GERD is a day to day common problem, which is on the increase due to so many obvious reasons. It needs to be addressed to the public and the medical fraternity for proper management and treatment.
2. Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease
(GERD)(GERD)
• Any symptoms or esophageal mucosal damageAny symptoms or esophageal mucosal damage
that results from reflux of gastric acid into thethat results from reflux of gastric acid into the
esophagusesophagus
• Classic GERD symptomsClassic GERD symptoms
– Heartburn (pyrosis): substernal burning discomfortHeartburn (pyrosis): substernal burning discomfort
– Regurgitation: bitter, acidic fluid in the mouthRegurgitation: bitter, acidic fluid in the mouth
when lying down or bending overwhen lying down or bending over
4. ObjectivesObjectives
• Definition of GERDDefinition of GERD
• Epidemiology of GERDEpidemiology of GERD
• Pathophysiology of GERDPathophysiology of GERD
• Clinical ManisfestationsClinical Manisfestations
• Diagnostic EvaluationDiagnostic Evaluation
• TreatmentTreatment
• ComplicationsComplications
5. DefinitionDefinition
– American College ofAmerican College of
Gastroenterology (ACG)Gastroenterology (ACG)
– Symptoms OR mucosal damageSymptoms OR mucosal damage
produced by the abnormal reflux ofproduced by the abnormal reflux of
gastric contents into the esophagusgastric contents into the esophagus
– Often chronic and relapsingOften chronic and relapsing
– May see complications of GERD inMay see complications of GERD in
patients who lack typicalpatients who lack typical
symptomssymptoms
8. Physiologic vs PathologicPhysiologic vs Pathologic
• Physiologic GERDPhysiologic GERD
– PostprandialPostprandial
– Short livedShort lived
– AsymptomaticAsymptomatic
– No nocturnal sxNo nocturnal sx
• Pathologic GERDPathologic GERD
– SymptomsSymptoms
– Mucosal injuryMucosal injury
– Nocturnal sxNocturnal sx
9. Locke et al. Gastroenterology 1997;112:1148.Locke et al. Gastroenterology 1997;112:1148.
High Prevalence of GastroesophagealHigh Prevalence of Gastroesophageal
Reflux SymptomsReflux Symptoms
19.8%
59%
0%
10%
20%
30%
40%
50%
60%
Weekly Monthly
Frequency of heartburn and/or
regurgitation
11. Important Reasons to Diagnose and TreatImportant Reasons to Diagnose and Treat
GERDGERD
• Negative impact on health-related quality of lifeNegative impact on health-related quality of life11
• Risk factor for esophageal adenocarcinomaRisk factor for esophageal adenocarcinoma22
1.1. Revicki et al. Am J Med 1998;104:252.Revicki et al. Am J Med 1998;104:252.
2.2. Lagergren et al. N Engl J Med 1999;340:825.Lagergren et al. N Engl J Med 1999;340:825.
13. PathophysiologyPathophysiology
• Primary barrier toPrimary barrier to
gastroesophageal reflux isgastroesophageal reflux is
the lower esophagealthe lower esophageal
sphinctersphincter
• LES normally works inLES normally works in
conjunction with theconjunction with the
diaphragmdiaphragm
• If barrier disrupted, acidIf barrier disrupted, acid
goes from stomach togoes from stomach to
esophagusesophagus
15. Clinical Presentations of GERDClinical Presentations of GERD
• Classic GERDClassic GERD
• Extraesophageal/Atypical GERDExtraesophageal/Atypical GERD
• Complicated GERDComplicated GERD
20. Symptoms of Complicated GERDSymptoms of Complicated GERD
• DysphagiaDysphagia
– Difficulty swallowing: food sticks or hangsDifficulty swallowing: food sticks or hangs
upup
• OdynophagiaOdynophagia
– Retrosternal pain with swallowingRetrosternal pain with swallowing
• BleedingBleeding
22. When to Perform Diagnostic TestsWhen to Perform Diagnostic Tests
• Uncertain diagnosisUncertain diagnosis
• Atypical symptomsAtypical symptoms
• Symptoms associated with complicationsSymptoms associated with complications
• Inadequate response to therapyInadequate response to therapy
• Recurrent symptomsRecurrent symptoms
• Prior to anti-reflux surgeryPrior to anti-reflux surgery
28. Wireless, Catheter-Free Esophageal pH Monitoring
• Improved patientImproved patient
comfort and acceptancecomfort and acceptance
• Continued normal work,Continued normal work,
activities and diet studyactivities and diet study
• Longer reporting periodsLonger reporting periods
possible (48 hours)possible (48 hours)
• Maintain constant probeMaintain constant probe
position relative to SCJposition relative to SCJ
Potential AdvantagesPotential Advantages
29. Esophageal ManometryEsophageal Manometry
• Assess LES pressure,Assess LES pressure,
location and relaxationlocation and relaxation
– Assist placement of 24 hr.Assist placement of 24 hr.
pH catheterpH catheter
• Assess peristalsisAssess peristalsis
– Prior to antireflux surgeryPrior to antireflux surgery
Limited role in GERDLimited role in GERD
30. GERD vs DyspepsiaGERD vs Dyspepsia
• Distinguish from DyspepsiaDistinguish from Dyspepsia
– Ulcer-like symptoms-burning, epigastric painUlcer-like symptoms-burning, epigastric pain
– Dysmotility like symptoms-nausea, bloating,Dysmotility like symptoms-nausea, bloating,
early satiety, anorexiaearly satiety, anorexia
• Distinct clinical entityDistinct clinical entity
• In addition to antisecretory meds and anIn addition to antisecretory meds and an
EGD need to consider an evaluation forEGD need to consider an evaluation for
Helicobacter pyloriHelicobacter pylori
31. Treatment Goals for GERDTreatment Goals for GERD
• Eliminate symptomsEliminate symptoms
• Heal esophagitisHeal esophagitis
• Manage or prevent complicationsManage or prevent complications
• Maintain remissionMaintain remission
32. Lifestyle Modifications areLifestyle Modifications are
Cornerstone of GERD TherapyCornerstone of GERD Therapy
• Elevate head of bed 4-6 inchesElevate head of bed 4-6 inches
• Avoid eating within 2-3 hours of bedtimeAvoid eating within 2-3 hours of bedtime
• Lose weight if overweightLose weight if overweight
• Stop smokingStop smoking
• Modify dietModify diet
– Eat more frequent but smaller mealsEat more frequent but smaller meals
– Avoid fatty/fried food, peppermint, chocolate,Avoid fatty/fried food, peppermint, chocolate,
alcohol, carbonated beverages, coffee and teaalcohol, carbonated beverages, coffee and tea
• OTC medications prnOTC medications prn
33. Better LivingBetter Living
• Lifestyle modificationsLifestyle modifications
– Avoid large mealsAvoid large meals
– Avoid acidic foods (citrus/tomato), alcohol, caffiene,Avoid acidic foods (citrus/tomato), alcohol, caffiene,
chocolate, onions, garlic, peppermintchocolate, onions, garlic, peppermint
– Decrease fat intakeDecrease fat intake
– Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal
– Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches
– Avoid meds that may potentiate GERD (CCB, alphaAvoid meds that may potentiate GERD (CCB, alpha
agonists, theophylline, nitrates, sedatives, NSAIDS)agonists, theophylline, nitrates, sedatives, NSAIDS)
– Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist
– Lose weightLose weight
– Stop smokingStop smoking
35. Better LivingBetter Living
• Lifestyle modificationsLifestyle modifications
– Avoid large mealsAvoid large meals
– Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic,Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic,
peppermintpeppermint
– Decrease fat intakeDecrease fat intake
– Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal
– Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches
– Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates,Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates,
sedatives, NSAIDS)sedatives, NSAIDS)
– Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist
– Lose weightLose weight
– Stop smokingStop smoking
36. TreatmentTreatment
• AntacidsAntacids
– Over the counter acidOver the counter acid
suppressants and antacidssuppressants and antacids
appropriate initial therapyappropriate initial therapy
– Approx 1/3 of patients withApprox 1/3 of patients with
heartburn-related symptomsheartburn-related symptoms
use at least twice weeklyuse at least twice weekly
– More effective than placeboMore effective than placebo
in relieving GERD symptomsin relieving GERD symptoms
37. TreatmentTreatment
• Histamine H2-Receptor AntagonistsHistamine H2-Receptor Antagonists
– More effective than placebo and antacids forMore effective than placebo and antacids for
relieving heartburn in patients with GERDrelieving heartburn in patients with GERD
– Faster healing of erosive esophagitis whenFaster healing of erosive esophagitis when
compared with placebocompared with placebo
– Can use regularly or on-demandCan use regularly or on-demand
39. TreatmentTreatment
• Proton Pump InhibitorsProton Pump Inhibitors
– Better control of symptoms with PPIs vsBetter control of symptoms with PPIs vs
H2RAs and better remission ratesH2RAs and better remission rates
– Faster healing of erosive esophagitis with PPIsFaster healing of erosive esophagitis with PPIs
vs H2RAsvs H2RAs
41. TreatmentTreatment
• H2RAs vs PPIsH2RAs vs PPIs
– 12 week freedom from symptoms12 week freedom from symptoms
• 48% vs 77%48% vs 77%
– 12 week healing rate12 week healing rate
• 52% vs 84%52% vs 84%
– Speed of healingSpeed of healing
• 6%/wk vs 12%/wk6%/wk vs 12%/wk
42. TreatmentTreatment
• Antireflux surgeryAntireflux surgery
– Failed medical managementFailed medical management
– Patient preferencePatient preference
– GERD complicationsGERD complications
– Medical complications attributable to a largeMedical complications attributable to a large
hiatal herniahiatal hernia
– Atypical symptoms with reflux documented onAtypical symptoms with reflux documented on
24-hour pH monitoring24-hour pH monitoring
43. TreatmentTreatment
• Antireflux surgery candidatesAntireflux surgery candidates
– EGD proven esophagitisEGD proven esophagitis
– Normal esophageal motilityNormal esophageal motility
– Partial response to acid suppressionPartial response to acid suppression
44. TreatmentTreatment
• Antireflux surgeryAntireflux surgery
– Tenets of surgeryTenets of surgery
• Reduce hiatal herniaReduce hiatal hernia
• Repair diaphragmRepair diaphragm
• Strengthen GE junctionStrengthen GE junction
• Strengthen antireflux barrier via gastric wrapStrengthen antireflux barrier via gastric wrap
• 75-90% effective at alleviating symptoms of75-90% effective at alleviating symptoms of
heartburn and regurgitationheartburn and regurgitation
45. TreatmentTreatment
• PostsurgeryPostsurgery
– 10% have solid food dysphagia10% have solid food dysphagia
– 2-3% have permanent symptoms2-3% have permanent symptoms
– 7-10% have gas, bloating, diarrhea, nausea,7-10% have gas, bloating, diarrhea, nausea,
early satietyearly satiety
– Within 3-5 years 52% of patients back onWithin 3-5 years 52% of patients back on
antireflux medicationsantireflux medications
46. TreatmentTreatment
• Endoscopic treatmentEndoscopic treatment
– Relatively newRelatively new
– No definite indicationsNo definite indications
– Select well-informed patients with well-documentedSelect well-informed patients with well-documented
GERD responsive to PPI therapy may benefitGERD responsive to PPI therapy may benefit
• Three categoriesThree categories
– Radiofrequency application to increase LES refluxRadiofrequency application to increase LES reflux
barrierbarrier
– Endoscopic sewing devicesEndoscopic sewing devices
– Injection of a nonresorbable polymer into LES areaInjection of a nonresorbable polymer into LES area
47. Effectiveness of Medical Therapies forEffectiveness of Medical Therapies for
GERDGERD
TreatmentTreatment ResponseResponse
Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %
HH22-receptor antagonists-receptor antagonists 50 %50 %
Single-dose PPISingle-dose PPI 80 %80 %
Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %
48. Treatment Modifications forTreatment Modifications for
Persistent SymptomsPersistent Symptoms
• Improve complianceImprove compliance
• Optimize pharmacokineticsOptimize pharmacokinetics
– Adjust timing of medication to 15 – 30 minutesAdjust timing of medication to 15 – 30 minutes
before meals (as opposed to bedtime)before meals (as opposed to bedtime)
– Allows for high blood level to interact withAllows for high blood level to interact with
parietal cell proton pump activated by the mealparietal cell proton pump activated by the meal
• Consider switching to a different PPIConsider switching to a different PPI
49. GERD is a Chronic Relapsing ConditionGERD is a Chronic Relapsing Condition
• Esophagitis relapses quickly after cessationEsophagitis relapses quickly after cessation
of therapyof therapy
– > 50 % relapse within 2 months> 50 % relapse within 2 months
– > 80 % relapse within 6 months> 80 % relapse within 6 months
• Effective maintenance therapy is imperativeEffective maintenance therapy is imperative
57. ComplicationsComplications
• Erosive esophagitisErosive esophagitis
– Responsible for 40-60% of GERD symptomsResponsible for 40-60% of GERD symptoms
– Severity of symptoms often fail to matchSeverity of symptoms often fail to match
severity of erosive esophagitisseverity of erosive esophagitis
59. ComplicationsComplications
• Barrett’s EsophagusBarrett’s Esophagus
– Columnar metaplasia ofColumnar metaplasia of
the esophagusthe esophagus
– Associated with theAssociated with the
development ofdevelopment of
adenocarcinomaadenocarcinoma
60. ComplicationsComplications
• Barrett’s EsophagusBarrett’s Esophagus
– Acid damages lining ofAcid damages lining of
esophagus and causesesophagus and causes
chronic esophagitischronic esophagitis
– Damaged area heals in aDamaged area heals in a
metaplastic process andmetaplastic process and
abnormal columnar cellsabnormal columnar cells
replace squamous cellsreplace squamous cells
– This specializedThis specialized
intestinal metaplasia canintestinal metaplasia can
progress to dysplasia andprogress to dysplasia and
adenocarcinomaadenocarcinoma
62. When to Discuss Anti-RefluxWhen to Discuss Anti-Reflux
Surgery with PatientsSurgery with Patients
• Intractable GERD – rareIntractable GERD – rare
– Difficult to manage stricturesDifficult to manage strictures
– Severe bleeding from esophagitisSevere bleeding from esophagitis
– Non-healing ulcersNon-healing ulcers
• GERD requiring long-term PPI-BID in aGERD requiring long-term PPI-BID in a
healthy young patienthealthy young patient
• Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms
• Not Barrett’s esophagus aloneNot Barrett’s esophagus alone
63. Partial fundoplication techniquesPartial fundoplication techniques
• Thal 90 deg. Ant. WrapThal 90 deg. Ant. Wrap
• Watson 120 deg ant-lat. wrapWatson 120 deg ant-lat. wrap
• Dor 150-200 deg ant. wrapDor 150-200 deg ant. wrap
• Toupet 270 deg posterior wrapToupet 270 deg posterior wrap
• Belsey Mark IV 270 deg transthoracicBelsey Mark IV 270 deg transthoracic
ant- lat wrap.ant- lat wrap.
64. Indications for partialIndications for partial
fundoplicationfundoplication
• 1.PRIMARY ESO. MOTILITY1.PRIMARY ESO. MOTILITY
DISORDERSDISORDERS
• Achalasia ( after myotomy)Achalasia ( after myotomy)
• SclerodermaScleroderma
• 2.SEC. ESOP. MOTILITY DISORDERS2.SEC. ESOP. MOTILITY DISORDERS
POOR MOTILITY SEC. TO CHRONICPOOR MOTILITY SEC. TO CHRONIC
/BARRETS ESOP/BARRETS ESOP
65. • 3. Inability to tolerate complete3. Inability to tolerate complete
fundoplicationfundoplication
• Dysphagia, gas bloatingDysphagia, gas bloating
• Chronic nauseaChronic nausea
• AerophagiaAerophagia
• Revision of obstructing360 deg wrapsRevision of obstructing360 deg wraps
66. Scores for heartburn (a) and acid regurgitationScores for heartburn (a) and acid regurgitation
(b) 12 months after an anterior or a posterior(b) 12 months after an anterior or a posterior
partial fundoplicationpartial fundoplication..
71. Endoscopic GERD TherapyEndoscopic GERD Therapy
• Endoscopic antireflux therapiesEndoscopic antireflux therapies
– Radiofrequency energy delivered to the LESRadiofrequency energy delivered to the LES
• Stretta procedureStretta procedure
– Suture ligation of the cardiaSuture ligation of the cardia
• Endoscopic plicationEndoscopic plication
– Submucosal implantation of inert material inSubmucosal implantation of inert material in
the region of the lower esophageal sphincterthe region of the lower esophageal sphincter
• EnteryxEnteryx
73. • This is how a laparoscopic fundoplication isThis is how a laparoscopic fundoplication is
performed to repair the antireflux valve inperformed to repair the antireflux valve in
patients with heartburn. It was performedpatients with heartburn. It was performed
by Dr Craig Taylor in Sydney. This type ofby Dr Craig Taylor in Sydney. This type of
anti-reflux procedure (anterioranti-reflux procedure (anterior
fundoplication) provides excellentfundoplication) provides excellent
heartburn control whilst minimising the sideheartburn control whilst minimising the side
effects that used to be common after theeffects that used to be common after the
older Nissen fundoplication, especially gasolder Nissen fundoplication, especially gas
bloating.bloating.
74. • This newer technique aims to restore theThis newer technique aims to restore the
function of the valve between stomach andfunction of the valve between stomach and
oesophagus in a more natural andoesophagus in a more natural and
anatomical way. Patients can expect to beanatomical way. Patients can expect to be
free of their heartburn and reflux and stopfree of their heartburn and reflux and stop
taking antireflux medication- for manytaking antireflux medication- for many
patients this can be quite life changing.Aspatients this can be quite life changing.As
with all surgical procedures there are risks,with all surgical procedures there are risks,
and patients need to be aware of these.and patients need to be aware of these.
75. • The procedure took approximately 1 hourThe procedure took approximately 1 hour
under a general anaesthetic, and onlyunder a general anaesthetic, and only
requires an overnight stay in hospital.requires an overnight stay in hospital.
Patients can generally return to work withinPatients can generally return to work within
a few days, and may resume all normala few days, and may resume all normal
physical activity including gym and liftingphysical activity including gym and lifting
within a monthwithin a month
Hinweis der Redaktion
--distinction between normal and GERD is blurred because some degree of reflux is physiologic is all folks Physiologic—postprandially, short lived, asymptomatic, not during sleep Pathologic—symptoms or mucosal injury and often with nocturnal symptoms
--At level of diaphragmatic hiatus—main deterrant to reflux --disruption due to –review slide--multifactorial
--Tums, rolaids, maalox --$1 billion in yearly expenditures --aluminum/calcium—constipation Mag--diarrhea
--otc dose uniformly half of standard lowest prescription dose --similar clinical efficacy
--no significant differences in symptomatic tx of GERD or healing of erosive esophagitis 1a evidence --works only on active pumps—take 30-60min prior to meals --long-term tx generally benefits outweigh risks
candidacy --esophagitis—by egd --need normal manometry/motility --partial response to acid suppression --reduce hh, repair diaphragm, strengthen ge jxn—antireflux barrier --75-90% effective at alleviating hrtburn/regurg --better at helping with hrtburn/regurg than atypical sx
Figure 11-18. Endoscopic appearance of benign strictures. Acid-septic strictures and Schatzki's rings are the most common strictures requiring dilation. Although in most instances endoscopic examination allows obvious distinction between the two, variation in air insufflation and the differences in magnification over short distances between the lower esophageal sphincter and the endoscope can make the assessment of the lower esophagus difficult in some patients. A subtle peptic stricture may be missed endoscopically, or, more precisely, may be confused with a Schatzki's ring. Contrast radiology can be a more sensitive technique for demonstrating subtle rings and strictures and for calibrating the lumen more precisely. A–C, Endoscopic photographs of several Schatzki's rings. D–G, peptic strictures. Note the esophageal pseudodiverticula proximal to the peptic stricture in panels F and G. Their presence increases the risk of unguided dilatation of the esophagus and mandates the use of a guidewire technique. H, Tight anastomotic stricture (suture at 10 o'clock) and “watermelon esophagus” viewed endoscopically. The watermelon seeds and kernel of corn provide a reference for the pinhole quality of this stricture.
Figure 11-21. Types of dilators: balloons. Balloon dilators are an additional option for the endoscopist approaching an esophageal stricture. They may be placed over a guidewire or through the scope (TTS). Theoretically, balloons have the advantage of being safer because of the radial application of force, and elimination of the shearing effect of rigid dilators. Moreover, dilation can be performed under direct visualization using the TTS balloon. Recent balloon innovations facilitating their use include longer balloons that avoid the tendency for slippage with inflation, and high-pressure balloons that should provide a truer diameter for the dilation of more resistant strictures. In the limited number of randomized studies comparing Savory-type dilators with balloon dilators, they appeared equally safe. Efficacy, as assessed by symptom improvement and luminal patency, has been variably reported in the literature favoring either technique [18], [19], [20]. A, Range of available balloons and an inflation gun. B–E, A peptic stricture before and after balloon dilation, thus demonstrating the direct visualization that is possible with the TTS technique. References: [18]. Saeed ZA, Winchester CB, Ferro PA, et al. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc 1995 41 189-195 [19]. Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilation of benign oesophageal stricture? An interim report of a randomized controlled trial. Gut 1988 29 1741-1747 [20]. Shemesh E, Czerniak A, Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures. World J Surg 1990 14 518-522
--black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --ulcerations in 2-7%
4-20% of patients
--1950—Norman Barrett --10-15% --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --RFs—male, smoker, age, obese
Adenoca with barretts 0.5%/yr--------without barretts 0.07%/yr