Objectives

1. Gastroesophageal reflux diseaseGERDRaika Jamali M.D.Gastroenterologist and hepatologist Sina Hospital Tehran University of Medical Sciences

2. Objectives • Appreciate the significance of GERD as a chronic disease • Identify patients with different presentations of GERD • Organize a rationale management plan for different types of GERD symptoms • Be familiar with various treatment modalities of GERD and their appropriate use

3. DefinitionsGERD: any symptomatic condition or histopathologic alteration resulting from episodes of gastroesophageal reflux●Erosive: 35% ●Nonerosive (NERD)

4. Why GERD is so important??● is very common & increasingBurden and Quality of life●complications: esophagitis, peptic stricture, inflammatory polyps ,Barrett's metaplasia , dysplasia ,adenocarcinoma

5. Epidemiology●Geographic variation● M=F●Barrett's metaplasia (M/F = 10 /1)

7. The prevalence of GERD in Asian populations is reported to be lower than that in the west. • Population-based data on the prevalence and symptom profile of GERD in developing Caucasian countries is lacking.

8. Frequency of Endoscopic GERD Iranian Experience: 1994-1999 Retrospective study of 4500 UGIE reports (5y): 34.3% E-GERD Malekzadeh,et al 2000

9. Prospective evaluation of referring Dyspeptics in Tehran • 269 (135 F) participant • Symptoms recorded, UGIE + Bx from Z-line was done: • 77.6% at least one major GERD symptom • 76.1% EE (most A & B) • 5% Specialized intestinal metaplasia • 3 Dysplasia • None of the symptoms could predict the endoscopic or histologic findings • Nasseri-Moghaddam, Malekzadeh et al 2002

10. CONCLUSION GERD is a common disease among Iranian general population and its prevalence is comparable with that of the western countries .

11. Pathogenesis●Transient L E S Relaxation●Hypotensive L E S●Anatomic Variables ●Delayed Gastric Emptying ●Esophageal Acid Clearance- Salivary Function-Impairments of Esophageal Emptying

12. اختلال پاك شدن مري اختلال عملكردبزاق هرني­هياتال اختلال مكانيسم­هاي دفاعيمخاطي شل شدن گذرا و نامناسب LES ترشح اسيد معده و پپسين: نرمال/افزايش يافته كاهش فشار استراحت LES بي­كفايتي دريچة پيلور؛ ريفلاكس دئودنوگاستريك تأخير تخليه معده

13. Case 1 • A 34 y engineer with heart burn for 8 y comes to your office for evaluation of his GERD symptoms. • He asks you about the diagnosis of GERD, if additional diagnostic work up is needed and his medical management.

14. Diagnosis ●History is usually sufficient to confirm the diagnosis Indications for Endoscopy Extra-esophageal or atypical symptoms Patients > 40 y with new onset GERD symptoms Dysphagia Weight Loss Anemia Family hx of Cancer Long(>5 y) or very severe symptoms

15. GERD-B

16. The Los Angeles Classification

17. GERD-A

18. GERD-C

19. GERD-D

21. Avoid: smoking stress Heavy meals Large quantities of liquid with meals Fatty foods Coffee Choclate Alcohol Mint Orange juice Tomato catch up Anticholinergic, calcium channel blockers, smooth muscle relaxants

24. Therapeutic regimens for GERD in order of increasing potency • Over-the-counter antacids and/or H2 receptor blockers • Omeprazole (20 mg QD) or equivalent dose of the other PPIs • Omeprazole (20 mg BID or 40 mg BD) or equivalent doses of the other PPIs

25. Step-up approach: with mild symptoms, no change in QOL • Step-down approach: with more severe symptoms affecting QOL or with higher grades of esophagitis / complications • Bed time H2B for nocturnal symptoms

26. Dose of the different H2 blockers Drug Daily dose • Cimetidine 800 mg • Ranitidine 300 mg • Famotidine 40 mg • Nizatidine 300 mg

27. PPI versus H2 blockers in treatment of erosive GERD symptoms (right panel) and esophageal healing (left panel)

28. PPI side effects • Pneumonia • Hypergastrinemia (Carcinoid tumor in animal model) • Enteric infections • Vitamin B12 malabsorption

29. PROKINETIC DRUGS • Metoclopramide • Cisapride • Tegaserod

30. Duration of therapy Maintenance therapy : lowest dose of PPI or H2 blockers, especially in severe esophagitis (grades C & D) and with complications (BE, stricture) Intermittent therapy : on-demand therapy in patients with mild to moderate heartburn without severe esophagitis.

32. Effective initial and long term mangement • Decreases amount of drugs used • Decreases doctor visits • Decreases the need for repeat UGIE (Bate et al 1992, Bloom et al 1994, Bardhan et al 1999)

33. Case 2 • Young woman with chronic cough who is refractory to treatment with sulbutamol is referred for evaluation of GERD. • She complains of morning hoarseness. • Sulbutamol was in effective and even aggravated her symptoms. • Laryngoscopy showed posterior vocal cord erythema. • Endoscopy showed esophagitis. • Symptoms respond to 20 mg of daily omeprazol.

34. CLINICAL PRESENTATIONTypical Symptoms●Heartburn● Regurgitation● Dysphagia

38. Case 3 • Middle age man is visited for evaluation of dysphagia to solids from 2 months duration. • He was a heavy smoker and used famotidine for heart burn for 14 y. • Ba swallow was performed. • Endoscopy and biopsy was done.

39. Proximal esophageal stricture

40. Peptic stricture

41. Hyperplasia of basal cells and infiltration of PMN with erosions in GERD.

42. Natural History●Peptic stricture ( 8 to 20 %)●Ulceration ( 5 %)●Significant bleeding ( 2 % )●Perforation extremely rare

43. Esophageal ulcer in reflux esophagitis

44. Case 4 • A 45 y old man with 25 y reflux symptoms comes to your office for evaluation of recent weight loss and dysphagia. • There was a histologic report of “Intestinal metaplasia” in distal esophagus in his last endoscopy 2 y ago. • Ba swallow and endoscopy was performed.

46. Adenocarcinoma

47. Barrett´s Esophagus

48. Barrett´s Esophagus