Gastroesophageal

Reflux Disease
Howard J. McGowan, Maj, USAF, MC
 Objectives
 Definition of GERD
 Epidemiology of GERD
 Pathophysiology of GERD
 Clinical Manisfestations
 Diagnostic Evaluation
 Treatment
 Complications
 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
 Physiologic vs Pathologic
 Physiologic GERD  Pathologic GERD
• Postprandial • Symptoms
• Short lived • Mucosal injury
• Asymptomatic • Nocturnal sx
• No nocturnal sx
 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
 Pathophysiology
 Primary barrier to
gastroesophageal
reflux is the lower
esophageal sphincter
 LES normally works in
conjunction with the
diaphragm
 If barrier disrupted,
acid goes from
stomach to esophagus
 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 Manisfestations
• Dysphagia—difficulty swallowing
• Other symptoms include:
 Chest pain, water brash, globus sensation,
odynophagia, nausea
• Extraesophageal manifestations
 Asthma, laryngitis, chronic cough
 Diagnostic Evaluation

• If classic symptoms of heartburn and

regurgitation exist in the absence of
“alarm symptoms” the diagnosis of
GERD can be made clinically and
treatment can be initiated
 Alarms
• Alarm Signs/Symptoms
 Dysphagia
 Early satiety
 GI bleeding
 Odynophagia
 Vomiting
 Weight loss
 Iron deficiency anemia
 Trial of Medications
 H2RA or PPI
• Expect response in 2-4 weeks
• If no response
 Change from H2RA to PPI
 Maximize dose of PPI
 Trial of Medications
 If PPI response inadequate despite
maximal dosage
• Confirm diagnosis
 EGD
 24 hour pH monitor
 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
 pH
 24-hour pH monitoring
• Accepted standard for establishing or
excluding presence of GERD for those
patients who do not have mucosal
changes
• Trans-nasal catheter or a wireless,
capsule shaped device
 Patient with heartburn

Iniate tx with H2RA or PPI

H2RA taken PPI taken QD

BID
No
Good response
No
Good response Yes Yes
Yes
Maintenance therapy Increase to
Frequent relapses max dose QD
with lowest effective dose
or BID
No
Yes
On demand tx
Symptoms persist Good response
No

Consider EGD if
Confirm diagnosis
risk factors present
EGD, ph monitor
(> 45, white, male
and > 5 yrs of sx)
 GERD vs Dyspepsia
 Distinguish from Dyspepsia
• Ulcer-like symptoms-burning, epigastric
pain
• Dysmotility like symptoms-nausea,
bloating, early satiety, anorexia
 Distinct clinical entity
 In addition to antisecretory meds
and an EGD need to consider an
evaluation for Helicobacter pylori
 Treatment
 Goals of therapy
• Symptomatic relief
• Heal esophagitis
• Avoid complications
 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
 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
 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
 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
 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
 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
 Treatment
 H2RAs vs PPIs
• 12 week freedom from symptoms
 48% vs 77%
• 12 week healing rate
 52% vs 84%
• Speed of healing
 6%/wk vs 12%/wk
 Treatment
 Antireflux surgery
• Failed medical management
• Patient preference
• GERD complications
• Medical complications attributable to a
large hiatal hernia
• Atypical symptoms with reflux
documented on 24-hour pH monitoring
 Treatment
 Antireflux surgery candidates
• EGD proven esophagitis
• Normal esophageal motility
• Partial response to acid suppression
 Treatment
 Antireflux surgery
• Tenets of surgery
 Reduce hiatal hernia
 Repair diaphragm
 Strengthen GE junction
 Strengthen antireflux barrier via gastric
wrap
 75-90% effective at alleviating symptoms of
heartburn and regurgitation
 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
 Treatment
 Endoscopic treatment
• Relatively new
• No definite indications
• Select well-informed patients with well-
documented GERD responsive to PPI therapy may
benefit
 Three categories
• Radiofrequency application to increase LES reflux
barrier
• Endoscopic sewing devices
• Injection of a nonresorbable polymer into LES area
 Complications
 Erosive esophagitis
 Stricture
 Barrett’s esophagus
 Complications
 Erosive esophagitis
• Responsible for 40-60% of GERD
symptoms
• Severity of symptoms often fail to
match severity of erosive esophagitis
 Complications
 Esophageal
stricture
• Result of healing
of erosive
esophagitis
• May need
dilation
Complications

 Barrett’s Esophagus
• Columnar metaplasia
of the esophagus
• Associated with the
development of
adenocarcinoma
 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
 Complications
• Patient’s who need EGD
 Alarm symptoms
 Poor therapeutic response
 Long symptom duration
• “Once in a lifetime” EGD for patient’s
with chronic GERD becoming accepted
practice
• Many patients with Barrett’s are
asymptomatic
 Complications
 Barrett’s Esophagus
• Manage in same manner as GERD
• EGD every 3 years in patient’s without
dysplasia
• In patients with dysplasia annual to
shorter interval surveillance
 Summary
 Definition of GERD
 Epidemiology of GERD
 Pathophysiology of GERD
 Clinical Manisfestations
 Diagnostic Evaluation
 Treatment
 Complications
?QUESTIONS?