1. gastroesophageal reflux disease GERD
Department of gastroenterology,
1st hospital of jilin university
Tongyu Tang

2. Definition American College of Gastroenterology (ACG)
Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
Often chronic and relapsing
May see complications of GERD in patients who lack typical symptoms

3. Barrett’s esophagus,BE
GERD
Barrett’s esophagus,BE
non-erosive reflux disease, NERD
reflux esophagitis, RE

4. 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

5. 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

6. Pathogenesis of GERD Decreased Salivation Impaired Tissue Resistance
LES
Impaired Esophageal Clearance
Hiatal Hernia
Decreased LES Resting Tone
Duodenum
The main culprit in GERD is the movement of reflux, which is a mix of bile acid, pepsin, trypsin, and food, from the stomach back into the esophagus. In GERD, the antireflux barrier located at the gastroesophageal junction is no longer preventing reflux because of any of 3 reasons:
Transient relaxation of the LES (predominant in milder disease)
Hiatal hernia (predominant in more severe disease)
Hypotension of the LES (predominant in more severe disease)
Reflux involves a 2- to 3-fold increase in esophageal acid clearance time (time the esophageal mucosa is acidified to a pH of <4) of 2 to 3 times due to impairment in both esophageal emptying and salivary function
Prolonged exposure to acid damages the esophageal mucosa, compromising the ability of the epithelium to resist acid injury
Delayed Gastric Emptying
Bile Reflux 6

7. Clinical Manisfestations
Most common symptoms
Heartburn—retrosternal burning discomfort
Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions
--gerd related chest pain may mimic angina—squeezing/burning, substernal, radiates to back, neck, jaw, arms. Minutes to hours. After meals, awakens patient from sleep, exacerbated by emotional stress
--water brash—hypersalivation—heartburn and regurg of sour fluid or tasteless saliva into mouth
--globus—lump in throat irrespective of swallowing
--odynophagia—esophageal ulcer
--nausea—infrequent
--hrt burn 70-85%//regurg 60%//dysphagi 15-20%//angina 33%//asthma 15-20%

8. Clinical Manisfestations
Dysphagia—difficulty swallowing
Other symptoms include:
Chest pain, water brash, globus sensation, odynophagia, nausea
Extraesophageal manifestations
Asthma, laryngitis, chronic cough

9. Complications Stricture Barrett’s esophagus Bleeding
--dysphagia, odynophagia, early satiety, gi bleed, anemia, vomit, wt loss

10. Complications Esophageal stricture
Result of healing of erosive esophagitis
May need dilation
4-20% of patients

11. Complications Barrett’s Esophagus Columnar metaplasia of the esophagus
Associated with the development of adenocarcinoma
--1950—Norman Barrett %
--black arrow squamo-columnar jxn—Z-line
--Z-line has undulating smooth contours
--green arrow—gastric columnar epithelium above round black sphincter
--red arow—pink white esophageal squamous epithelium
--RFs—male, smoker, age, obese

12. 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
Adenoca with barretts 0.5%/yr without barretts 0.07%/yr

13. Diagnostic Tests for GERD
Endoscopy
Barium swallow
Ambulatory pH monitoring
Esophageal manometry

14. 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
--if trial of med did not work or if alarm symptoms or long term 5yrs need egd 1a evidence—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia
% of patient’s with gerd will have a neg egd.

16. ＞ ＞

19. LA Classification of Esophagitis
From Nayar DS et al. Gastrointest Endosc 2004;60:253-7. 19

20. 24-Hour Esophageal pH Monitoring
Most accurate test for measuring pattern, frequency, and duration of reflux episodes
Documents correlation between reflux episodes and symptoms
Sensitivity (77-100%)
Normal in 25% of esophagitis!
Specificity %
Most useful when diagnosis still unclear
24-Hour esophageal pH monitoring verifies whether symptoms are related to reflux. Using this test, physicians can document the pattern, frequency, and duration of reflux episodes. Its usefulness as a test for GERD, however, is unclear with regard to its sensitivity and specificity
24-Hour esophageal pH monitoring is useful in patients whose diagnosis is still unclear following trial therapy and endoscopy
Dent et al. Gut. 1999;44(suppl 2):S1-S16. 20

21. Ambulatory 24 hr. pH Monitoring
Physiologic study
Quantify reflux in proximal/distal esophagus
% time pH < 4
DeMeester score
Symptom correlation

22. Esophageal Manometry Limited role in GERD
Assess LES pressure, location and relaxation
Assist placement of 24 hr. pH catheter
Assess peristalsis
Prior to antireflux surgery

23. A级 B级 D级 C级

24. Treatment Goals for GERD
Eliminate symptoms
Heal esophagitis
Manage or prevent complications
Maintain remission

25. 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

26. 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

27. Treatment AGENT EQUIVALENT DOSAGE DOSAGES
Cimetadine mg twice daily mg twice daily
Tagamet
Famotidine mg twice daily mg twice daily
Pepcid
Nizatidine mg twice daily mg twice daily
Axid
Ranitidine mg twice daily mg twice daily
zantac
--otc dose uniformly half of standard lowest prescription dose
--similar clinical efficacy

28. 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

29. Treatment AGENT EQUIVALENT DOSAGE DOSAGES
Esomeprazole mg daily mg daily
Nexium
Omeprazole mg daily mg daily
Prilosec
Lansoprazole mg daily md daily
Prevacid
Pantoprazole mg daily mg daily
Protonix
Rabeprazole mg daily mg daily
Aciphex
--no significant differences in symptomatic tx of GERD or healing of erosive esophagitis 1a evidence
--works only on active pumps—take 30-60min prior to meals
--long-term tx generally benefits outweigh risks

30. 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

31. Surgical Treatment Indications
Esophagitis
Stricture
Barrett’s metaplasia
Medication failure
Purpose of surgery  restoration the LES

32. 谢 谢