This document discusses Gastroesophageal Reflux Disease (GERD). It defines GERD as refluxed stomach contents entering the esophagus or beyond, causing symptoms or complications. The document discusses the epidemiology, anatomy, mechanisms of reflux, etiology, pathophysiology, clinical manifestations, diagnostic evaluation and treatment approaches for GERD, including lifestyle modifications, medications like PPIs, and surgical procedures. The goals of treatment are to alleviate symptoms, decrease reflux frequency and promote healing of injured mucosa.

1. Gastro Esophageal Reflux
Disease
K.DINESH KUMAR
PHARM.D 4TH YEAR

2. DEFINITION
OF GERD
DIAGNOSTIC
EVALUATION
EPIDEMOLOGY
OF GERD
BASIC
ANATOMY
BODY REFLUX
PREVENTING
MECHANISMS
ETIOLOGY
PATHOPHYSIOLOGY
OF GERD
CLINICAL
MANIFESTATIONS
TREATMENT
OBJECTIVES

3. SYMPTOMS OR COMPLICATIONS
RESULTING FROM THE REFLUXED
STOMACH CONTENTS INTO THE
ESOPHAGUS OR BEYOND INTO THE
ORAL CAVITY (INCLUDING THE
LARNYX) OR LUNG.
DEFINITION

5. EPIDEMIOLOGY
• GERD OCCURS IN ALL AGES BUT MOST
COMMON IN THOSE OLDER THAN 40 YEARS OF
AGE.
• ABOUT 7% HAVE SYMPTOMS DAILY.
• EXCEPT FOR NERD AND PREGNANCY , NOT
MUCH DIFFERENCE IN INCIDENCE BETWEEN
MEN AND WOMEN.
• BUT FOR BARRETT ESOPHAGUS PREVALENCE
IS MORE IN MALES PARTICULARLY WHITE
ADULT MALES.

6. BASIC ANATOMY
“The upper GI or gastro-intestinal
tract consists of the:
Mouth
Pharynx
Esophagus
Stomach
The small & large intestines form
the lower GI tract”.

7. Peristalsis continues in the
esophagus.
The food is carried
from the esophagus
to the stomach
where acid
production is formed.

8. There are specialized cells deep in the
stomach lining that affect the rate of
acid production. The primary cells
which contribute to acid production
are known as parietal cells.

9. The binding of these 3 receptors in the
parietal cells initiates the process of
acid production.
PARIETAL
CELLS
Acetylcholine Gastrin Histamine

10. The 3 mechanisms during
swallowing that keep acid out of the
esophagus include:
“Swallowed saliva which helps
neutralize stomach acid”.
“Sweeping muscles contractions that
act to cleanse the lower esophagus of
stomach acid”.
Protective contracture of the LES

11. The 3 mechanisms of the lower
esophageal sphincter (LES)
which prevent backflow are:
Pressure in the LES is greater than
that of the stomach.
High levels of Acetylcholine, a
neurotransmitter increases
constriction of the LES.
Gastrin, a hormone also increases
constriction of the LES.

12. PATHOPHYSIOLOGY
1. TRANSIENT RELAXATIONS OF LES
2. ESOPHAGEAL ACID CLEARENCE
AND BUFFERING CAPACITIES
3. ANATOMIC ABNORMALITIES
4. GASTRIC EMPTYING
5. MUCOSAL RESISTANCE

14. This discomfort can be
precipitated by lifestyle, diet,
and even certain medications.
ETIOLOGY

15. Lifestyle
“Smoking – Inhibits saliva, may also
increase acid production & weaken the
LES”.
Certain exercising & bending – that may
increase the abdominal pressure.
“Wearing of tight clothing – increases the
abdominal pressure”.
Lying flat after a meal – relaxes the
muscles making susceptibility for reflux.

16. Diet
“Fatty, greasy foods - take longer to digest
keeping food in the stomach longer”.
“Peppermint, spearmint, and chocolate
weaken the LES”.
“Carbonated and alcoholic beverages
increase the acidity in the stomach”.
Large meal portions – produce large acid
levels.
Citrus, onions, and acid from tomatoes can
be irritating to the esophagus.

17. “Medications that relax the LES”
Benzodiazepines
Theophylline
Narcotics
containing codeine.
Calium channel
Blockers
Nitroglycerine
Anticholinergics
Potassium
supplements
Iron supplements
NSAIDS
Fosamax
Erythromycin

18. Some conditions that can interfere
with the 3 mechanisms of the Lower
Esophageal Sphincter (LES):
OBESITY - “excess weight puts extra pressure on
the stomach & diaphragm”.
Pregnancy – “results in greater pressure on the
stomach & also has a higher level of
progesterone. This hormone relaxes many
muscles, including the LES”.
ASTHMA – it is unsure why, but, is believed that
the coughing leads to pressure changes on the
diaphragm.
HIATAL HERNIA – which is the following topic.

19. “In individuals with hiatal hernia, the
opening of the esophageal hiatus is
larger than normal, and a portion of
the upper stomach slips up or passes
(herniates) through the hiatus and into
the chest.”
A hiatal hernia is an
anatomical abnormality

20. “The diaphragm supports and puts
pressure on the sphincter to keep it
closed when you’re swallowing”.
“But a hiatal hernia raises the
sphincter above the diaphragm,
reducing pressure on the valve. This
causes the sphincter muscle to open
at the wrong time”.

21. HIATAL HERNIA

23. There are 3 inflammatory
processes that can occur with
esophagitis:
Erosive Esophagitis
Esophageal Strictures
Barrett’s Esophagus

24. EROSIVE ESOPHAGITIS

25. ESOPHAGEAL STRICTURES

26. BARRETS ESOPHAGITIS

27. DIAGNOSTIC EVALUATION
1. ACID SUPRESSION EMPIRIC TEST
A trial of a PPI is commonly used to empirically
diagnose typical GERD-like symptoms in patients
without alarm symptoms or symptoms of
complicated disease.
Doses used in clinical trials range from 20 to 80 mg
of omeprazole (or equivalent) once daily for
up to 4 weeks. If symptoms are relieved after a
short trial of a PPI(7 to 14 days) an empiric
diagnosis of GERD may be made and other
invasive and costly diagnostic methods may be
avoided.

28. 2. UPPER ENDOSCOPY
AND BIOPSY

29. 3. 24 – HOURS
CONTINUOUS
AMBULATORY
PH MONITORING

30. 4. RADIOLOGIC TESTING
(BARIUM ESOPHAGRAM)

31. 5. ESOPHAGEAL MANOMETRY/
HIGH – RESOLUTION
ESOPHAGEAL PRESSURE
TOPOGRAPHY (HREPT)

32. GOALS OF THERAPY
1. ALLIVATE OR ELIMINATE THE PATIENT
SYMPTOMS.
2. DECREASE THE FREQUENCY OR
RECURRENCE AND DURATION OF REFLUX.
3. PROMOTE HEALING OF INJURED
MUCOSA .
4. PREVENT THE DEVELOPMENT OF
COMPLICATIONS.

33. TREATMENT APPROACHES
A. MEDICAL TREATMENT
a) LIFESTYLE MODIFICATIONS
b) PHARMACOLOGIC THERAPY
1) H2 BLOCKERS
2) PROTON PUMP INHIBITORS
3) ANTACIDS
4) PROKINETIC DRUGS
5) SUCRALFATE
B. ANTIREFLUX SURGERY

37. ANTI REFLUX PROCEDURES
NISSEN FUNDOPLICATION

38. STRETTA PROCEDURE

39. ENDOSCOPIC SUTURING