Gastroesophageal Reflux Disease (GERD)

* Definition: inflammation of the lower part of the esophagus due to abnormal reflux of gastric contents into the esophagus – Often chronic and relapsing 2

GERD is due to weakness of the lower esophageal sphincter (LES) leading to reflux of the acidic gastric content to the lower part of the esophagus. 3

* Risk factors: - Obesity - Sliding Hiatal hernia - Pregnancy - Smoking - Delayed stomach emptying - Connective tissue disorders, such as scleroderma - Alcoholism. 4

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* Clinical Manifestations: 1. Heartburn: retrosternal burning discomfort. 2. Regurgitation: effortless return of gastric contents into the pharynx without nausea, or abdominal contractions. To be differentiated from vomiting. 3. Dysphagia: difficulty in swallowing 4. Extra-esophageal manifestations: laryngitis, chronic cough 7

* Morphological features of GERD: * Grossly: the lower part of the esophagus is red, and may shows erosions.

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* Microscopically: 1. Inflammatory cellular infiltrate in the squamous epithelium including neutrophils, esinophils and lymphocytes. 2. Basal cell hyperplasia. 3. Acute inflammation of the sub epithelium (lamina propria) 10

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Esophagogastrodudenoscopy Indications (with biopsy if needed): – In patients with alarm signs/symptoms – Those who fail a medication trial – Those who require long-term treatment. * Investigations: 14

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* Complications of GERD: Erosive esophagitis Stricture of esophagus due to healing by fibrosis. Barrett’s esophagus 16

Erosive esophagitis: – Responsible for 40-60% of GERD symptoms 17

Esophageal stricture – Result of healing of erosive esophagitis – May need dilatation 18

Barrett’s Esophagus: – Transformation of the stratified squamous epithelium of the lower end of the esophagus into intestinal epithelium (glandular metaplasia). – The clinical significance of Barrett’s Esophagus is that it is associated with the development of dysplasia and subsequently adenocarcinoma. 19

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References: Robbins and Cotran’s: Pathologic Basis of Disease. Seventh edition. References: Robbins and Cotran’s: Pathologic Basis of Disease. Seventh edition. 22