Gastroesophageal Reflux Disease 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 Physiologic vs Pathologic
Physiologic GE Pathologic GE reflux reflux • Postprandial • Pathologic • Short lived symptoms • Asymptomatic • Mucosal injury • No nocturnal • Nocturnal symptoms symptoms 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 Etiology of GERD
Increase of intragastral Nutritional factors (foods that contein cofein) pressure Medications that dicrease Pneumocardiodilitation tone of the lower Disfunction of salivary esophageal sphincter – gland nitrate, calcium channel- Stress blocking, antidepressants, prednisolone, spasmolitics, Aerophagia, meteorism NSAID) Laying in horizontal Smoking, alcohol pose after food intake Vegetative neuropathy, Dyskinesia overweight, scleroderma, Hernia of esophageal Pregnancy opening, duodenostasis Cough Work that deals with Operative intervention bending of body and physical load Etiology of GERD 2
Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors Obesity: increasing body mass index is associated with more severe GERD. Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production. Hypercalcemia, which can increase gastrin production, leading to increased acidity. Scleroderma and systemic sclerosis, which can feature esophageal dysmotility. Visceroptosis. Pathophysiology
Primary barrier to gastroesophageal reflux is the lower esophageal sphincter LES normally works in conjunction with the diaphragm If barrier disrupted, acid goes from stomach to esophagus Pathogenesis of GERD Clinical Manisfestations
Most common symptoms
• Heartburn—retrosternal burning discomfort
• Regurgitation—effortless return of gastric contents into the pharynx without nausea, vomiting, or abdominal contractions Clinical Manisfestations
• Dysphagia—difficulty swallowing • Other symptoms include:
Chest pain, water brash, dysphagia, nausea • Extraesophageal manifestations Clinical signs of GERD
typicaltyt atypicalms
- PAIN in the thorax - HEARTBURN - COUGH - ACUTE PAIN (especially night cough) in the larynx - ASTHMATIC fit - SOUR AIR HICCUP - HOARSENESS - ERUCTATION - RELAPSE pneumonia - CHRONIC bronchitis - DYSPHAGY (painful or with asthmatic content hard transaction - PARASTERNAL pain through the esophagus) - Pain similar to - SOUR or salty taste in stenocardia mouth - Arrhythmia - Caries - PAIN in the epigastria Extraesophageal syndroms
1. Stomatology syndrome (gingivitis, stomatitis, caries, paraodontosis),
2. Laryngologist syndrome (Laryngitis, pharingitis, rhinitis, otitis).
3. Bronchopulmonary syndrome (chr. bronchitis, pneumonia, pneumofibrosis, br. astma)
4. Cardial syndrome ( pains in the heart, arritrmias). INFORMATION OF PHYSICAL EXAMINATION Satisfactory overall condition
Xerostomia – dry mouth
Hypertrophied mashroom-like papilla
Positive phrenicus symptoms (left or right) during laryngitis in combination with hoarseness During outside esophageal symptoms – dry, medium moist rales and fine moist rales, alveolar crepitation, infringement of heart rhythm and rate Diagnostic Evaluation
• If classic symptoms of heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated Alarms
• Alarm Signs/Symptoms
Dysphagia
Early satiety
GI bleeding
Odynophagia
Vomiting
Weight loss
Iron deficiency anemia INVESTIGATION Clinical blood and urine analyses.
X-ray study organs of gastrointestinal tract (presence of the reflux of the contrast medium in the esophagus or diaphragmatic hernia)
FGDS (endoskopy) with target biopsy with secondary histological and cytological research of biopsy material
Chromoendoscopy - during FGDS with methylene blue detection metaplastic epithelium in esophagus INVESTIGATION (2) Tests on Helicobacter pylori Twenty-four-hour monitoring of pH in the esophagus – «golden standard» of diagnostics GERD (twenty-four-hour oxidation of the lower third esophagus - рН < 4 – increases from 15-30 minutes to 60 and more per day) Manometric research (pressure in the distal part of the esophagus is normally 20-50% higher than in the stomach which make up 11- 19 millimeter of mercury, with a deficiency of the lower sphincter of the esophagus – doesn’t differ from pressure in the stomach) РРІ (proton pump inhibitor)-test – course of trial treatment by one of the medicines of PPI group in standard dose Bernshtein’s Test (by introducing 0,1N solution of HCl into esophagus appear symptoms of GERD) 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 Erosive esophagitis Methods of detecting H. pylori
Biochemical: Microbiological: - CLO-test - Elution of pure culture from - Campy-test different biological - De-Nol test etc. environment of a patient Radionuclein: - respiratory Morphological: - urease - histological - cytological Immunological: - discovering in the blood antibodies to HP Classification of reflux-esophagitis (Los-Angeles, 1998)
A – one (or more) defect, less than 5 mm in length, limited to one fold of mucosa of esophagus B – one (or more) defects, longer than 5 mm, not connected to each other, limited to one fold of mucosa C - one (or more) defects extending to 2 folds (and more) and between them, but takes less than 75% of circumference of esophagus D – defect of mucosa, taking over 75% of circumference of esophagus pH
24-hour pH monitoring • Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes • Trans-nasal catheter or a wireless, capsule shaped device Endoscopy Ph-monitoring Differential diagnosis of GERD
Tumor of esophagus Esophagospasm Peptic esophageal stricture Hernia of esophageal opening Esophageal diverticulum Esophageal achalasia Scleroderma IHD, aortic aneurysm Mediastinal adenopathy ( blood diseases, metastases and etc.) Postoperative changes (operative intervention on stomach and esophageus) Complications of GERD
Esophageal stricture
Peptic esophageal ulcer
Bleeding from esophageal ulcer
Barrett’s esophagus
Adenocarcinoma of esophagus
In 18% of occasions patients who suffer GERD take medical help for the first time only when complications are noticed Complications
Erosive esophagitis • Responsible for 40-60% of GERD symptoms • Severity of symptoms often fail to match severity of erosive esophagitis 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 Complications
• Patient’s who need endoscopy (EGD)
Alarm symptoms
Poor therapeutic response
Long symptom duration • “Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice • Many patients with Barrett’s are asymptomatic TREATMENT
Lifestyle modifications
• Avoid large meals • Avoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate, onions, garlic, peppermint • Decrease fat intake • Avoid lying down within 3-4 hours after a meal • Elevate head of bed for 15 degrees • 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
Antacids • Over the counter acid suppressants and antacids appropriate initial therapy • Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly • More effective than placebo in relieving GERD symptoms ANTACIDS Neutralize HCL, decrease activity of pepsin, connect bile acids and lysolicytiny, stop HP growth, gastromucoprotaction, stimulation of synthesis of endogenous nitrates
Which are absorbed: sodium bicarbonate Which are not absorbed : Maalox, Phosphalugel, Almagel, Gastal, Gasterin-gel, Gelusil-lak Adsorbenets: Vikalin, Vikair, De-Nol 120 mg 60 min before food intake 3 times per day and before sleep Prescribed by fractional portions, not less than 5-6 times per day, 30 min before or 60-90 min after food and before sleep Out-side effects: defecatory disability, diarrhea, hypercalcemia 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 - H2 blokers
AGENT EQUIVALENT DOSAGE DOSAGES Cimetadine 400mg twice daily 400-800mg twice daily Tagamet
Ranitidine 150mg twice daily 150mg twice daily Zantac
Famotidine 20mg twice daily 20-40mg twice daily Quamatel
Nizatidine 150mg twice daily 150mg twice daily Axid
Roxatidine 75mg twice daily 75mg twice daily 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 PPI
AGENT EQUIVALENT DOSAGE DOSAGES Omeprazole 40mg daily 20mg daily Omez
Lansoprazole 60mg daily 15-30mg daily Lanzap
Rabeprazole 20mg daily 20mg daily Pariet
Pantoprazole 40mg daily 40mg daily Controloc
Esomeprazole 40mg daily 20-40mg daily Nexium Medications which normalize motoric function Cerucal (metoclopamid, reglan) – blocks dopamine receptors, suppresess the release of acetylcholine. Is used to suppress duodenogastric and gastroesophageal reflux 5-10 mg 4 times per day before food Domperidon (Motilium) - antagonist of dopamine accelerates gastric evacuation, disposes reflux – 10mg 3 times per day Sulpiridum (Eglonil, Dogmatil) 100 mg 2-3 times per day intramusculary - neuroleptic, central cholinergic antagonist, selective antagonist of dopamine, accelerates gastric evacuation. Side effects: galactorrhea, alactorrhea, headache, weakness, dry mouth, allergy. Treatment
Indications for antireflux surgery: • Failed medical management • Patient preference • GERD complications • Medical complications attributable to a large hiatal hernia • Atypical symptoms with reflux documented on 24-hour pH monitoring