Gastroesophageal Reflux

Disease
Lecturer
Dr. Asad Raza
 Introduction
• Gastroesophageal reflux
• It is the involuntary movement of gastric contents to the esophagus.
Gastroesophageal reflux is a normal physiological process that occurs several
times a day without symptoms or damage of the esophageal mucosa in most
otherwise healthy individuals.
• Gastroesophageal reflux disease (GERD)
• is a condition in which reflux of gastric contents into the esophagus produces
frequent or severe symptoms that negatively affect the individual’s quality of life
or result in damage to esophagus, pharynx, or the respiratory tract.
• Gastroesophageal reflux disease (GERD) is a digestive disorder that occurs when
acidic stomach juices, or food and fluids back up from the stomach into the
esophagus. GERD affects people of all ages—from infants to older adults.
 Normal Anti GERD Mechanisms
• Although all normal individuals experience some sort of “physiological”
gastroesophageal reflux, a highly efficient barrier exists between the stomach and
the esophagus. From the esophageal side, esophageal clearance is promoted by
peristalsis and salivary production. A valve mechanism exists between the
esophagus and the stomach, formed by the lower esophageal sphincter (LES), the
diaphragm, the His angle, the Gubaroff valve and the phrenoesophageal membrane
• Other factors certainly play significant ancillary roles in preventing reflux. In the
absence of a hiatal hernia, the crural fibers of the diaphragm serve as an "extrinsic"
sphincter. Furthermore, the unique anatomy of the proximal stomach (e.g., the
angle of His, mucosal flap valve, posterolateral location of the fundus) serves to
keep gastric contents away from the gastroesophageal junction, making it less likely
for reflux to occur when the LES relaxe.
 Angle of His
The angle of His is the acute angle between the stomach
 and the esophagus. It is created by the collar sling
fibres and the circular muscles around this
gastroesophageal junction
The angle of His forms an anatomical sphincter. This
prevents the reflux of stomach acid, digestive enzymes,
and duodenal bile from entering the esophagus. This is
important in preventing gastroesophageal reflux disease
 and inflammation of the esophagus.
Loss of normal angle of HIS due to any pathology leads
to GERD
 Peristalsis
• Esophageal peristalsis is an important component of the antireflux mechanism because it is
the main determinant of esophageal clearance of the refluxate. Defective peristalsis is
associated with severe GERD, both in terms of symptoms and of mucosal damage
• It is known that 40%-50% of patients with GERD have abnormal peristalsis. This
dysmotility is particularly severe in about 20% of patients because of very low amplitude
of peristalsis and/or abnormal propagation of the peristaltic waves (ineffective esophageal
motility). Esophageal clearance is slower than normal, therefore, the refluxate is I
• In contact with the esophageal mucosa for a longer period of time and it is able to reach
more often the upper esophagus and pharynx. Thus, these patients are prone to severe
mucosal injury (including Barrett’s esophagus) and frequent extra-esophageal symptoms
such as cough.
• Also the anti paristalsis which is an anti gravity movement leads to the reflux of gastric
contents into the esophagus causin GERD
 Diaphragm

• The crus of the diaphragm provides an

extrinsic component to the gastroesophageal
barrier. This pinchcock action of the
diaphragm is particularly important as a
protection against reflux induced by sudden
increases in intra-abdominal pressure
• Any incompetence in the diaphragmatic
musculature leads to reflux of gastric
contents into the esophagus causing GERD
 Lower Esophageal Sphincter.
• Physiologically, the LES is a 3-4-cm-long segment of tonically
contracted smooth muscle at the distal end of the esophagus. It is
intuitive that the LES creates a high pressure zone between the
esophagus and the stomach that prevents reflux. An effective LES
must have an adequate total and intra-abdominal length, and an
adequate resting pressure to contribute in anti GERD mechanisms.
 Etiology
Periodic relaxation of the LES in normal individuals has been termed transient
lower esophageal sphincter relaxation (TLESR), to distinguish it from
relaxation triggered by swallowing. TLESR accounts for the physiological
reflux found in normal subjects. When it becomes more frequent and
prolonged, TLESR can contribute to reflux disease
Most episodes of physiological reflux occur during postprandial transient
Lower Esophageal Sphincter LOS relaxations (TLESRs). In the early stages of
GERD, most pathological reflux occurs as a result of an increased number of
TLESRs rather than a persistent fall in overall sphincter pressure. In more
severe GERD, LES pressure tends to be generally low, and this loss of
sphincter function seems to be made worse if there is loss of an adequate
length of intraabdominal oesophagus.
• GERD is the most common condition affecting the upper GI tract. This is
partly due to the declining incidence of peptic ulcer as the incidence of
infection with Helicobacter pylori has reduced as a result of improved
socioeconomic conditions, along with a rising incidence of GERD in the last
30 years.
• The cause of the increase is unclear, but may be due in part to increasing
obesity. The strong association between GERD, obesity and the parallel rise
in the incidence of adenoarcinoma.
• Abnormal gastric emptying might contribute to GERD by increasing intra-
gastric ppressure.
• The failure at any point in Anti Reflux mechanism can lead to GERD.
• Factors that can lead to this include:
• Too much pressure on the abdomen. Some pregnant women
experience heartburn almost daily because of this increased
pressure.
• Particular types of food (for example, dairy, spicy or fried foods) and
eating habits.
• Medications that include medicines for asthma, high blood pressure
and allergies; as well as painkillers, sedatives and anti-depressants.
 Clinical features

The classic triad of symptoms is

1. retrosternal burning pain (heartburn),
2. epigastric pain (sometimes radiating through to the back) and
3. regurgitation.
Most patients do not experience all three. Symptoms are often provoked by food, particularly those that delay gastric emptying
(e.g. fats, spicy foods).
• As the condition becomes more severe, gastric juice may reflux to the mouth and produce an unpleasant taste, often described
as ‘acid’ or ‘bitter’.
• Heartburn and regurgitation can be brought on by stooping or exercise.
• A proportion of patients have odynophagia with hot beverages, citrus drinks or alcohol.
• Patients with nocturnal reflux and those who reflux food to the mouth nearly always have severe GERD.
• Some patients present with less typical symptoms such as angina-like chest pain, pulmonary or laryngeal symptoms.
• Dysphagia is usually a sign that a stricture has occurred, but may be caused by an associated motility disorder.
Continued
• Bitter/sour taste in the back of the throat
• Sense of a lump in the throat
• Abdominal bloating/Abdominal discomfort
• Gas
• Chronic Cough
• Feeling the food is trapped behind the breastbone or in the throat
• Nausea after eating
• Burning sensation that begins at the xiphoid processs and radiates up toward the neck
• Intense sharp pain behind sternum with radiation to the backAs GERD is such a common
disorder, it should always be the first thought when a patient presents with oesophageal
symptoms that are unusual or that defy diagnosis after a series of investigations.
 Less Common Symptoms

• Difficulty swallowing (dysphagia)

• Hiccups
• Hoarseness or change in voice
• Sore throat
• Wheezing
• Ear Ache
 Diagnosis of GERD
• Upper gastrointestinal (GI) endoscopy
• Upper GI endoscopy is a procedure in which a doctor uses an
endoscope—a flexible tube with a camera—to see the lining of your
upper GI tract, including your esophagus, stomach, and duodenum.
During upper GI endoscopy, a doctor may obtain biopsies by passing
an instrument through the endoscope to take small pieces of tissue
from the lining of your esophagus. A pathologist will examine the
tissue under a microscope. Doctors may order an upper GI endoscopy
to check for complications of GERD or problems other than GERD that
may be causing your symptoms.
 Esophageal pH monitoring

• Esophageal pH monitoring is the most accurate way to detect stomach acid in the esophagus. Two types of
esophageal pH monitoring are
• catheter monitoring, in which a health care professional passes one end of a catheter—a thin, flexible tube
—through your nose and into your esophagus to measure acid and nonacid reflux
• capsule monitoring, in which a health care professional uses an endoscope to place a small, wireless capsule
on the lining of your esophagus to measure acid reflux
• During esophageal pH monitoring, you’ll wear a monitor that receives information from the catheter or
capsule and tracks information about your diet, sleep, and symptoms. Your doctor will use this information
to see how your diet, sleep, and symptoms relate to acid reflux in your esophagus. Doctors may order this
test to confirm the diagnosis of GERD or to find out if GERD treatments are working.
Continuous pH monitoring is considered the best test for the diagnosis of GERD. However, there is a 10–20%
false-negative response rate (a negative test result in patient who actually has reflux disease). The results
must, therefore, be interpreted in the context of the overall clinical picture. If the intra-esophageal pH is less
than 4 more than 10% of the time, the patient is considered to have pathologic reflux.
 Complications of GERD
• GERD can worsen and result in other conditions if left untreated. These may include:
• Esophagitis: This is inflammation of the esophagus. It can also lead to gastrointestinal
(GI) bleeding.
• Esophageal stricture: Repeated irritation can cause scarring in the esophagus, making
it narrow. This can cause difficulty swallowing.
• Barrett’s esophagus: The cells lining the esophagus can change into cells similar to
the lining of the intestine.i.e Squamous Epithelium of esophagus is replaced by
glandular mucus secreting columnar epithelium as a result of acid reflux into
esophagus. This can develop into esophageal cancer.
• Respiratory problems: It is possible to breathe stomach acid into the lungs, which can
cause a range of problems, such as chest congestion, hoarseness, asthma, laryngitis,
and pneumonia.
 Medical management

Most sufferers from GERD do not consult a doctor and do not need to
do so. They self-medicate with over-the-counter medicines such as
simple antacids, antacid–alginate preparations, H2-receptor antagonists
or PPIs.
 Antacids

• Over-the-counter antacids are best for intermittent and relatively infrequent symptoms
of reflux. When taken frequently, antacids may worsen the problem. They leave the
stomach quickly, and your stomach actually increases acid production as a result.
• Examples of antacids include:
• Aluminum hydroxide gel (Alternagel, Amphojel)
• Calcium carbonate (Alka-Seltzer, Tums)
• Magnesium hydroxide (Milk of Magnesia) 
• Gaviscon, Gelusil, Maalox, Mylanta, Rolaids
• Pepto-Bismol
• Proton pump inhibitors (PPIs) 
• Proton pump inhibitors (PPIs) are drugs that block the three major pathways for acid
production. PPIs suppress acid production much more effectively than H2 blockers.
PPIs heal erosive esophagitis in many patients, even those with severe esophageal
damage.
dexlansoprazole (Dexilant®), esomeprazole (Nexium®), omeprazole (Prilosec®,
Zegerid®), lansoprazole (Prevacid®), pantoprazole (Protonix®), and rabeprazole
(Aciphex®).
• H2 blockers 
Histamine 2 (H2) blockers are drugs that help lower acid secretion. H2 blockers heal
esophageal erosions in about 50 percent of patients.
• cimetidine (Tagamet®), famotidine (Pepcid®), and nizatidine (Axid®).
 Life Style Changes
• Dietary Changes
• The first step in reducing GERD is often to limit foods that set off
reflux. These “trigger foods” differ from person to person but often
include chocolate, coffee, fried foods, peppermint, spicy foods, and
carbonated beverages.
• Your doctor may advise that you eliminate some or all of these foods
or keep a food diary to pinpoint which foods trigger GERD symptoms.
 Other Lifestyle Changes

• In addition to avoiding dietary triggers, our doctors may recommend several lifestyle changes you can make to
alleviate GERD symptoms:
• Avoid lying down for at least two hours after a meal or after drinking acidic beverages, like soda, or other
caffeinated beverages. This can help to prevent stomach contents from flowing back into the esophagus.
• Keep your head elevated while you sleep. Using an extra pillow or two can also help to prevent reflux. Tilting
the bed has been shown to have an effect that is similar to taking an H2-receptor antagonist. The common
practice of using additional pillows has no significant effect.
• Eat smaller and more frequent meals each day instead of a few large meals. This promotes digestion and can
aid in preventing heartburn.
• Wear loose-fitting clothes to ease pressure on the stomach, which can worsen heartburn and reflux.
• Quit smoking. Smoking can increase the production of stomach acid and reduce the function of the lower
esophageal sphincter, the muscle that keeps acid and other stomach content from reentering the esophagus.
Smoking can also decrease the amount of saliva, which neutralizes acid produced by the body.
• Reduce excess weight around the midsection. This can ease pressure on the stomach. Such pressure can force
some stomach contents back up the esophagus.
 Surgical Procedure for GERD
• Fundoplication is a surgical procedure used to treat stomach
acid reflux. During fundoplication, the top part of your stomach
— called the fundus — is wrapped and plicated around the
lower esophageal sphincter, a muscular valve at the bottom of
your esophagus and stitched in place. This reinforces the lower
esophageal sphincter, making it less likely that acid will back up
into the esophagus.
Types of Fundoplication
LAPAROSCOPIC FUNDOPLICATION
Five cannulae are inserted in the upper abdomen. The cardia and lower
oesophagus are separated from the diaphragmatic hiatus. An
appropriate length of oesophagus is mobilised in the mediastinum. The
fundus may be mobilised by dividing the short gastric vessels that
tether the fundus to the spleen, although some surgeons feel that this
is unnecessary. The hiatus is narrowed by sutures placed behind the
oesophagus.
Total Fundoplication
In total (Nissen) fundoplication, the fundus is drawn behind the oesophagus
and then sutured to itself in front of the oesophagus.
In a Nissen fundoplication, also called a complete fundoplication, the fundus is
wrapped the entire 360 degrees around the esophagus.
Partial Fundoplication
In partial fundoplication, the fundus is drawn either behind or in front of the
oesophagus and sutured to it on each side, leaving a strip of exposed
oesophagus either at the front or at the back.
In partial fundoplication fundus is wrapped 270 degrees around the esophagus.
Complications of Fundoplication

Total fundoplication (Nissen) tends to be associated with slightly more short-term dysphagia but
is the most durable repair in terms of long-term reflux control. Partial fundoplication, whether
performed posteriorly (Toupet) or anteriorly (Dor, Watson), has fewer short-term side effects,
although this is sometimes at the expense of a slightly higher long-term failure rate.
One disadvantage of total fundoplication is the creation of an overcompetent cardia, resulting in
the ‘gas bloat’ syndrome in which belching is impossible. The stomach fills with air, the patient
feels very full after small meals and passes excessive flatus. This does not seem to occur with
partial fundoplication. The problem has been largely overcome by the ‘floppy’ Nissen technique
in which the fundoplication is loose around the oesophagus and is kept short in length.
Although the other short-term side effects of fundoplication usually resolve within 3 months of
surgery, this is rarely the case for gas bloat. The problem is best remedied by conversion to a
partial fundoplication.
 Physical Therapy For GERD
• Patients with GERD occasionally present to the clinic with atypical head and neck symptoms
without complaints of heartburn. It is important for the Physical Therapist to be aware of pain
referral patterns for the esophagus. With an atypical presentation, the Physical Therapist may need
to ask if the patient has a history of difficulty swallowing, difficulty speaking, chronic dry cough, etc.
• There are also those patients who attend physiotherapy for other conditions, but have a history of
GERD. In this case the Physical Therapist has to be aware of positioning and education on lifestyle
modifications if necessary. When treating a patient with GERD:
• Assist the patient in implementing changes related to the diet and exercise
• Educate and encourage the patient on lifestyle modifications
• Educate on Positioning:
• Supine interventions should be avoided after meal
• Encourage the patient to sleep on the left side
• Right side lying allows the acid to flow into the esophagus more easily
• Head up positions minimize reflux and reduce intraabdominal pressure.
 Shaker Head Lifting Exercise
• It is designed for patients who do not have cervical disc disease, but
have dysphagia. The benefits of this technique are:
• Used to strengthen the muscles of the Upper Esophageal Sphincter
(UES)
• Used with dysphagia, hiatal hernia, and GERD
• Helps restore normal swallowing
• Helps keep stomach contents from being aspirated into the lungs
 Performance of Shaker Head Lifting
Exercise
• The patient should lie in the supine position on firm, flat surface, without a pillow and
arms resting by their sides. They should be instructed to breathe slow and steady
throughout the exercise.
• Lift Head (to look at the toes) and Hold
• Lift head to look at toes
• Shoulders should be kept flat on the surface it is only the head that lifts up.
• Hold for 1 minute then the head returns to the starting position.
• Repeat 2 more times, relaxing for 1 minute between each repetition.
• Head Lift and Lower
• Lift head up to look toward the chin and then put return to the start position. (It resembles a sit up
but with the head).
• Repeat 30 times.
• Relax
Thanks Alot