gastroesophageal reflux disease gerd department of gastroenterology, 1 st hospital of jilin...
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gastroesophageal reflux
diseaseGERD
Department of gastroenterology,1st hospital of jilin university
Tongyu Tang
Definition
• American College of Gastroenterology (ACG)American College of Gastroenterology (ACG)
Symptoms OR mucosal damage produced by Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the abnormal reflux of gastric contents into the esophagusthe esophagusOften chronic and relapsingOften chronic and relapsingMay see complications of GERD in patients May see complications of GERD in patients who lack typical symptomswho lack typical symptoms
Barrett’s esophagus,BE
GERD
non-erosive reflux disease, NERD
reflux esophagitis, RE
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
• 8.97% in china
Pathophysiology
• 80% of reflux symptoms occur as a result of transient LES relaxation
• Other motility defects– LES incompetence– Gastroparesis– Esophageal body dymotility
• Anatomic defects: Hiatal hernia
Pathogenesis of GERD Pathogenesis of GERD
Impaired Esophageal Impaired Esophageal ClearanceClearance
Decreased SalivationDecreased SalivationImpaired Tissue Impaired Tissue ResistanceResistance
Decreased LES Resting Decreased LES Resting ToneTone
Delayed Gastric Delayed Gastric EmptyingEmptying
Bile Bile RefluxReflux
Hiatal HerniaHiatal Hernia
LESLES
DuodenuDuodenumm
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
Complications
Stricture
Barrett’s esophagus
Bleeding
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
Diagnostic Tests for GERDDiagnostic Tests for GERD
EndoscopyEndoscopy Barium swallowBarium swallow Ambulatory pH monitoringAmbulatory pH monitoring Esophageal manometryEsophageal manometry
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
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LA Classification of EsophagitisLA Classification of Esophagitis
From Nayar DS et al. Gastrointest Endosc 2004;60:253-7.From Nayar DS et al. Gastrointest Endosc 2004;60:253-7.
24-Hour Esophageal pH Monitoring24-Hour Esophageal pH Monitoring
• Most accurate test for measuring Most accurate test for measuring pattern, frequency, and duration of pattern, frequency, and duration of reflux episodes reflux episodes
• Documents correlation between Documents correlation between reflux episodes and symptomsreflux episodes and symptoms
• Sensitivity (77-100%) Sensitivity (77-100%)
– Normal in 25% of esophagitis!Normal in 25% of esophagitis!
• Specificity 85-100%Specificity 85-100%
• Most useful when diagnosis still Most useful when diagnosis still unclearunclear
Dent et al. Dent et al. GutGut. 1999;44(suppl 2):S1-S16.. 1999;44(suppl 2):S1-S16.
• Ambulatory 24 hr. pH Monitoring• Physiologic study
• Quantify reflux in proximal/distal esophagus
– % time pH < 4
– DeMeester score
• Symptom correlation
Esophageal Manometry
• Assess LES pressure, location and relaxation– Assist placement of 24 hr.
pH catheter
• Assess peristalsis– Prior to antireflux surgery
Limited role in GERDLimited role in GERD
B 级
C 级 D 级
A 级
Treatment Goals for GERDTreatment Goals for GERD
Eliminate symptomsEliminate symptomsHeal esophagitisHeal esophagitisManage or prevent complicationsManage or prevent complicationsMaintain remissionMaintain remission
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
• 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 DOSAGESCimetadine 400mg twice daily 400-800mg twice dailyTagamet
Famotidine 20mg twice daily 20-40mg twice dailyPepcid
Nizatidine 150mg twice daily 150mg twice dailyAxid
Ranitidine 150mg twice daily 150mg twice dailyzantac
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
TreatmentAGENT EQUIVALENT DOSAGE DOSAGESEsomeprazole 40mg daily 20-40mg dailyNexium
Omeprazole 20mg daily 20mg dailyPrilosec
Lansoprazole 30mg daily 15-10md dailyPrevacid
Pantoprazole 40mg daily 40mg dailyProtonix
Rabeprazole 20mg daily 20mg dailyAciphex
Endoscopic Treatments
• In development with ongoing studies
• Most try to improve LES function in some manner
• Not quite ready for prime time in community practice
Surgical Treatment
• Indications– Esophagitis– Stricture– Barrett’s metaplasia– Medication failure
• Purpose of surgery restoration the LES