Gastro -esophageal reflux disease (GERD)

Gastro esophageal reflux diseases (GERD) is upper GI tract disease cause by reverse acid secretion in esophagus from stomach.
Anatomy of esophagus will change, there will be a transient LES relaxation and excessive acid secretion will cause erosion and some other complication in GI tract.
Heart burn, chest pain. Throat burn, pyrosis, regurgitation are common sign and symptoms of the disease.
risk factors are smoking, alcohol, pregnancy, age, body position, food and some drugs.
Antacid, H2RA, PPI are mainly given to treat this patient.

1. Gastro esophageal reflux disease (GERD) By : Dr. Swati S. Sandhan Met’ Institute of P harmacy, Nashik

2. Definition : Gastro esophageal reflux disease (GERD) refers to symptoms or mucosal damage resulting from the abnormal retrograde movement of gastric contents from the stomach into the esophagus. When the esophagus is repeatedly exposed to refluxed material for prolonged periods, inflammation of the esophagus (reflux esophagitis) can occur and in some cases it progresses to erosion of the squamous epithelium (erosive esophagitis).

3. Etiology : 1.Impaired esophageal acid clearance 2.Impairment in the tone of the lower esophageal sphincter (LES) 3.Transient LES relaxation 4 . Delayed gastric emptying are included in the causation of GERD. 6 .Presence of hiatal hernia 5.Increase in intra-abdominal pressure

4. Risk Factors : low socioeconomic status connective tissue disorder postprandial supination Drugs - Anticholinergic drugs Benzodiazepines NSAID or aspirin use Nitroglycerin Calcium channel blockers Antidepressants Glucagon

5. Pathophysiology: Development of GERD is the abnormal reflux of gastric contents from the stomach into the esophagus . Variety of food will also decreased LES. Normal mucosal defense mechanisms may also contribute to the development of GERD, including prolonged acid clearance time from the esophagus, delayed gastric emptying, and reduced mucosal resistance. Gastric acid, pepsin, bile acids, and pancreatic enzymes will also promote esophageal damage.

6. Clinical Presentation: Major Symptoms – 1. Heart burn (sub sternal sensation of warmth or burning that may radiate to the neck) 2 . Pyrosis (burning sensation in chest or throat) 3. Water brash ( hyper salivation ), 4. Belching or burp 5. Regurgitation( expulsion of material from the esophagus or stomach, or to a heart valve condition Symptoms will aggravated by activities that worsen gastroesophageal reflux (e.g., recumbent position, bending over, eating a high-fat meal) Atypical Symptoms – 1. non-allergic asthma 2 . Chronic cough 3 . Hoarseness

7. 4. Pharyngitis 5. Dental erosions 6. Chest pain that mimics angina. Complications – occurred due to long-term acid exposure like; 1. Continual pain 2. Dysphagia (difficulty in swallowing) 3. Odynophagia ( pain in swallowing) Other severe complications include esophageal 1. Strictures 2. Hemorrhage 3. Barrett’s esophagus 4. Esophageal adenocarcinoma.

8. Diagnosis C linical history P resenting symptoms A ssociated risk factors. Endoscopy – 1. assessing the mucosa for esophagitis 2.complications such as Barrett’s esophagus 3.visualization and biopsy of the esophageal mucosa https://www.youtube.com/watch?v=_ qrbzpDA98g&t=1s&pp=ygUPZW5kb3Njb3B5IHZpZGVv https:// www.youtube.com/watch?v=jw5sKLRRBzA&pp=ygUPZW5kb3Njb3B5IHZpZGVv https:// www.youtube.com/watch?v=ej0xhVKgnBg&pp=ygUPZW5kb3Njb3B5IHZpZGVv

9. PillCam ESO- A camera-containing capsule swallowed by the patient is a new technology for visualizing the esophageal mucosa. less invasive than endoscopy takes about 20 minutes to perform in the clinician’s office. Images of the esophagus are downloaded through sensors placed on the patient’s chest that are connected to a data collector . The camera-containing capsule is passed in the stool. https ://www.youtube.com/watch?v=xj0E1U7ciaA Barium radiography – Less expensive but lacks sensitivity and Specificity Twenty-four-hour ambulatory pH monitoring is useful in patients who continue to have symptoms without evidence of esophageal damage, patients who are refractory to standard treatment, and patients who present with atypical symptoms (e.g., chest pain or pulmonary symptoms). The test helps to correlate symptoms with abnormal esophageal acid exposure, documents the percentage of time the intraesophageal pH is low, and determines the frequency and severity of reflux. M eprazole given empirically in standard or double doses as a “therapeutic trial” for diagnosing GERD may be as beneficial as ambulatory pH monitoring Esophageal manometry to evaluate motility should be performed in any patient who is a candidate for antireflux surgery. It is useful in determining which surgical procedure is best for the patient.

10. Treatment : Goal of treatment – to reduce or eliminate symptoms decrease the frequency and duration of gastro esophageal reflux promote healing of the injured mucosa prevent the development of complications Lifestyle modifications should be started initially and continued throughout the treatment course. The initial therapeutic modality depends in part on the patient’s condition (symptom frequency, degree of esophagitis, presence of complications). Historically, a step-up approach has been used, starting with phase I and then progressing through phases II and III if necessary. A step-down approach is also effective, starting with a PPI once or twice daily instead of an H2RA and then stepping down to the lowest acid suppression needed to control symptoms.

11. ANTACIDS AND ANTACID-ALGINIC ACID PRODUCTS –

12. H2-RECEPTOR ANTAGONISTS: CIMETIDINE, RANITIDINE , FAMOTIDINE, AND NIZATIDINE –

13. PROTON PUMP INHIBITORS: ESOMEPRAZOLE, LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE, AND RABEPRAZOLE – PPIs are superior to H2RAs in patients with moderate to severe GERD, including those with erosive esophagitis, complicated symptoms (Barrett’s esophagus, strictures), and non-erosive GERD with moderate to severe symptoms. Relapse is common in these patients, and long-term maintenance therapy is generally indicated. Symptomatic relief is achieved in approximately 83% of patients, and endoscopic healing rates are about 78% at 8 weeks. A dverse effects: 1.headache 2.dizziness 3.somnolence 4.diarrhea , 5.constipation , 6.nausea 7.vitamin B12 deficiency. All PPIs can decrease the absorption of drugs such as ketoconazole or itraconazole that require an acidic environment for absorption. The PPIs degrade in acidic environments and are therefore formulated in delayed-release capsules or tablets. Lansoprazole , esomeprazole, and omeprazole contain enteric-coated (pH-sensitive) granules in a capsule form.

14. Esomeprazole granules can be dispersed in water. Lansoprazole is also available in packets for oral suspension and delayed-release orally disinte grating tablets; the packet for oral suspension should not be placed through nasogastric tubes. Patients taking pantoprazole or rabeprazole should be instructed not to crush, chew, or split the delayed-release tablets. 1. Zegerid – containing omeprazole (20- 40mg) and sodium bicarbonate Dosage from - immediate-release oral capsules and powder for oral suspension It should be taken on an empty stomach at least 1 hour before a meal alternative to the delayed-release capsules or the IV formulation in adult patients with nasogastric tubes. 2. Lansoprazole , esomeprazole, and pantoprazole - Dosage form – oral and IV Patients should be instructed to take oral PPIs in the morning 15 to 30 minutes before breakfast to maximize efficacy, because these agents inhibit only actively secreting proton pumps. PROMOTILITY AGENTS - Promotility agents may be useful as adjuncts to acid suppression therapy in patients with a known motility defect (e.g., LES incompetence, decreased esophageal clearance, delayed gastric emptying). However, these agents are generally not as effective as acid suppression therapy and have undesirable side effects. 1.Cisapride - For mild esophagitis No longer available for routine use because of life-threatening arrhythmias when combined with certain medications and other disease states.

15. 2.Metoclopramide ( Dopamine antagonist) ↓ Increases LES pressure in a dose related manner ↓ Accelerates gastric emptying. Metoclopramide provides symptomatic improvement for some patients with GERD, but substantial evidence of endoscopic healing is lacking. Adverse effects – a. somnolence b. nervousness c.fatigue , d.dizziness e.weakness f.depression g.diarrhea h. rash i . Tachyphylaxis ( major side effects limits the treatment)

16. MUCOSAL PROTECTANTS – Sucralfate is a nonabsorbable aluminum salt of sucrose octasulfate that has limited value and is not routinely recommended for treatment of GERD . COMBINATION THERAPY - Combination therapy with an acid-suppressing agent and a prokinetic agent or mucosal protectant seems logical, but data supporting such therapy are limited. This approach should be reserved for patients who have esophagitis plus concurrent motor dysfunction or for those who have failed high-dose PPI therapy. MAINTENANCE THERAPY - Although healing and/or symptomatic improvement may be achieved via many different therapeutic modalities, 70% to 90% of patients relapse within 1 year of discontinuation of therapy. Long-term maintenance therapy should be considered to prevent complications and worsening of esophageal function in patients who have symptomatic relapse after discontinuation of therapy or dosage reduction, including patients with complications such as Barrett’s esophagus, strictures, or hemorrhage. Most patients require standard doses to prevent relapses. H2RAs may be an effective maintenance therapy in patients with mild disease. The PPIs are the drugs of choice for maintenance treatment of moderate to severe esophagitis. Usual once-daily doses are omeprazole 20 mg, lansoprazole 30 mg, rabeprazole 20 mg, or esomeprazole 20 mg. Lower doses of a PPI or alternate-day regimens may be effective in some patients with less severe disease.

17. Therapeutic Outcome The short-term goals are to relieve symptoms such as heartburn and regurgitation so that they do not impair the patient’s quality of life. The frequency and severity of symptoms should be monitored, and patients should be counseled on symptoms that suggest the presence of complications requiring immediate medical attention, such as dysphagia or odynophagia. Patients with persistent symptoms should be evaluated for the presence of strictures or other complications. Patients should also be monitored for the presence of atypical symptoms such as cough, non allergic asthma, or chest pain. These symptoms require further diagnostic evaluation.