Gastro Oesophagal Reflux Disease

1. Gastro Oesophageal
reflux disease (GERD)
Presented By Miss Sudipta Roy
Associate Professor
East Point College of Pharmacy

2. Gastro Oesophageal reflux
disease (GERD).
The term gastrooesophageal refers to the stomach and
esophagus. Reflux meas to flow back or return .
Gastroesophageal reflux is when the content of stomach
backs up into esophagus.
Definition :
Gastro-oesophageal reflux disease occurs when stomach acid
leaks from the stomach and moves up into the oesophagus
(food pipe). This is also known as 'reflux'.
or,
It is a digestive disease in which stomach acid or bile irritates
the food pipe lining.It occurs when stomach and frequently
flows back into the tube connecting mouth and stomach
(esophagus). This backwash (acid reflux) can irritate the
linining of the esophagus.

3. Etiology .
• When we eat , food passes , from the throat to the
stomach through the esophagus . A ring of muscle
fibres in the lower esophagus prevents swallowed
food from moving back up. These muscle fibers are
called the lower esophageal sphincter (LES).
• When this ring of muscle does not close all the way,
stomach contents can leak back into the
esophagus. This is called reflux or gastroesophageal
reflux. Harsh stomach acids can also damage the
lining of esophagus.
• Smoking
• Eating large meals or eating late at night.

4. Other Risk Factors for Reflux
Use of Alcohol
Haital hernia (a condition in which part of the
stomach moves above the diaphragm , which is the
muscle that separates the chest and abdominal
cavities)
obesity
pregnancy
scleroderma
smoking
reclining within 3 hours after eating

5. Pathophysiology
• If the lower esophageal sphincter does not close
properly - decreased LES pressure - Intragastric
pressure increases - hypersecretion of acid (reflux) -
prolonged esophageal mucosal acid contact -
esophagitis -decreased acid clearnce resulting from
impaired peristalsis-GERD

6. Clinical Manifestations
• The most common symptoms of GERD include:
• Heartburn (acid indigestion)
• Burning chest pain that starts behind the
breastbone and moves upward to neck and throat.
• Feeling like food is coming back into the
mouth,leaving an acid or bitter taste.
• Pain in stomach
• Nausea
• Bad breath
• Trouble breathing

7. Diagnosis
• Endocopy :
• A small lighted tube is put with a tiny video camera on the end
(endoscope) into esophagus to look for inflammation or irritation
of tissue (esophagitis) . If the results are abnormal , then a small
tissue sample can be removed for more testing (biopsy).
• Upper GI series : It's a special X-Ray that shows your esophagus,
stomach and the upper part of your small intestine (duodenum) .
It gives limited information about possible reflux, but it can help
rule out other conditions , such as peptic ulcers.
• Esophageal Manometry : This test checks for low pressure in the
esophagus . It can also show defects in how your esophageal
muscles contract.
• pH testting : If it's hard to make a definite diagnosis , your doctor
may measure the acid levels inside the esophagus through this
test.

8. Treatment.
• 1. Non-Pharmacological Treatment :
• GERD is usually first treated via lifestyle
modifications , such as :
• Keeping the head of the bed elevated.
• Stay at a healthy weight : Being overweight often
worsen symptoms . Many overweight people find
releif when they lose weight.
• Quit smoking : cigarette smoking weakens the LES .
Stopping smoking is important to reduce GERD
symptoms .

9. Avoid foods and beverages
triggers.
• Stay away from foods that can relax the LES , including
chocolate , peppermint , fatty foods , caffeine and alcoholic
beverages. You should also avoid foods and bevarages that
can irritate a damaged esophageal lining if they cause
symptoms such as citrus and juices, tomato products , and
pepper .
• Eat smaller servings : Eating smaller portions at mealtime
may also help control symptoms. Also eating meals at least
2 to 3 hours before bedtime.
• Chew your food thoroughly and eat slowly : Take your time
at every meal .
• Wear loose clothes : Clothes that squeeze your waist put
pressure on your belly and the lower part of your
esophagus.
• Acupuncture : It may also stop reflux.

10. Pharmacological Treatment.
• The aim of GERD treatment to cut down the amount of reflux or decrease the
damage to the lining of oesophagus from acid.
• Antacids : These drugs neutralize the acid in esophagus and stomach and stop
heartburn .
• Examples : Aluminium hydroxide gel , Calcium carbonate , Magnesium hydroxide
(Milk of Magnesia ) , Gaviscon , Gelusil , Pepto-Bismol.
• H2 blockers : These medicines bind on H2 receptors on stomach and block the
acid secretion in the stomach .
• Examples: Cimetidine , Famotidine , Ranitidine and Nizatidine.
• Proton Pump Inhibitors (PPIs): These drugs block a protein needed to make
stomach acid .
• Examples : Omeprazole , Pantoprazole , Dexlansoprazole , Esomeprazole ,
Lansoprazole and Rabeprazole .
• Prokinetics :
• In rare cases, these drugs help your stomach empty faster so you don't have as
much acid left behind. They also help with symptoms like bloating, nausea , and
vomiting .
• Examples : Domperidone and Metoclor pramide

11. Peptice Ulcer.
• Peptic refers to pepsin . Pepsin is stomach enzyme
enzyme that breaks down protein . An ulcer occurs
when the linining of these organs is corroded by the
acidic digestive juices secreted by the stomach cells .
• Definitions : Peptic ulcers are the lesions (sores) that
develop in the mucosal lining of the stomach , lower
esophagus , small intestine or any other part of git.
• or
• peptic ulcer is a lesion in the lining (mucosa) of the
digestive tract , typically in the stomach or duodenum ,
caused by the digestive action of pepsin and stomach
acid .

12. • There are three common forms of peptic
ulcers :
• 1. Helicobacter pylori (h.Pylori ) associated ulcers.
• 2. Non steroidal anti-inflammatory drug (nsaids) induced
ulcers.
• 3. Stress related mucosal damage (stress ulcers).
• Types of ulcers :
• Generally , ulcers develop occur in three parts of the GI
tract and are classified them .
• 1.Gastric ulcers : Gastric ulcers develop on the inner
linining of the stomach from digestive juices is reduced. It
allows the diestive acids to destruct tissues that line the
stomach causing an ulcer.

13. • Esophageal Ulcers :
• Esophageal ulcers develop inside the esophagus . If
the lower esophageal sphincter (LES) does not
close properly then stomach acid can leak back into
the esophagus . This causes chronic inflammation
and irritation of esophagus , allowing ulcers to
develop.
• Duodenal Ulcers :
• Deuodenal Ulcers develop on the inside of the
upper part of the small intestine , known as the
duodenum . It is the common type of peptic ulcer .

14. Etiology .
• There are number of which are responsible for the development of
ulcers. These are :
• 1. Peptic ulcers occur when acid in the digestive tract eats away at
inner surface of the stomach or small intestine . The acid can create
a painful open sore that may bleed . The digestive tract is coated
with a mucous layer that normally protects against acid. But if the
amout of acid is increased or the amount of mucus is decreased , it
may develop an ulcer.
• Helicobacter pylori : Helicobacter pylori bacteria commonly live in
the mucous layer that covers and protects tissues that line the
stomach and small intestine. H.pylori bacterium has ability to
produce enzyme uerease. This urease splits urea into the ammonia
and CO2. This action is particularly responsible for its survival in acid
media of stomach where it causes inflammation and triggers peptic
ulcer. H.pylori adheres to the gastric mucosa and avoids gastric
clearance. It also produces protease and lipase that are responsible
for degradation of gastric mucus and cell injury from back infusion
of gastric acid.

15. • Regular use of NSAIDs:
• NSAIDs are well known for development of peptic ulcer .
Aspirin , as well as certain over-the-counter and
prescritption pain medications called nonsteroidal anti-
inflammatory drugs (NSAIDs). can irritate or inflame the
lining of the stomach and small intestine . These
medications include ibuprofen , naproxen sodium ,
ketoprofen and others.
• other medications.
• Taking certain other medications along with NSAIDs, such
as steroids , anticoagulants , low-dose aspirin , selective
serotonin reuptake inhibitors (SSRIs), alendronate
(Fosamax) and risedronate (Actonel ), can greatly increase
th chance of developing ulcers.

16. • Other Risk Factors :
• Risk Factors that make ulcers more likely
• include:
• Family History
• Genetic Factors
• Obesity
• Smoking
• Alcohol consumption
• Coffee consumption
• Stress
• Eas-spicy

17. Pathophysiology .
• In stomach both type of factors are present one which are
protectors of the stomach mucosal lining and the other that are
harmful to stomach mucosal cells. There is a balance between
these two factors. If this balance disturbs then it causes the injury
to stomach mucosal lining.
• Agreesive factors such as NSAIDs, h.Pylori infection , acid , pepsin
, alcohol , bile salts can alter the mucosal defense mechanism by
allowing back diffusion of hydrogen ions and subsequent epthelial
cell injury .
• H.pylori bacteria excretes the enzyme urease which converts urea
into ammonia and bicarbonate . The release of ammonia
neutralizes the acidic environment in the stomach . This action is
particularly responsible for its survival in the stomach . Ammonia
is toxic to the epithelial cell and it damage the lining of the
stomach that leads to peptic ulcer .

18. Clinical Manifestations.
• The most common peptic ulcer symptom is burning stomach pain in the middle of the abdomen
. Stomach acid makes the pain worse , as does having an empty stomach . The pain will be more
intense when stomach is empty and it can last for a few minutes to several hours.
• Other common symptoms of ulcers include :
• Feeling of fullness,bloating or belching
• Intolerance to fatty foods
• Heart burn
• Nausea
• Loss of weight
• Not willing to eat due to pain
• Many people with peptic ulcers don't even have symptoms.
• Many people with peptic ulcers don't even have symptoms.
• Less often , uncelrs may severe signs or symptoms such as :
• Vomiting
• Dark blood in stools , or stools that are black or tarry
• Trouble breathing
• Feeling faint
• Appetite changes

19. Diagnosis .
• 1. Laboratory test for h.pylori :
• Blood test
• Stool test
• Breathe test : The breath test is the most accurate. For the breathe test
, you drink or eat something that contains radioactive carbon . H.Pylori
breaks down the substance in your stomach . Later , you blow into a bag
, which is then sealed . IF you are infected with h.Pylori , your breath
sample will contain the radioactive carbon in the form of carbon
dioxide.
• Endoscopy : Doctor may use a scope to examine upper digestive system
endoscopy . During endoscopy , doctor passes a hollow tube equipped
with a lens (endoscope) down the throat and into the esophagus ,
stomach and small intestine. Using the endoscope , doctor looks for
ulcers.
• Biopsy : If doctor detectcs an ulcer , a small tissue sample (biopsy ) may
be removed for examination in a lab. A biopsy can also identify whether
h.pylori is in the stomach lining.

20. Upper gastroinestinal series:
• Sometimes called a barium sswallow , this series of
x-rays of upper digestive system creates images of
the esophagus , stomach and small intestine.
• During the X-ray , you swallow , this series of x-rays
of upper digestive system creates images of the
esophagus, stomach and small intestine.
• During the x-ray , you swallow a white liquid
(containing barium) that coats your digestive tract
and makes an ulcer more visible.

21. • Avoid alcohol
• Control disease
• 2. Pharmacological treatment : The drug include
• 1. Cytoprotective drugs : These drugs have mucosal protective properties.
• Example : sucralfates, bi-chelates , misoprostol and antacids like sodium
bicarbonates.
• 2. Antitbiotics : To kill h.Pylori bacterium
• Example: amoxicillin , metronidazole
• Antisecretory drugs : these drugs reduce gastric acid secretion.
• A. H2 blockers : ranitidine , cimetidine , famotidine , nizatidine .
• B. Proton pump inhibitors : omeprazole, pantoprazole , lansoprazole ,
rabeprazole
• C. Anti-muscarinic drugs : These drugs reduce pepsin and acid secretion.
• Examples : Pinerzepine and telenzepine.