patients > 40 y with new onset GERD symptoms DysphagiaWeight Loss Anemia Family hx of CancerLong(>5 y) or very severe symptoms

GERD-B

The Los Angeles ClassificationThe Los Angeles Classification

GERD-A

GERD-C

GERD-D

Avoid:smokingstressHeavy meals Large quantities of liquid with mealsFatty foodsCoffeeChoclateAlcoholMintOrange juiceTomato catch upAnticholinergic, calcium channel

blockers, smooth muscle relaxants

Therapeutic regimens for GERD in Therapeutic regimens for GERD in order of increasing potencyorder of increasing potency

• Over-the-counter antacids and/or H2 receptor blockers

• Omeprazole (20 mg QD) or

equivalent dose of the other PPIs • Omeprazole (20 mg BID or 40 mg BD)

or equivalent doses of the other PPIs

• Step-up approach: with mild symptoms, no change in QOL

• Step-down approach: with more severe symptoms affecting QOL or with higher grades of esophagitis / complications

• Bed time H2B for nocturnal symptoms

Dose of the different H2 Dose of the different H2 blockersblockers

Drug Daily dose • Cimetidine 800 mg • Ranitidine 300 mg • Famotidine 40 mg • Nizatidine 300 mg

PPI versus H2 blockers in treatment of erosive PPI versus H2 blockers in treatment of erosive GERD symptoms (right panel) and esophageal GERD symptoms (right panel) and esophageal

healing (left panel)healing (left panel)

PPI side effectsPPI side effects• Pneumonia • Hypergastrinemia (Carcinoid tumor in

animal model)• Enteric infections• Vitamin B12 malabsorption

PROKINETIC DRUGSPROKINETIC DRUGS

• Metoclopramide• Cisapride • Tegaserod

Duration of therapyDuration of therapy

Maintenance therapy :Maintenance therapy :lowest dose of PPI or H2 blockers,

especially in severe esophagitis (grades C & D) and with complications (BE, stricture)

Intermittent therapy :Intermittent therapy :on-demand therapy in patients

with mild to moderate heartburn without severe esophagitis.

Effective initial and long Effective initial and long term mangementterm mangement

• Decreases amount of drugs used

• Decreases doctor visits

• Decreases the need for repeat UGIE

(Bate et al 1992, Bloom et al 1994, Bardhan et al 1999)

Case 2Case 2• Young woman with chronic cough who is

refractory to treatment with sulbutamol is referred for evaluation of GERD.

• She complains of morning hoarseness.• Sulbutamol was in effective and even

aggravated her symptoms.• Laryngoscopy showed posterior vocal

cord erythema.• Endoscopy showed esophagitis.• Symptoms respond to 20 mg of daily

omeprazol.

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Typical SymptomsTypical Symptoms

●● HeartburnHeartburn

●● Regurgitation Regurgitation

●● Dysphagia Dysphagia

Case 3Case 3• Middle age man is visited for

evaluation of dysphagia to solids from 2 months duration.

• He was a heavy smoker and used famotidine for heart burn for 14 y.

• Ba swallow was performed.• Endoscopy and biopsy was done.

Proximal esophageal Proximal esophageal stricturestricture

Peptic stricturePeptic stricture

Hyperplasia of basal cells and Hyperplasia of basal cells and infiltration of PMN with infiltration of PMN with

erosions in GERD.erosions in GERD.

Natural HistoryNatural History

●● Peptic stricture ( 8 to 20 %)Peptic stricture ( 8 to 20 %)

●● Ulceration ( 5 %)Ulceration ( 5 %)

●● Significant bleeding ( 2 % )Significant bleeding ( 2 % )

●● Perforation extremely rarePerforation extremely rare

Esophageal ulcer in reflux Esophageal ulcer in reflux esophagitisesophagitis

Case 4Case 4• A 45 y old man with 25 y reflux

symptoms comes to your office for evaluation of recent weight loss and dysphagia.

• There was a histologic report of “Intestinal metaplasia” in distal esophagus in his last endoscopy 2 y ago.

• Ba swallow and endoscopy was performed.

AdenocarcinomaAdenocarcinoma

Barrett´s EsophagusBarrett´s Esophagus

Barrett´s EsophagusBarrett´s Esophagus

Long Segment Barrett’s

Endoscopic mucosal Endoscopic mucosal resectionresection

Case 5Case 5• A 38 y old woman comes to the clinic

for her severe chronic reflux symptoms and consults about antireflux surgery.

• She is on long term Omeprazole 40 mg twice a day and ranitidine before bed time.

• Serum Gastrin level is in upper normal limits.

• Endoscopy was normal (NERD).

Refractory Refractory gastroesophageal reflux gastroesophageal reflux

diseasedisease• Failure to control symptoms with full

dose of PPI + life style modification raises the possibility that symptoms are due to another disease or refractory GERD.

• Reduced bioavailability• Effect of food• Dosing interval• Gastric acid hypersecretion • Drug resistance• Slow healing• Esophageal hypersensitivity

(viseral hyperalgesia)• Eosinophilic esophagitis• Pill induced esophagitits

TREATMENTTREATMENT • First confirm the diagnosis then,

• Increase the frequency of dosing• Increasing the dose (Omeprazole to

80 mg/day)• Add a second drug • Switch to another drug• Check for Gastrinoma• Surgery

Preoperative evaluation for Preoperative evaluation for gastroesophageal reflux diseasegastroesophageal reflux disease

• Detailed clinical history and physical examination

• Endoscopy to assess degree of esophagitis

• Esophageal manometry to define LES pressure and disorders of peristalsis

• Upper gastrointestinal series to assess esophageal length and hiatal hernia

• 24 hour esophageal pH monitoring

Indications for esophageal Indications for esophageal pH recordingpH recording

• to document abnormal esophageal acid exposure in an endoscopy-negative patient being considered for surgical antireflux repair

• to evaluate patients after antireflux

surgery who are suspected to have ongoing abnormal reflux

• to evaluate patients with normal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy

• to detect refractory reflux in patients with extraesophageal or atypical symptoms using symptom association probability calculation

INDICATIONS FOR OPERATION INDICATIONS FOR OPERATION AND PREOPERATIVE AND PREOPERATIVE

EVALUATIONEVALUATION

• Persistent or recurrent symptoms with appropriate response to medical THX.

• Severe esophagitis by endoscopy• Benign stricture • Recurrent pulmonary symptoms

Predictors of successful Predictors of successful surgerysurgery

• Response to medical therapy• Typical reflux symptoms• Erosive GERD• Abnormal pH study

Predictors of unsuccessful Predictors of unsuccessful surgerysurgery

• Lack of response to medical therapy – (medical failure?)– It could be something other than GERD

• Non-erosive GERD (NERD)

Helicobacter pylori and GERDHelicobacter pylori and GERD

• Eradication of H. pylori is associated with mild worsening of GERD in patients with corpus-predominant gastritis and improvement in those with antral-predominant gastritis.

• The standard of care is to eradicate H. pylori in the context of peptic ulcer disease.