GAROINTESTINAL REFLUX DESEASE , REGURGITATION

GERD

1. . GASTR0ESOPHAGEAL REFLUX DISEASE (GERD) GERD 08-Sep-24 PRESENTED BY MUTEGEKI ADOLF

2. Objectives Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manisfestations Diagnostic Evaluation Treatment Complications

3. Definition Gastroesophageal Reflux Disease (GERD) is a chronic condition where stomach contents, including acid and bile, flow back (reflux) into the esophagus, leading to symptoms like heartburn and regurgitation. GERD occurs when the lower esophageal sphincter (LES) is weak or relaxes inappropriately, allowing the stomach contents to flow back into the esophagus.

4. ETIOLOGY/ RISK FACTORS Weak or dysfunctional LES: The primary cause of GERD is a LES that relaxes inappropriately or is weakened, allowing stomach contents to reflux. Hiatal hernia: A condition where part of the stomach pushes up through the diaphragm into the chest cavity, which can compromise the LES function. Obesity: Increased abdominal pressure can lead to reflux. Pregnancy: Hormonal changes and increased abdominal pressure can contribute to GERD

5. Smoking: Reduces LES pressure and increases acid production. Dietary factors: Certain foods and beverages, such as fatty foods, caffeine, chocolate, alcohol, and spicy foods, can trigger reflux. Medications: Certain drugs, including calcium channel blockers, anticholinergics , and NSAIDs, can relax the LES or irritate the esophageal lining. Delayed gastric emptying: Conditions that slow stomach emptying can increase the likelihood of reflux.

6. Physiologic vs Pathologic Physiologic GERD Postprandial(eating) Short lived Asymptomatic No nocturnal symptorms Pathologic GERD Symptoms Mucosal injury Nocturnal symptoms

7. What happens during nonpathologic reflux

8. Epidemiology GERD occurs in all ages but, most common in those older than 40 years of age. About 10-20% of people in western countries suffer from GERD symptoms on a weekly basis About 7% have symptoms daily. Except for NERD and pregnancy , no much difference in incidence between men and women. But for Barrett’s esophagus, prevalence is more in males particularly white adult males.

9. PATHOPHYSIOLOGY 1) Decreased lower esophageal sphincter pressure Primary barrier to gastro esophageal reflux is the lower esophageal sphincter LES normally works in conjunction with the diaphragm If barrier disrupted, acid goes from stomach to esophagus May be due to Spontaneous transient LES relaxations Transient increase in intra abdominal pressure An atonic LES

10. Factors affecting les tone Drugs that reduce LES tone include calcium channel antagonists (e.g., nifedipine , verapamil, diltiazem ), nitrates, anticholinergic agents( e.g.,tricyclic antidepressants , antihistamines), and oral contraceptives and estrogen. Foods that reduce LES tone include chocolate, fatty foods , onions, peppermint, and garlic Smoking(nicotine) reduces LES tone.

11. 2)DISRUPTION OF ANATOMICAL BARRIERS Associated with hiatal hernia The size of hiatal hernia is proportional to the frequency of LES relaxations Hypotensive LES pressures and large hiatal hernia- more chance of GERD following abrupt increase in intra abdominal pressure 3) esophageal clearance The GI acid produced spent too much time in contact with the esophageal mucosa Normally swallowing contributes to esophageal clearance by increasing salivary flow Saliva decreases with increasing age, so more often seen with elderly.

12. 4)MUCOSAL RESISTANCE The mucus secreated by the mucus secreting glands involves in the protection of esophagus The bicarbonates moving from the blood to the lumen can neutralize acidic refluxate in the esophagus. On repeated exposure to the refluxate or due to some defect in normal mucosal defenses hydrogen ions diffuse into the mucosa, leading to cellular acidification and necrosis leading to esophagitis. 5)DELAYED GASTRIC EMPTYING An increase in gastric volume may increase both the frequency of reflux and the amount of gastric fluid available to be refluxed Physiologic Postprandial Gastro esophageal reflux occurs

13. PATHOGENESIS Amount of esophageal damage seen dependent on: Composition of refluxed material Volume of refluxed material Length of contact time Natural sensitivity of esophageal mucosa Rate of gastric emptying

14. COMPLICATIONS Esophagitis Esophageal strictures and ulcers Hemorrhage Perforation Aspiration Development of Barrett’s esophagus ( cahage in the lining of esophagus to be more like that of small intestines) Precipitation of an asthma attack

15. Erosive esophagitis Erosive esophagitis is a condition in which areas of the esophageal lining are inflamed and ulcerated. The most common cause of erosive esophagitis is chronic acid reflux. Responsible for 40-60% of GERD symptoms Severity of symptoms often fail to match severity of erosive esophagitis.

16. Esophageal stricture A benign esophageal stricture , or peptic stricture , is a narrowing or tightening of the esophagus that causes swallowing difficulties. May need dilation Common in the distal esophagus and are generally 1 to 2 cm in length.

17. Barrett’s Esophagus Columnar metaplasia of the esophagus,i.e replacement of the squamous epithelial lining of the esophagus by specialized columnar- type epithelium Associated with the development of adenocarcinoma Have a greater chance (30%) of developing esophageal stricture

18. Asthma GERD can lead to the reflux of fluid into the lungs ; this can result in choking, coughing , or even pneumonia . In some patients, reflux may worsen asthma symptoms . Treating GERD may help improve asthma symptoms in these people. And GERD can be worsened by asthma and by some of the medicines that are used to treat asthma . GERD can also lead to chronic hoarseness, sleep disturbance, laryngitis , halitosis ( bad breath ), growths on the vocal cords, a feeling as if there is a lump in your throat.

19. CLINICAL PRESENTATIONS Heartburn: A burning sensation in the chest, usually after eating, which might worsen when lying down or bending over. Regurgitation: A sour or bitter-tasting acid backing up into the throat or mouth. Dysphagia: Difficulty swallowing or feeling of a lump in the throat. Chest pain: May mimic cardiac pain but is related to reflux. Chronic cough, laryngitis, or hoarseness: Due to reflux affecting the throat and larynx. Nausea and vomiting: In some cases, GERD can cause persistent nausea.

20. CLASSES OF SYMPTOMS Typical symptoms May be aggravated by activities that worsen gastroesophageal reflux such as recumbent position, bending over, or eating a meal high in fat. Heartburn — retrosternal burning discomfort (behind the breastbone) Regurgitation (spitting up of food) —effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions Water brash (hyper salivation) Belching

21. Alarm Signs/Symptoms These symptoms may be indicative of complications of GERD such as Barrett’s esophagus, esophageal strictures, or esophageal cancer Dysphagia (difficulty swallowing ) Early satiety (feeling full) GI bleeding Odynophagia (painful swallowing) Vomiting Unexplained Weight loss Iron deficiency anemia Choking Continual pain

22. INVESTIGATIONS Clinical history and physical examination: Often sufficient for diagnosis based on symptoms. Upper endoscopy (EGD): To visualize the esophagus, look for inflammation, erosions, or Barrett's esophagus, and rule out other conditions. 24-hour pH monitoring: Measures acid levels in the esophagus over 24 hours to confirm abnormal acid exposure. Esophageal manometry : Assesses the function of the LES and esophageal motility. Barium swallow ( esophagram ): An X-ray study to visualize reflux and assess for structural abnormalities. Bravo pH monitoring: A wireless capsule attached to the esophagus that measures acid exposure over a 48-hour period.

23. Barium Swallow An esophagram or barium swallow is an X-ray imaging test used to visualize the structures of the esophagus. The patient swallows liquid barium while X-ray images are obtained. The barium fills and then coats the lining of the esophagus so that it can diagnose anatomical abnormalities such as tumors . Useful first diagnostic test for patients with dysphagia Stricture (location, length) Mass (location, length) Hiatal hernia (size, type) Limitations Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus

24. Endoscopy Indications Alarm symptoms Empiric therapy failure Preoperative evaluation Detection of Barrett’s esophagus

25. Ambulatory 24 hr. pH Monitoring Normal GERD

26. Treatment Goals of therapy Alleviate or eliminate the patients symptoms. Decrease the frequency or recurrence and duration of gastro esophageal reflux. Promote healing of the injured mucosa. Prevent the development of complications.

27. MANAGEMENT: 1. Lifestyle and dietary modifications: Eat smaller, more frequent meals and avoid eating close to bedtime. Avoid trigger foods (e.g., fatty foods, caffeine, alcohol, chocolate, spicy foods). Elevate the head of the bed to prevent nighttime symptoms. Avoid lying down immediately after meals. Maintain a healthy weight and quit smoking.

28. 2. Medications: Antacids: Provide quick, short-term relief by neutralizing stomach acid. H2 receptor blockers (e.g., ranitidine, famotidine): Reduce acid production. Proton pump inhibitors (PPIs) (e.g., omeprazole, esomeprazole): More effective in reducing stomach acid production and healing the esophagus. Prokinetics (e.g., metoclopramide): Help strengthen the LES and speed up gastric emptying, though used less frequently due to side effects.

29. Treatment Antacids Over the counter acid suppressants and antacids appropriate initial therapy Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly More effective than placebo in relieving GERD symptoms

30. 3. Surgical interventions: Fundoplication (e.g., Nissen fundoplication): A surgical procedure where the top of the stomach is wrapped around the LES to strengthen it and prevent reflux. LINX device: A ring of magnetic beads is placed around the LES to augment its function without inhibiting swallowing or belching.

31. Nissen Fundoplication Laparoscopic

32. Complete vs. partial fundoplication Ant. partial fundoplication  Thal/Dor procedure Post. partial fundoplication  Toupet procedure

33. TREATMENT Postsurgery 10% have solid food dysphagia 2-3% have permanent symptoms 7-10% have gas, bloating, diarrhea, nausea, early satiety Within 3-5 years 52% of patients back on antireflux medications

34. TTS Balloon Dilation of a Peptic Stricture

35. PREVENTION: Maintain a healthy weight to reduce abdominal pressure. Avoid foods and drinks that trigger reflux symptoms. Eat meals at least 2-3 hours before lying down or going to bed. Elevate the head of the bed or use wedge pillows to prevent nighttime symptoms. Avoid smoking and alcohol consumption. Use medications like NSAIDs cautiously and under supervision if prone to GERD symptoms.