Transcript GERD - muhadharaty.com

Gastroesophageal Reflux Disease
( GERD )
Prof.Dr.Khalid A. Al-Khazraji
MBCHB , MD, CAMB , FRCP , FACP
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2014
• GERD: is a clinical manifestations of reflux of stomach and
duodenal contents into esophagus , with specific symptoms,
radiological, endoscopical, and pathological changes.
• GERD is the most common disorder of the esophagus, and
resulting in heartburn affects approximately 10-20 % of general
population.
Pathophysiology
GERD develops when esophageal mucosa exposed to
gastroduodenal contents for prolonged periods of time (fail of
antireflux mechanisms), resulting in symptoms and, in a proportion
of cases, esophagitis.
Factors associated with development of GERD:
1- Abnormalities of LES: ( Reduced LES tone, Inappropriate
sphincter relaxation).
2- Hiatus hernia.
3- Delayed esophageal clearance ( defective esophageal peristaltic
activity).
4- Composition and quantity of reflux materials
A- Pepsin and gastric acid.
B- Bile salts & pancreatic enzymes both cause more injury than any
one alone.
5- Defective gastric emptying.
6- Increased intra-abdominal pressure ( pregnancy , obesity).
7- Dietary and environmental factors ( fat, chocolate, alcohol,
coffee: lead to relax LES).
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8- Cigarette smoking.
9- Drugs( like anti-muscarinic, calcium channel blockers).
10- Large meal.
11-Abnormal esophagus mucus, swallowed saliva of high
bicarbonate content.
Esophagus squamous epithelium reacts with reflux by increase
basal cell
If the reflux was continues
Epithelium destroyed
Polymorphonuclear leukocyte infiltration and edema,
inflammation lamina properia, micro ulcer
Submucosal and muscular inflammation and fibrosis
Stricture
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Clinical features
1- The two major symptoms are:
- Heartburn.
- Regurgitation.
Usually provoked by ( bending, straining, lying down).
2- Waterbrash.
3- Odynophagia and dysphagia.
4- Atypical chest pain ; mimic angina due to reflux-induced
esophageal spasm. (20% of cases admitted to CCU have
GERD). But reflux pain: burning, worse on bending,
stooping or lying down, seldom radiates to the arms,
worse with hot drinks or alcohol, and relieved by
antacids.
5- Acid laryngitis.
6- Pulmonary manifestations (recurrent chest infectionpneumonia is unusual without accompanying stricture,
Chronic cough. Asthma).
7- Chronic blood loss from hematamesis and iron
deficiency anemia.
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Diagnostic Evaluation
Indicated for a patient with GERD when:1- Heartburn is extremely chronic.
2- Refractory to treatment.
3- accompanied by dysphagia, Odynophagia, or GI bleeding.
-
-
Endoscopy (with biopsy when indicated) is the initial
procedure.
Barium swallow usually fail to detect most cases of esophagitis
or Barrett's.
Esophageal manometry is of minimum use in diagnosis of
GERD.
- In atypical or complicated cases:
1- Bernstein test ( acid perfusion test).
2- Ambulatory pH monitoring: the principal indication for it is to
document persistent excessive acid reflux despite medical or
surgical treatment.
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Normal
Normal
GERD
GERD
GERD
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Los Angeles Classification System
GRADE A:
One or more mucosal
breaks no longer than 5
mm, non of which
extends between the
tops of the mucosal
folds
GRADE B:
One or more
mucosal breaks
more than 5 mm
long, none of which
extends between
the tops of two
mucosal folds
GRADE C:
Mucosal breaks that
extend between the
tops of two or more
mucosal folds, but
which involve less than
75% of the
oesophageal
circumference
GRADE D:
Mucosal breaks
which involve at
least 75% of the
oesophageal
circumference
Complications:
1- Esophageal stricture.
2- Esophageal ulcer.
3- Barrett’s esophagus.
4- Pulmonary aspiration.
Peptic Stricture
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Treatment
1- Simple (lifestyle) measures: include
A- Raise the head of bed 6 to 8 inches by putting blocks under the
bedposts. just using extra pillows will not help.
B- Avoidance of food or liquids 2-3 hr before bedtime.
C- Avoidance of fatty food, spicy food, chocolate, coffee, tea, cola.
D- Avoidance of cigarettes, and alcohol.
E- Weight reduction (if overweight).
F- Wear loose-fitting clothes.
G- Liquid antacid ( aluminum hydroxide, magnesium hydroxide).
H- H2 receptors blockers (over the counter).
2- Persistent symptoms without esophagitis:
A- Alginic acid antacid.
B- Promotility drugs (domperidone , metaclopramide).
C- H2 receptors blockers ( cimetidine, ranitidine, famotidine, nizatidine).
3- With esophagitis:
A- H2 receptor blockers (regular or double dose depending on severity).
B- H2 receptor blockers and Promotility agent.
C- Proton pump inhibitors (PPI): (omeprazole, lansoprazole, pantoprazole,
rabeprazole, esomeprazole). PPI are drugs of choice for all but mild
cases.
D- Antireflux surgery: Nissen fundoplication by laprotomy or laparoscopy.
indications include intolerance to medications, the desire for freedom from
medications, the expense of therapy and the concern of long-term side
effects.
- There is no evidence that H.pylori eradication has any therapeutic value.
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Atlas of Barrett’s
esophagus
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Figure 1 Histological features of low-grade
dysplasia in Barrett esophagus
Odze, R. D. (2009) Barrett esophagus: histology and pathology for the clinician
Nat. Rev. Gastroenterol Hepatol doi:10.1038/nrgastro.2009.103
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Thank you
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