gastroesophageal reflux

diseaseGERD

Department of gastroenterology,1st hospital of jilin university

Tongyu Tang

Definition

• American College of Gastroenterology (ACG)American College of Gastroenterology (ACG)

Symptoms OR mucosal damage produced by Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the abnormal reflux of gastric contents into the esophagusthe esophagusOften chronic and relapsingOften chronic and relapsingMay see complications of GERD in patients May see complications of GERD in patients who lack typical symptomswho lack typical symptoms

Barrett’s esophagus,BE

GERD

non-erosive reflux disease, NERD

reflux esophagitis, RE

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

• 8.97% in china

Pathophysiology

• 80% of reflux symptoms occur as a result of transient LES relaxation

• Other motility defects– LES incompetence– Gastroparesis– Esophageal body dymotility

• Anatomic defects: Hiatal hernia

Pathogenesis of GERD Pathogenesis of GERD

Impaired Esophageal Impaired Esophageal ClearanceClearance

Decreased SalivationDecreased SalivationImpaired Tissue Impaired Tissue ResistanceResistance

Decreased LES Resting Decreased LES Resting ToneTone

Delayed Gastric Delayed Gastric EmptyingEmptying

Bile Bile RefluxReflux

Hiatal HerniaHiatal Hernia

LESLES

DuodenuDuodenumm

Clinical Manisfestations

• Most common symptoms– Heartburn—retrosternal

burning discomfort– Regurgitation—effortless

return of gastric contents into the pharynx without nausea, retching, or abdominal contractions

Clinical Manisfestations

– Dysphagia—difficulty swallowing

– Other symptoms include:

• Chest pain, water brash, globus sensation, odynophagia, nausea

– Extraesophageal manifestations

• Asthma, laryngitis, chronic cough

Complications

Stricture

Barrett’s esophagus

Bleeding

Complications

• Esophageal stricture

– Result of healing of erosive esophagitis

– May need dilation

Complications

• Barrett’s Esophagus– Columnar metaplasia of

the esophagus– Associated with the

development of adenocarcinoma

Complications

• Barrett’s 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

Diagnostic Tests for GERDDiagnostic Tests for GERD

EndoscopyEndoscopy Barium swallowBarium swallow Ambulatory pH monitoringAmbulatory pH monitoring Esophageal manometryEsophageal manometry

Esophagogastrodudenoscopy• Endoscopy (with biopsy if needed)

– In patients with alarm signs/symptoms– Those who fail a medication trial– Those who require long-term tx

• Lacks sensitivity for identifying pathologic reflux

• Absence of endoscopic features does not exclude a GERD diagnosis

• Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD

＞＞

LA Classification of EsophagitisLA Classification of Esophagitis

From Nayar DS et al. Gastrointest Endosc 2004;60:253-7.From Nayar DS et al. Gastrointest Endosc 2004;60:253-7.

24-Hour Esophageal pH Monitoring24-Hour Esophageal pH Monitoring

• Most accurate test for measuring Most accurate test for measuring pattern, frequency, and duration of pattern, frequency, and duration of reflux episodes reflux episodes

• Documents correlation between Documents correlation between reflux episodes and symptomsreflux episodes and symptoms

• Sensitivity (77-100%) Sensitivity (77-100%)

– Normal in 25% of esophagitis!Normal in 25% of esophagitis!

• Specificity 85-100%Specificity 85-100%

• Most useful when diagnosis still Most useful when diagnosis still unclearunclear

Dent et al. Dent et al. GutGut. 1999;44(suppl 2):S1-S16.. 1999;44(suppl 2):S1-S16.

• Ambulatory 24 hr. pH Monitoring• Physiologic study

• Quantify reflux in proximal/distal esophagus

– % time pH < 4

– DeMeester score

• Symptom correlation

Esophageal Manometry

• Assess LES pressure, location and relaxation– Assist placement of 24 hr.

pH catheter

• Assess peristalsis– Prior to antireflux surgery

Limited role in GERDLimited role in GERD

B 级

C 级 D 级

A 级

Treatment Goals for GERDTreatment Goals for GERD

Eliminate symptomsEliminate symptomsHeal esophagitisHeal esophagitisManage or prevent complicationsManage or prevent complicationsMaintain remissionMaintain remission

Better Living• Lifestyle modifications

– Avoid large meals– Avoid acidic foods (citrus/tomato), alcohol, caffiene,

chocolate, onions, garlic, peppermint– Decrease fat intake– Avoid lying down within 3-4 hours after a meal– Elevate head of bed 4-8 inches– Avoid meds that may potentiate GERD (CCB, alpha

agonists, theophylline, nitrates, sedatives, NSAIDS)– Avoid clothing that is tight around the waist– Lose weight– Stop smoking

Treatment

• Histamine H2-Receptor Antagonists– More effective than placebo and antacids for

relieving heartburn in patients with GERD– Faster healing of erosive esophagitis when

compared with placebo– Can use regularly or on-demand

Treatment

AGENT EQUIVALENT DOSAGE DOSAGESCimetadine 400mg twice daily 400-800mg twice dailyTagamet

Famotidine 20mg twice daily 20-40mg twice dailyPepcid

Nizatidine 150mg twice daily 150mg twice dailyAxid

Ranitidine 150mg twice daily 150mg twice dailyzantac

Treatment

• Proton Pump Inhibitors– Better control of symptoms with PPIs vs

H2RAs and better remission rates– Faster healing of erosive esophagitis with PPIs

vs H2RAs

TreatmentAGENT EQUIVALENT DOSAGE DOSAGESEsomeprazole 40mg daily 20-40mg dailyNexium

Omeprazole 20mg daily 20mg dailyPrilosec

Lansoprazole 30mg daily 15-10md dailyPrevacid

Pantoprazole 40mg daily 40mg dailyProtonix

Rabeprazole 20mg daily 20mg dailyAciphex

Endoscopic Treatments

• In development with ongoing studies

• Most try to improve LES function in some manner

• Not quite ready for prime time in community practice

Surgical Treatment

• Indications– Esophagitis– Stricture– Barrett’s metaplasia– Medication failure

• Purpose of surgery restoration the LES