GERD UPDATEGERD UPDATE

OVERVIEWOVERVIEW DefinitionDefinition

Incidence and BackgroundIncidence and Background

SymptomsSymptoms

Other conditions associated with GERDOther conditions associated with GERD

Basic AnatomyBasic Anatomy

PathophysiologyPathophysiology

ComplicationsComplications

Diagnostic TestsDiagnostic Tests

TreatmentTreatment

GERD DEFINITIONGERD DEFINITIONGastroesophageal reflux disease (GERD): Gastroesophageal reflux disease (GERD):

• Is a term used to collectively describe the

problems and symptoms that occur when acid

from the stomach washes up into the

esophagus.

•This can lead to inflammation and irritation of

the lining of the esophagus as well as causing

the typical symptoms that are generally

associated with GERD or acid reflux.

• Alternate names: reflux, acid reflux,

reflux esophagitis, acid regurgitation,

and heartburn.

INCIDENCE AND INCIDENCE AND BACKGROUNDBACKGROUND

It is one of the most common conditions affecting the gastrointestinal system. Anywhere from 36-77% of people have symptoms

of GERD (heartburn, regurgitation of acid etc.) spread equally between men and women.

7% have daily heartburn 14-20% have weekly heartburn 15-50% have monthly heartburn Even children – especially neurodevelopmental

disorders – 90%

SYMPTOMSSYMPTOMS

SYMPTOMSSYMPTOMS Symptoms typically occur after eating a meal Symptoms typically occur after eating a meal

and…and…

Can be especially noticeable with a large meal Can be especially noticeable with a large meal

or spicy foods.or spicy foods.

Symptoms may be relieved by antacids.Symptoms may be relieved by antacids.

Symptoms often are worse when lying flat, Symptoms often are worse when lying flat,

straining or sleeping.straining or sleeping.

SYMPTOMS MADE SYMPTOMS MADE WORSE…WORSE…

Fatty foods, chocolate, coffee, peppermint as

well as alcohol and use of tobacco products

can cause or worsen symptoms.

Theophylline, Albuterol, and Calcium channel

blockers can also cause symptoms of GERD.

OTHER PROBLEMS OR OTHER PROBLEMS OR DISEASES ASSOCIATED WITH DISEASES ASSOCIATED WITH

GERDGERD Pregnancy is the most common condition

associated with GERD. The pressure of the fetus on the stomach can increase the amount of acid “splashing” up into the esophagus

Diseases characterized by high stomach acid production as well as connective tissue disorders (i.e. scleroderma) are also frequently associated with GERD.

Obesity which causes an increase in abdominal pressure is also thought to contribute to and worsen acid reflux.

BASIC BASIC ANATOMYANATOMY

Esophagus – muscular tube which Esophagus – muscular tube which brings food from the mouth to the brings food from the mouth to the stomachstomach

Stomach – holds food and produces Stomach – holds food and produces acid to help with digestion. Breaks up acid to help with digestion. Breaks up food into small pieces to prepare it food into small pieces to prepare it for the small intestine where for the small intestine where digestion takes place.digestion takes place.

Duodenum – receives food from Duodenum – receives food from stomach. Enzymes from the stomach. Enzymes from the pancreas and bile from the liver mix pancreas and bile from the liver mix with the food to break it down into with the food to break it down into nutrients that can be absorbed.nutrients that can be absorbed.

ANATOMY, ANATOMY, CONT’DCONT’D Hiatus of Diaphragm (colored area) – Hiatus of Diaphragm (colored area) –

where the esophagus passes through the where the esophagus passes through the diaphragm to connect with the stomach.diaphragm to connect with the stomach.

Muscular fibers of the diaphragm wrap Muscular fibers of the diaphragm wrap around the esophagus as it passes into the around the esophagus as it passes into the abdomen. abdomen.

When this area is too loose or lax , the When this area is too loose or lax , the stomach can “slip” or “slide” through up stomach can “slip” or “slide” through up into the chest. into the chest.

This creates a pressure differential which This creates a pressure differential which allows stomach acid to freely wash up into allows stomach acid to freely wash up into the esophagus. the esophagus.

This condition is known as a hiatal or hiatus This condition is known as a hiatal or hiatus hernia.hernia.

ANATOMY, ANATOMY, CONT’DCONT’D

Normal inner anatomy of esophagus and Normal inner anatomy of esophagus and stomach – normally, the lining of the stomach – normally, the lining of the esophagus and stomach are made of esophagus and stomach are made of different types of cells.different types of cells.

The cells which line the esophagus are not as The cells which line the esophagus are not as resistant to acid as the cells which line the resistant to acid as the cells which line the stomach. stomach.

There is normally a sphincter muscle (a There is normally a sphincter muscle (a “gate”) between the esophagus and “gate”) between the esophagus and stomach called the LES (lower esophageal stomach called the LES (lower esophageal sphincter) which serves as a barrier and sphincter) which serves as a barrier and protects the esophagus from acid.protects the esophagus from acid.

PATHOPHYSIOLOGY PATHOPHYSIOLOGY OF GERDOF GERD

A complex interaction of many problems can A complex interaction of many problems can

cause reflux:cause reflux:

Esophageal Dysmotility – weak or Esophageal Dysmotility – weak or

uncoordinated esophageal contractions uncoordinated esophageal contractions

(movement)(movement)

Inadequate saliva production – seen in Inadequate saliva production – seen in

smokers, in certain diseases and normally smokers, in certain diseases and normally

seen during sleep. seen during sleep.

Saliva normally “buffers” any acid which is Saliva normally “buffers” any acid which is

found in the esophagus.found in the esophagus.

PATHOPHYSIOLOGY, CONT’D

Impaired resistance of esophageal lining.Impaired resistance of esophageal lining.

LES dysfunction – poorly functioning LES dysfunction – poorly functioning sphincter muscle allowing acid to wash up sphincter muscle allowing acid to wash up into the esophagusinto the esophagus

Delayed emptying of the stomach – poor Delayed emptying of the stomach – poor motor function of the stomach (not motor function of the stomach (not draining into the intestine) allowing acid draining into the intestine) allowing acid to “pool” in the stomach. to “pool” in the stomach.

Hiatal hernia – allows acid to wash up into Hiatal hernia – allows acid to wash up into the esophagus due to pressure differences the esophagus due to pressure differences between the abdomen and chest.between the abdomen and chest.

Loose hiatus muscle fibers causes reflux Loose hiatus muscle fibers causes reflux even without a hiatal hernia.even without a hiatal hernia.

COMPLICATIONS OF COMPLICATIONS OF GERDGERD

Reflux esophagitis

Injury and inflammation of the inner lining of

the esophagus from prolonged exposure to

acid and digestive enzymes.

This produces pain as well as sometimes

painful swallowing (odynophagia) or a

“sticking” sensation (dysphagia)

COMPLICATIONS OF COMPLICATIONS OF GERDGERD

Reflux esophagitis can progress to complicationsReflux esophagitis can progress to complications::

Long-standing inflammation and scarring can progress to

Barrett’s esophagus which is a premalignant condition.

Severe scarring and narrowing of the esophagus can

occur called strictures. These can cause food to become

“stuck” or can cause pain when swallowing.

Advanced cases can lead to outpouchings of the walls of

the esophagus called a diverticula.

COMPLICATIONS OF COMPLICATIONS OF GERDGERD

Barrett’s EsophagusBarrett’s Esophagus

This is the replacement of the cells lining This is the replacement of the cells lining

the esophagus with cells more typical of the esophagus with cells more typical of

the stomach or intestines (metaplasia) the stomach or intestines (metaplasia)

due to the long-term damage caused by due to the long-term damage caused by

GERD and acid.GERD and acid.

Occurs in approx 10% of patients Occurs in approx 10% of patients

with GERD.with GERD.

BARRETT’S BARRETT’S ESOPHAGUSESOPHAGUS

Barrett’s esophagus

Represents one of the more serious

complications of GERD. It is a precancerous

condition associated with cancer of the

esophagus. It is thought to be caused by

ongoing injury, inflammation and damage

to the lining of the esophagus.

DIAGNOSTIC DIAGNOSTIC TESTSTESTS

Barium swallowBarium swallow

Barium coats the lining Barium coats the lining

and produces a very and produces a very

detailed pictures of the detailed pictures of the

inner lining of the inner lining of the

esophagus and stomach.esophagus and stomach.

DIAGNOSTIC TESTSDIAGNOSTIC TESTS

Upper endoscopyUpper endoscopy Most commonly used test to evaluate the

esophagus and stomach.

Requires mild sedation

Requires technical skill and experience

Most accurate way to evaluate damage to or inflammation of the upper gastrointestinal tract.

DIAGNOSTIC DIAGNOSTIC TESTSTESTS

24-hr pH Monitoring24-hr pH Monitoring

Registers the amount and frequency of acid Registers the amount and frequency of acid

in the esophagus and allows correlation with in the esophagus and allows correlation with

symptoms such as heartburn and pain. A symptoms such as heartburn and pain. A

probe is placed into the esophagus which probe is placed into the esophagus which

records the acid level in both the esophagus records the acid level in both the esophagus

and stomach for a full 24 hours.and stomach for a full 24 hours.

This is the most accurate method of This is the most accurate method of

detecting reflux and GERD.detecting reflux and GERD.

DIAGNOSTIC TESTSDIAGNOSTIC TESTS

24-hr pH Monitoring24-hr pH Monitoring

Newer systems now allow 24-hr monitoring of Newer systems now allow 24-hr monitoring of

esophageal acid without the need for an uncomfortable esophageal acid without the need for an uncomfortable

and unsightly nasal probe.and unsightly nasal probe.

ESOPHAGEAL ESOPHAGEAL MANOMETRYMANOMETRY

Esophageal Manometry

Measures the motor activity

(movement) of the esophagus and

sphincter pressure via a probe

placed into the esophagus.

Usually used in patients who are

considering surgery to treat their

GERD.

TREATMENTTREATMENT

TREATMENTTREATMENTMild and infrequent symptomsMild and infrequent symptoms Nonprescription therapy is often enoughNonprescription therapy is often enough

Avoiding foods that induce reflux (coffee, fat, etc.)Avoiding foods that induce reflux (coffee, fat, etc.)

Avoid eating close to bedtime, and lying down after mealsAvoid eating close to bedtime, and lying down after meals

Elimination of smokingElimination of smoking

Reduction/elimination of alcoholReduction/elimination of alcohol

Elevation of the head of the bedElevation of the head of the bed

Weight lossWeight loss

Over-the-counter antacids as neededOver-the-counter antacids as needed

GERD TREATMENT GERD TREATMENT ALGORITHMALGORITHM

FrequentFrequentRelapsesRelapses

OccasionalOccasionalSymptomsSymptoms

Good ResponseGood Response Suboptimal ResponseSuboptimal Responseoror

Initiate b.i.d. HInitiate b.i.d. H22RARA

HeartburnHeartburn

GERD TREATMENT GERD TREATMENT ALGORITHMALGORITHM

Good ResponseGood Response Suboptimal ResponseSuboptimal Response

Begin PPI and Titrate Up to b.i.d. if NeededBegin PPI and Titrate Up to b.i.d. if Needed

Maintenance withMaintenance withLowest EffectiveLowest EffectiveDose of HDose of H22RA orRA orPPI or SurgeryPPI or Surgery

Confirm DiagnosisConfirm Diagnosis(24 Hr. pH, Endoscopy)(24 Hr. pH, Endoscopy)

No GERDNo GERD

Consider Other DiagnosisConsider Other Diagnosis

GERDGERD

TREATMENT - TREATMENT - SURGERYSURGERY

FundoplicationFundoplication

Nissen, ToupetNissen, Toupet

Other techniques (approved by FDA but Other techniques (approved by FDA but

unproven long-term)unproven long-term) Stretta – radiofrequency creates tissue response at LESStretta – radiofrequency creates tissue response at LES

Endocinch - endoscopic suturing at GE junctionEndocinch - endoscopic suturing at GE junction

Enteryx – “plastic” endoscopically injected into LESEnteryx – “plastic” endoscopically injected into LES

Plicator – endoscopically created plication (“fold”) at LESPlicator – endoscopically created plication (“fold”) at LES

FUNDOPLICATIOFUNDOPLICATIONN

Currently most clinically effective and proven treatment Currently most clinically effective and proven treatment

for severe or complicated GERD is fundoplication surgery. for severe or complicated GERD is fundoplication surgery.

Recently, innovative surgical techniques have allowed Recently, innovative surgical techniques have allowed

surgeons to perform this operation using laparoscopic surgeons to perform this operation using laparoscopic

techniques (use of very small incisions,special techniques (use of very small incisions,special

instruments, and a video camera).instruments, and a video camera).

FUNDOPLICATION

Nissen FundoplicationNissen Fundoplication

360 degrees360 degrees

Toupet FundoplicationToupet Fundoplication

270 degrees270 degrees

FUNDOPLICATFUNDOPLICATIONION

Top part of stomach wrapped around Top part of stomach wrapped around the esophagusthe esophagus

Esophageal hiatus is also narrowedEsophageal hiatus is also narrowed

Any hiatus hernia is repairedAny hiatus hernia is repaired

Excellent/good in 90% properly Excellent/good in 90% properly selected patientsselected patients

May reverse long-term damage from May reverse long-term damage from GERDGERD

May be able to stop medications May be able to stop medications completelycompletely

COMPLICATIONS OF COMPLICATIONS OF SURGERYSURGERY

Injury to an abdominal organ or to the bowel, Injury to an abdominal organ or to the bowel, stomach, or esophagusstomach, or esophagus

BleedingBleeding

Failure to completely relieve reflux symptomsFailure to completely relieve reflux symptoms

Difficulty swallowingDifficulty swallowing

Inability to vomitInability to vomit

DiarrheaDiarrhea

Distended abdomenDistended abdomen

Vagus nerve injuryVagus nerve injury