GERD. GASTRO ESOPHAGEAL REFLUX DISEASE. GIT

GERD. GASTRO ESOPHAGEAL REFLUX DISEASE.

1. . GASTR0ESOPHAGEAL
REFLUX DISEASE (GERD)
GERD
14-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
•GastroesophagealReflux 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.

5. 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

6. •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.

7. Physiologic vsPathologic
Physiologic GERD
•Postprandial(eating)
•Short lived
•Asymptomatic
•No nocturnal
symptorms
Pathologic GERD
•Symptoms
•Mucosal injury
•Nocturnal
symptoms

8. •What happens during nonpathologicreflux

9. 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.

10. PATHOPHYSIOLOGY
1) DECREASEDLOWERESOPHAGEAL SPHINCTERPRESSURE
•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

11. 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.

12. 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.

13. 4)MUCOSAL RESISTANCE
•Themucussecreatedbythemucussecretingglandsinvolvesinthe
protectionofesophagus
•Thebicarbonatesmovingfromthebloodtothelumencanneutralizeacidic
refluxateintheesophagus.Onrepeatedexposuretotherefluxateordueto
somedefectinnormalmucosaldefenseshydrogenionsdiffuseintothe
mucosa,leadingtocellularacidificationandnecrosisleadingtoesophagitis.
5)DELAYEDGASTRICEMPTYING
•Anincreaseingastricvolumemayincreaseboththefrequencyofrefluxand
theamountofgastricfluidavailabletoberefluxed
•PhysiologicPostprandialGastroesophagealrefluxoccurs

15. 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

16. 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

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

18. •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.

19. •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

20. 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
GERDmay help improve asthma symptoms in these
people. And GERD can be worsened by asthmaand 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.

21. 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.

22. CLASSES OF SYMPTOMS
•TYPICALSYMPTOMS
May be aggravated by activities that worsen
gastroesophagealreflux such as recumbent
position, bending over, or eating a meal high
in fat.
•Heartburn—retrosternalburning 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

23. •ALARMSIGNS/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

24. 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.

25. An esophagramor barium swallowis an X-ray
imaging test used to visualize the structures of the
esophagus. The patient swallowsliquid bariumwhile
X-ray images are obtained. The bariumfills 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)
Hiatalhernia (size, type)
Limitations
Detailed mucosal exam for erosive
esophagitis, Barrett’s esophagus

26. Indications
Alarm symptoms
Empiric therapy failure
Preoperative evaluation
Detection of Barrett’s
esophagus

27. Ambulatory 24 hr. pH Monitoring
Normal
GERD

28. 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.

29. 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.

30. 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.

31. Treatment
•Antacids
•Over the counter acid
suppressants and
antacids appropriate
initial therapy
•Approx1/3 of patients
with heartburn-related
symptoms use at least
twice weekly
•More effective than
placebo in relieving GERD
symptoms

32. 3. Surgical interventions:
•Fundoplication (e.g., Nissenfundoplication):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.

34. Laparoscopic

35. Ant. partial fundoplication
Thal/Dor procedure
Post. partial fundoplication
Toupet procedure

36. 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

38. 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.