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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