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gastroesophageal reflux disease GERD. Department of gastroenterology, 1 st hospital of jilin university Tongyu Tang. Definition. American College of Gastroenterology (ACG)

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gastroesophageal reflux disease gerd

gastroesophageal reflux diseaseGERD

Department of gastroenterology,

1st hospital of jilin university

Tongyu Tang

definition
Definition
  • American College of Gastroenterology (ACG)
    • Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
    • Often chronic and relapsing
    • May see complications of GERD in patients who lack typical symptoms
slide3

GERD

Barrett’s esophagus,BE

non-erosive reflux disease, NERD

reflux esophagitis, RE

epidemiology
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
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

Decreased Salivation

Impaired Tissue Resistance

LES

Impaired Esophageal Clearance

Hiatal Hernia

Decreased LES Resting Tone

Duodenum

Delayed Gastric Emptying

Bile Reflux

clinical manisfestations
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 manisfestations1
Clinical Manisfestations
  • Dysphagia—difficulty swallowing
  • Other symptoms include:
    • Chest pain, water brash, globus sensation, odynophagia, nausea
  • Extraesophageal manifestations
    • Asthma, laryngitis, chronic cough
complications
Complications

Stricture

Barrett’s esophagus

Bleeding

complications1
Complications
  • Esophageal stricture
    • Result of healing of erosive esophagitis
    • May need dilation
complications2
Complications
  • Barrett’s Esophagus
    • Columnar metaplasia of the esophagus
    • Associated with the development of adenocarcinoma
complications3
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
slide13

Diagnostic Tests for GERD

Endoscopy

Barium swallow

Ambulatory pH monitoring

Esophageal manometry

esophagogastrodudenoscopy
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
slide16

la classification of esophagitis
LA Classification of Esophagitis

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

24 hour esophageal ph monitoring
24-Hour Esophageal pH Monitoring

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

Documents correlation between reflux episodes and symptoms

Sensitivity (77-100%)

Normal in 25% of esophagitis!

Specificity 85-100%

Most useful when diagnosis still unclear

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

slide21
Ambulatory 24 hr. pH Monitoring
  • Physiologic study
  • Quantify reflux in proximal/distal esophagus
    • % time pH < 4
    • DeMeester score
  • Symptom correlation
esophageal manometry
Esophageal Manometry

Limited role in GERD

  • Assess LES pressure, location and relaxation
    • Assist placement of 24 hr. pH catheter
  • Assess peristalsis
    • Prior to antireflux surgery
slide23

A级

B级

D级

C级

slide24

Treatment Goals for GERD

Eliminate symptoms

Heal esophagitis

Manage or prevent complications

Maintain remission

better living
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
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
treatment1
Treatment

AGENT EQUIVALENT DOSAGE

DOSAGES

Cimetadine 400mg twice daily 400-800mg twice daily

Tagamet

Famotidine 20mg twice daily 20-40mg twice daily

Pepcid

Nizatidine 150mg twice daily 150mg twice daily

Axid

Ranitidine 150mg twice daily 150mg twice daily

zantac

treatment2
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
treatment3
Treatment

AGENT EQUIVALENT DOSAGE

DOSAGES

Esomeprazole 40mg daily 20-40mg daily

Nexium

Omeprazole 20mg daily 20mg daily

Prilosec

Lansoprazole 30mg daily 15-10md daily

Prevacid

Pantoprazole 40mg daily 40mg daily

Protonix

Rabeprazole 20mg daily 20mg daily

Aciphex

endoscopic treatments
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
Surgical Treatment
  • Indications
    • Esophagitis
    • Stricture
    • Barrett’s metaplasia
    • Medication failure
  • Purpose of surgery  restoration the LES