Gastro esophageal Gastro esophageal Reflux DiseaseReflux Disease

My room

My mess

ENT

Central emergency

Gasroesophageal Gasroesophageal reflux diseasereflux disease

(GERD)(GERD)

ObjectivesObjectives

Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManisfestationsClinical Manisfestations Diagnostic EvaluationDiagnostic Evaluation TreatmentTreatment ComplicationsComplications

DefinitionDefinition American College of American College of

Gastroenterology (ACG)Gastroenterology (ACG)• Symptoms OR mucosal Symptoms OR mucosal

damage produced by the damage produced by the abnormal reflux of gastric abnormal reflux of gastric contents into the esophaguscontents into the esophagus

• Often chronic and relapsingOften chronic and relapsing• May see complications of May see complications of

GERD in patients who lack GERD in patients who lack typical symptomstypical symptoms

Physiologic vs PathologicPhysiologic vs Pathologic

Physiologic GERDPhysiologic GERD PostprandialPostprandial

Short livedShort lived AsymptomaticAsymptomatic No nocturnal sxNo nocturnal sx

Pathologic GERDPathologic GERD SymptomsSymptoms Mucosal injuryMucosal injury Nocturnal sxNocturnal sx

EpidemiologyEpidemiology

About 44% of the adult population About 44% of the adult population have heartburn at least once a have heartburn at least once a monthmonth

14% of adults have symptoms 14% of adults have symptoms weeklyweekly

7% have symptoms daily7% have symptoms daily

These are US dataIn INDIA the prevalence is somewhat lesser but on an INCREASING trend

PathophysiologyPathophysiology Primary barrier to Primary barrier to

gastroesophageal gastroesophageal reflux is the lower reflux is the lower esophageal sphincteresophageal sphincter

LES normally works in LES normally works in conjunction with the conjunction with the diaphragmdiaphragm

If barrier disrupted, If barrier disrupted, acid goes from acid goes from stomach to esophagusstomach to esophagus

Clinical Manisfestations Clinical Manisfestations

Most common symptomsMost common symptoms• Heartburn—retrosternal burning Heartburn—retrosternal burning

discomfortdiscomfort• Regurgitation—effortless return of Regurgitation—effortless return of

gastric contents into the pharynx gastric contents into the pharynx without nausea, retching, or without nausea, retching, or abdominal contractionsabdominal contractions

Clinical ManisfestationsClinical Manisfestations

• Dysphagia—difficulty swallowingDysphagia—difficulty swallowing• Other symptoms include:Other symptoms include:

Chest pain, water brash, globus sensation, Chest pain, water brash, globus sensation, odynophagia, nauseaodynophagia, nausea

• Extraesophageal manifestationsExtraesophageal manifestations Asthma, laryngitis, chronic coughAsthma, laryngitis, chronic cough

Extraesophageal Extraesophageal Manifestations of GERDManifestations of GERD

PulmonaryPulmonary

AsthmaAsthmaAspiration pneumoniaAspiration pneumoniaChronic bronchitisChronic bronchitisPulmonary fibrosisPulmonary fibrosis

OtherOther Chest painChest pain Dental erosionDental erosion

ENTENT

HoarsenessHoarseness

LaryngitisLaryngitis

PharyngitisPharyngitis

Chronic coughChronic cough

Globus sensationGlobus sensation

DysphoniaDysphonia

SinusitisSinusitis

Subglottic stenosisSubglottic stenosis

Laryngeal cancerLaryngeal cancer

Potential Oral and Laryngopharyngeal Potential Oral and Laryngopharyngeal Signs Associated with GERDSigns Associated with GERD

• Edema and hyperemia of Edema and hyperemia of larynxlarynx

• Vocal cord erythema, Vocal cord erythema, polyps, granulomas, polyps, granulomas, ulcersulcers

• Hyperemia and lymphoid Hyperemia and lymphoid hyperplasia of posterior hyperplasia of posterior pharynx pharynx

• Interarytenyoid changesInterarytenyoid changes

• Dental erosionDental erosion

• Subglottic stenosisSubglottic stenosis

• Laryngeal cancerLaryngeal cancer

Pathophysiology of Pathophysiology of Extraesophageal GERDExtraesophageal GERD

Diagnostic EvaluationDiagnostic Evaluation

• If classic symptoms of heartburn and If classic symptoms of heartburn and regurgitation exist in the absence of regurgitation exist in the absence of “alarm symptoms” the diagnosis of “alarm symptoms” the diagnosis of GERD can be made clinically and GERD can be made clinically and treatment can be initiatedtreatment can be initiated

AlarmsAlarms

• Alarm Signs/SymptomsAlarm Signs/Symptoms DysphagiaDysphagia Early satietyEarly satiety GI bleedingGI bleeding OdynophagiaOdynophagia VomitingVomiting Weight lossWeight loss Iron deficiency anemiaIron deficiency anemia

When to Perform Diagnostic When to Perform Diagnostic TestsTests

Uncertain diagnosisUncertain diagnosis Atypical symptomsAtypical symptoms Symptoms associated with Symptoms associated with

complicationscomplications Inadequate response to therapy Inadequate response to therapy Recurrent symptomsRecurrent symptoms Prior to anti-reflux surgeryPrior to anti-reflux surgery

Diagnostic Tests for GERDDiagnostic Tests for GERD

Trial of H2RA/PPITrial of H2RA/PPI Barium swallowBarium swallow Ambulatory pH Ambulatory pH

monitoringmonitoring EsophagogastroduodeEsophagogastroduode

noscopy(EGD)noscopy(EGD) Esophageal Esophageal

manometrymanometry

Trial of MedicationsTrial of Medications

H2RA or PPIH2RA or PPI• Expect response in 2-4 weeksExpect response in 2-4 weeks• If no responseIf no response

Change from H2RA to PPIChange from H2RA to PPI Maximize dose of PPIMaximize dose of PPI

Trial of MedicationsTrial of Medications

If PPI response inadequate despite If PPI response inadequate despite maximal dosage maximal dosage • Confirm diagnosisConfirm diagnosis

EGDEGD 24 hour pH monitor24 hour pH monitor

Barium SwallowBarium Swallow

Useful first diagnostic test Useful first diagnostic test for patients with dysphagiafor patients with dysphagia• Stricture (location, length)Stricture (location, length)• Mass (location, length)Mass (location, length)• Bird’s beakBird’s beak• Hiatal hernia (size, type)Hiatal hernia (size, type)

LimitationsLimitations• Detailed mucosal exam for Detailed mucosal exam for

erosive esophagitis, Barrett’s erosive esophagitis, Barrett’s esophagusesophagus

Ambulatory 24 hr. pH Ambulatory 24 hr. pH MonitoringMonitoring

Physiologic studyPhysiologic study Quantify reflux in Quantify reflux in

proximal/distal proximal/distal esophagusesophagus

• % time pH < 4% time pH < 4

• DeMeester scoreDeMeester score

Symptom Symptom correlationcorrelation

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

NormalNormal

GERDGERD

Wireless, Catheter-Free Esophageal pH Wireless, Catheter-Free Esophageal pH MonitoringMonitoring

• Improved patient Improved patient comfort and acceptancecomfort and acceptance

• Continued normal work, Continued normal work, activities and diet studyactivities and diet study

• Longer reporting periods Longer reporting periods possible (48 hours)possible (48 hours)

• Maintain constant probe Maintain constant probe position relative to SCJposition relative to SCJ

Potential AdvantagesPotential Advantages

EsophagogastrodudenoscopyEsophagogastrodudenoscopy Endoscopy (with biopsy if Endoscopy (with biopsy if

needed)needed)• In patients with alarm In patients with alarm

signs/symptomssigns/symptoms• Those who fail a medication Those who fail a medication

trialtrial• Those who require long-term txThose who require long-term tx

Lacks sensitivity for Lacks sensitivity for identifying pathologic refluxidentifying pathologic reflux

Absence of endoscopic Absence of endoscopic features does not exclude a features does not exclude a GERD diagnosisGERD diagnosis

Allows for detection, Allows for detection, stratification, and stratification, and management of esophageal management of esophageal manisfestations or manisfestations or complications of GERDcomplications of GERD

Esophageal ManometryEsophageal Manometryinvestigation of choice in diffuse esophageal spasm(AI08)investigation of choice in diffuse esophageal spasm(AI08)

Assess LES pressure, Assess LES pressure, location and relaxationlocation and relaxation• Assist placement of 24 Assist placement of 24

hr. pH catheterhr. pH catheter Assess peristalsisAssess peristalsis

• Prior to antireflux Prior to antireflux surgery surgery

Limited role in GERDLimited role in GERD

Patient with heartburn

Iniate tx with H2RA or PPI

H2RA taken BID

Good response

Frequent relapses

On demand tx

PPI taken QD

Good response

Maintenance therapywith lowest effective dose

Symptoms persist

Consider EGD if risk factors present(> 45, white, maleand > 5 yrs of sx)

Increase tomax dose QD or BID

Good response

Confirm diagnosisEGD, ph monitor

No

Yes YesNo

Yes

Yes

No

No

Differential diagnosisDifferential diagnosis

Angina pectorisAngina pectoris GastritisGastritis Peptic ulcer diseasePeptic ulcer disease GallstonesGallstones pancreatitispancreatitis Achalasia cardiaAchalasia cardia Carcinoma oesophagusCarcinoma oesophagus

TreatmentTreatment

Goals of therapyGoals of therapy• Symptomatic reliefSymptomatic relief• Heal esophagitisHeal esophagitis• Avoid complicationsAvoid complications

Better LivingBetter Living Lifestyle modificationsLifestyle modifications

• Avoid large mealsAvoid large meals• Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate,

onions, garlic, peppermintonions, garlic, peppermint• Decrease fat intakeDecrease fat intake• Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal• Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches• Avoid meds that may potentiate GERD (CCB, alpha agonists, Avoid meds that may potentiate GERD (CCB, alpha agonists,

theophylline, nitrates, sedatives, NSAIDS)theophylline, nitrates, sedatives, NSAIDS)• Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist• Lose weightLose weight• Stop smokingStop smoking

1. Orr WC, et al. Gastroenterology. 1984;86:814-819.2. Orr WC, et al. Am J Gastroenterol. 2000;95:37-42.3. Orr WC, et al. Am J Gastroenterol. 1994;89:509-512.4. Kjellén G, Tibbling L. Scand J Gastroenterol. 1978;13:283-288.

Sleep May Impair Esophageal Acid Clearance

Gravity-Mediated Drainage4

Esophageal Acid Clearance1–3

Salivary Flow and Swallowing1

AsleepAwake

Factors    

FACTORS THAT MAY CONTRIBUTE TOINCREASED ESOPHAGEAL ACID EXPOSURE DURING SLEEP

TreatmentTreatment AntacidsAntacids

• Over the counter acid Over the counter acid suppressants and suppressants and antacids appropriate antacids appropriate initial therapyinitial therapy

• Approx 1/3 of patients Approx 1/3 of patients with heartburn-related with heartburn-related symptoms use at least symptoms use at least twice weeklytwice weekly

• More effective than More effective than placebo in relieving placebo in relieving GERD symptomsGERD symptoms

TreatmentTreatment

Histamine H2-Receptor AntagonistsHistamine H2-Receptor Antagonists• More effective than placebo and More effective than placebo and

antacids for relieving heartburn in antacids for relieving heartburn in patients with GERDpatients with GERD

• Faster healing of erosive esophagitis Faster healing of erosive esophagitis when compared with placebowhen compared with placebo

• Can use regularly or on-demandCan use regularly or on-demand

TreatmentTreatment

AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESCimetadine 400mg twice daily 400-800mg twice dailyCimetadine 400mg twice daily 400-800mg twice daily

Famotidine 20mg twice daily 20-40mg twice dailyFamotidine 20mg twice daily 20-40mg twice daily

Nizatidine 150mg twice daily 150mg twice dailyNizatidine 150mg twice daily 150mg twice daily

Ranitidine 150mg twice daily 150mg twice dailyRanitidine 150mg twice daily 150mg twice daily

TreatmentTreatment

Proton Pump InhibitorsProton Pump Inhibitors• Better control of symptoms with PPIs vs Better control of symptoms with PPIs vs

H2RAs and better remission ratesH2RAs and better remission rates• Faster healing of erosive esophagitis Faster healing of erosive esophagitis

with PPIs vs H2RAswith PPIs vs H2RAs

TreatmentTreatment

AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESEsomeprazole 40mg daily 20-40mg dailyEsomeprazole 40mg daily 20-40mg daily

Omeprazole 20mg daily 20mg dailyOmeprazole 20mg daily 20mg daily

Lansoprazole 30mg daily 15-10md dailyLansoprazole 30mg daily 15-10md daily

Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg daily

Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg daily

TreatmentTreatment

H2RAs vs PPIsH2RAs vs PPIs• 12 week freedom from symptoms12 week freedom from symptoms

48% vs 77%48% vs 77%

• 12 week healing rate12 week healing rate 52% vs 84%52% vs 84%

• Speed of healingSpeed of healing 6%/wk vs 12%/wk6%/wk vs 12%/wk

NOT ALL PROTON PUMPS ARE NOT ALL PROTON PUMPS ARE ACTIVE ACTIVE

AT ANY GIVEN TIMEAT ANY GIVEN TIME

1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology.4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376.

Unstimulated proton pumpsActive proton pumps

Unstimulated proton pumpsin cytoplasmic tubules

1. Blair JA, et al. J Clin Invest. 1987;79:582-587.2. Sachs G. Pharmacotherapy. 1997;17:22-37.

Gastrin

H2

ACh

H2 = Histamine

ACh = Acetylcholine

Proton pumps become activated in response to food1

Inactive Parietal Cell

After activation, the parietal cell undergoes a series of changes,allowing proton pumps to reach the surface of the parietal cell1

Active Parietal Cell

Only active proton pumps can secrete acid1However, not all pumps become activated1,2

ATPase

ATPase

H+

H+

H+

H+

K+

K+

K+

K+

MOA    

PPIs ONLY BIND TO ACTIVE PPIs ONLY BIND TO ACTIVE PROTON PUMPSPROTON PUMPS

Acid is required to convert a PPI into its active form1

1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology.4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376.

PPIs only bind to active proton pumps1

Unstimulated proton pumps remain

PPI

PPI PPI

PPI

MOA    

PPI USE AND INFECTION RISK:PPI USE AND INFECTION RISK:IS THERE A RELATIONSHIP?IS THERE A RELATIONSHIP?

Gastric acid plays a role in Gastric acid plays a role in eliminating ingested bacteria eliminating ingested bacteria from the digestive tractfrom the digestive tract11

PPI use associated withPPI use associated with• Enteric infection such asEnteric infection such as

Clostridium difficileClostridium difficile• Nonenteric infection suchNonenteric infection such

as community-acquiredas community-acquiredpneumoniapneumonia

C. difficile

Safety   

TreatmentTreatment

Antireflux surgeryAntireflux surgery• Failed medical managementFailed medical management• Patient preferencePatient preference• GERD complicationsGERD complications• Medical complications attributable to a Medical complications attributable to a

large hiatal hernialarge hiatal hernia• Atypical symptoms with reflux Atypical symptoms with reflux

documented on 24-hour pH monitoringdocumented on 24-hour pH monitoring

TreatmentTreatment

Antireflux surgery candidatesAntireflux surgery candidates• EGD proven esophagitisEGD proven esophagitis• Normal esophageal motilityNormal esophageal motility• Partial response to acid suppressionPartial response to acid suppression

TreatmentTreatment

Antireflux surgeryAntireflux surgery• Tenets of surgeryTenets of surgery

Reduce hiatal herniaReduce hiatal hernia Repair diaphragmRepair diaphragm Strengthen GE junctionStrengthen GE junction Strengthen antireflux barrier via gastric Strengthen antireflux barrier via gastric

wrapwrap 75-90% effective at alleviating symptoms of 75-90% effective at alleviating symptoms of

heartburn and regurgitationheartburn and regurgitation

(Nissen’s)

Complete vs. partial fundoplicationComplete vs. partial fundoplication

Complete – Nissen Complete – Nissen fundoplicationfundoplication

Ant. partial Ant. partial fundoplicationfundoplication

Thal/Dor Thal/Dor procedureprocedure

Post. partial Post. partial fundoplicationfundoplication

Toupet procedureToupet procedure

Laparoscopic Nissen Laparoscopic Nissen FundoplicationFundoplication

TreatmentTreatment

PostsurgeryPostsurgery• 10% have solid food dysphagia10% have solid food dysphagia• 2-3% have permanent symptoms2-3% have permanent symptoms• 7-10% have gas, bloating, diarrhea, 7-10% have gas, bloating, diarrhea,

nausea, early satietynausea, early satiety• Within 3-5 years 52% of patients back Within 3-5 years 52% of patients back

on antireflux medicationson antireflux medications

TreatmentTreatment Endoscopic treatmentEndoscopic treatment

• Relatively newRelatively new• No definite indicationsNo definite indications• Select well-informed patients with well-Select well-informed patients with well-

documented GERD responsive to PPI therapy documented GERD responsive to PPI therapy may benefitmay benefit

Three categoriesThree categories• Radiofrequency application to increase LES Radiofrequency application to increase LES

reflux barrierreflux barrier• Endoscopic sewing devicesEndoscopic sewing devices• Injection of a nonresorbable polymer into LES Injection of a nonresorbable polymer into LES

areaarea

ComplicationsComplications

Erosive esophagitisErosive esophagitis StrictureStricture Barrett’s esophagusBarrett’s esophagus

ComplicationsComplications

Erosive esophagitisErosive esophagitis• Responsible for 40-60% of GERD Responsible for 40-60% of GERD

symptomssymptoms• Severity of symptoms often fail to match Severity of symptoms often fail to match

severity of erosive esophagitisseverity of erosive esophagitis

ComplicationsComplications

Esophageal Esophageal stricturestricture• Result of healing Result of healing

of erosive of erosive esophagitisesophagitis

• May need May need dilationdilation

Peptic StricturePeptic Stricture

Barium SwallowBarium Swallow EndoscopyEndoscopy

Esophageal Stricture: Dilating DevicesEsophageal Stricture: Dilating Devices

TTS Balloon Dilation of a Peptic StrictureTTS Balloon Dilation of a Peptic Stricture

ComplicationsComplications

Barrett’s EsophagusBarrett’s Esophagus• Columnar metaplasia Columnar metaplasia

of the esophagus of the esophagus (AIIMS06)(AIIMS06)

• Associated with the Associated with the development of development of adenocarcinoma adenocarcinoma (AIMS97,06)(AIMS97,06)

Barrett’s EsophagusBarrett’s Esophagus

ComplicationsComplications Barrett’s EsophagusBarrett’s Esophagus

• Acid damages lining of Acid damages lining of esophagus and causes esophagus and causes chronic esophagitis chronic esophagitis (AIIMS98)(AIIMS98)

• Damaged area heals in Damaged area heals in a metaplastic process a metaplastic process and abnormal columnar and abnormal columnar cells replace squamous cells replace squamous cellscells

• This specialized This specialized intestinal metaplasia intestinal metaplasia can progress to can progress to dysplasia and dysplasia and adenocarcinomaadenocarcinoma

ComplicationsComplications

Barrett’s EsophagusBarrett’s Esophagus• Manage in same manner as GERDManage in same manner as GERD• EGD every 3 years in patient’s without EGD every 3 years in patient’s without

dysplasiadysplasia• In patients with dysplasia annual to In patients with dysplasia annual to

shorter interval surveillanceshorter interval surveillance

ComplicationsComplications

• Patient’s who need EGDPatient’s who need EGD Alarm symptomsAlarm symptoms Poor therapeutic responsePoor therapeutic response Long symptom durationLong symptom duration

• ““Once in a lifetime” EGD for patient’s Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted with chronic GERD becoming accepted practicepractice

• Many patients with Barrett’s are Many patients with Barrett’s are asymptomaticasymptomatic

Esophageal CancerEsophageal Cancer

Barium SwallowBarium Swallow EndoscopyEndoscopy

MCQ’sMCQ’s

Most prevalent esophageal cancer Most prevalent esophageal cancer worldwide worldwide (AI91)(AI91)

Most common site of Ca oesophagus Most common site of Ca oesophagus (AIIMS 97)(AIIMS 97)

Most common site for squamous cell Most common site for squamous cell Ca Ca (AI 01)(AI 01)

Most common site of esophageal Most common site of esophageal adenocarcinoma adenocarcinoma (AIIMS 96,2000)(AIIMS 96,2000)

MCQ’sMCQ’s

Most common site for Ca oesophagus Most common site for Ca oesophagus in indiain india

Predisposing fators for Ca Predisposing fators for Ca oesophagus are all exceptoesophagus are all except

a-plummer vinson syna-plummer vinson syn

b-tulosis palmarisb-tulosis palmaris

c-gerdc-gerd

d benzene therapyd benzene therapy

MCQ’sMCQ’s

Chemotherapy regimens for Ca Chemotherapy regimens for Ca oesophagus have improved with the oesophagus have improved with the use of use of (AI96)(AI96)

Commonest adverse effect of Commonest adverse effect of cisplatin cisplatin (AIIMS01)(AIIMS01)

Best substitute for esophagus after Best substitute for esophagus after esophagectomy esophagectomy (AI96)(AI96)

SummarySummary

Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManisfestationsClinical Manisfestations Diagnostic EvaluationDiagnostic Evaluation TreatmentTreatment ComplicationsComplications

?QUESTIONS??QUESTIONS?

A slideshow presentation A slideshow presentation

Prepared byPrepared by

Dr. ZEESHAN AHMADDr. ZEESHAN AHMADunder guidance ofunder guidance of

DR(Prof)CHANDRA SHEKHARDR(Prof)CHANDRA SHEKHARHead ENT depttHead ENT deptt

&&DR MK VERMADR MK VERMA

Assoc prof ENT depttAssoc prof ENT deptt

THANK YOUTHANK YOU