Gastro Esophageal Reflux
Disease
Dr. K. Sendhil Kumar
Dr. Piyush Patwa
Dr. Latif Bagwan
Today’s Talk
• Definition of GERD
• Pathophysiology of GERD
• Clinical Manifestations
• Diagnostic Evaluation
• Treatment
• Complications
• Montreal consensus panel (44 experts):
“a condition which develops when the reflux of stomach
contents causes troublesome symptoms and/or
complications”
• Troublesome—patient gets to decide when reflux
interferes with lifestyle
Vakil N, et al. Am J Gastroenterol 2006;101:1900
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 GERD • Pathologic GERD
– Postprandial – Symptoms
– Short lived – Mucosal injury
– Asymptomatic – Nocturnal sx
– No nocturnal sx
Lower Esophageal Sphincter
– Intrinsic distal esophageal muscles – tonically contracted
– Muscular Sling fibers of the gastric cardia
– Diaphragmatic crura
– Transmitted pressure of the abdominal cavity
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
Dr. K. Sendhil Kumar.
Surgical gastroenterologist
Gateway clinics & hospital
Hiatus Hernia
Symptoms of GERD
• Esophageal • Extraesophageal
– Cough
– Heartburn
– Wheezing
– Dysphagia – Hoarseness
– Odynophagia – Sore throat
– Regurgitation – Globus sensation
– Belching – Epigastric pain
– Non-cardiac chest
pain(NCCP)
Symptoms
Symptom Predominance (%)
Heartburn 80
Regurgitation 54
Abdominal Pain 29
Cough 27
Dysphagia for solids 23
Hoarseness 21
Belching 15
Aspiration 14
Wheezing 7
Globus 4
Montreal Classification of GERD
From Vakil N et al. Am J Gastroenterol 2006;101:1900-20.
Factors That Can Aggravate GERD
• Diet – Caffeine, fatty/spicy
foods, chocolate, coffee, peppermint
, citrus, alcohol
• Position/Activity – Bending, straining
• External Pressure – pregnancy, tight
clothing
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
Alarming Signs & Symptoms
• Dysphagia
• Early satiety
• GI bleeding
• Odynophagia
• Vomiting
• Weight loss
• Iron deficiency anemia
Diagnostic Tests for GERD
• Barium swallow
• Endoscopy
• Ambulatory pH monitoring
• Impedance-pH monitoring
• Esophageal manometry
Barium Swallow
• Useful first diagnostic test for
patients with dysphagia
– Stricture (location, length)
– Mass (location, length)
– Hiatal hernia (size, type)
• Limitations
– Detailed mucosal exam for
erosive esophagitis, Barrett’s
esophagus
Endoscopy
• Indications
– Alarm symptoms
– Empiric therapy
failure
– Preoperative
evaluation
– Detection of Barrett’s
esophagus
Esophago-gastro-duodenoscopy
• Endoscopy (with biopsy if needed)
– In patients with alarm
signs/symptoms
– Those who fail a medication trial
– Those who require long-term tx
• Absence of endoscopic features
does not exclude a GERD diagnosis
• Allows for
detection, stratification, and
management of esophageal
manisfestations or complications of
GERD
pH
• 24-hour pH monitoring-----Physiologic study
– 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
Ambulatory 24 hr. pH Monitoring
Normal
GERD
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
Treatment
–Symptomatic relief
–Heal esophagitis
–Prevent & Treat complications
–Maintain remission
Lifestyle Modifications
• Weight reduction if overweight
• Avoid clothing that is tight around the waist
• Modify diet
– Eat more frequent but smaller meals
– Avoid fatty/fried
food, peppermint, chocolate, alcohol, carb
onated beverages, coffee and
tea, onions, garlic.
– Stop smoking
• Elevate head of bed 4-6 inches
• Avoid eating within 2-3 hours of bedtime
Treatment
• Antacids
• Quick but short-lived relief
• Neutralize HCl acid
– Approx 1/3 of patients with heartburn-related
symptoms use at least twice weekly
– More effective than placebo in relieving GERD
symptoms
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 DOSAGE
Cimetadine 400-800mg twice daily
Famotidine 20-40mg twice daily
Ranitidine 150mg twice daily
Lafutidine 10mg twice daily
Dr. K. Sendhil kumar.
Surgical gastroenterologist
Gateway clinics & hospital
Collaborative Care
• Drug therapy (cont’d)
– Prokinetic drugs
• Promote gastric emptying
• Reduce risk of gastric acid reflux
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
Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Esomeprazole 40mg daily 20-40mg daily
Omeprazole 20mg daily 20mg daily
Lansoprazole 30mg daily 15-10mg daily
Pantoprazole 40mg daily 40mg daily
Rabeprazole 20mg daily 20mg daily
Treatment
• H2RAs v/s PPIs
– 12 week freedom from symptoms
• 48% vs 77%
– 12 week healing rate
• 52% vs 84%
– Speed of healing
• 6%/wk vs 12%/wk
Effectiveness of Medical Therapies for
GERD
Treatment Response
Lifestyle modifications/antacids 20 %
H2-receptor antagonists 50 %
Single-dose PPI 80 %
Increased-dose PPI up to 100 %
Treatment
• 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
Treatment
• Antireflux surgery candidates
– OGD proven esophagitis
– Normal esophageal motility
– Partial or complete response to acid suppression
Nissen Fundoplication
Laparoscopic
Complete vs. partial fundoplication
• Ant. partial fundoplication
Thal/Dor procedure
• Post. partial
fundoplication
Toupet procedure
Treatment
• Postsurgery
– 10% have solid food dysphagia
– 2-3% have permanent symptoms
– 7-10% have gas, bloating, diarrhea, nausea, early
satiety
Treatment
• Endoscopic treatment
– Relatively new
– No definite indications
– Select well-informed patients with well-documented GERD
responsive to PPI therapy may benefit
• Three categories
– Radiofrequency application to increase LES reflux barrier
– Endoscopic sewing devices
– Injection of a nonresorbable polymer into LES area
Complications
• Erosive esophagitis
• Stricture
• Barrett’s esophagus
• Adenocarcinoma
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
Barrett’s Esophagus
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
• Barrett’s Esophagus
– Manage in same manner as GERD
– EGD every 3 years in patient’s without dysplasia
– In patients with dysplasia annual to shorter
interval surveillance
Summary
• Definition of GERD
• Epidemiology of GERD
• Pathophysiology of GERD
• Clinical Manisfestations
• Diagnostic Evaluation
• Treatment
• Complications
Lafutidine
Acid breakthrough symptoms
Nocturnal Acid Breakthrough
• Nocturnal acid breakthrough is defined as the presence
of intragastric pH < 4 during the overnight period for at
least 60 continuous minutes in patients taking a proton-
pump inhibitor1
1. MedGenMed. 2004; 6(4): 11.
The need for H2RA
• Acid suppression of most PPIs, administered once daily
wanes during the night-time hours1
• PPIs are unable to eliminate nighttime heartburn
completely1
1. Rev Gastroenterol Disord. 2008 Spring;8(2):98-108
Lafutidine
• LAFUTIDINE is a synthetic H2 receptor antagonist for oral
administration
• Newly developed second generation H2 receptor antagonist1
• Receptor binding affinity upto 80 times that of other H2RAs
• Daytime and night-time acid inhibition
• Gastroprotective activity independent of acid antisecretory
activity
• Has multimodal mechanisms of action
1. World J Gastrointest Pharmacol Ther 2010 October 6; 1(5): 112-118
Lafutidine and H. pylori
• Lafutidine inhibits the adherence of Helicobacter
pylori to gastric cells1
• Lafutidine also inhibits subsequent IL-8 release -
protects against the mucosal inflammation associated
with H. pylori infection1
1. 1 J. Gastroenterol. Hepatol, 2004, 19: 506-511.
Conclusions
• LAFUTIDINE is a newly developed second generation
H2 receptor antagonist and has multimodal
mechanisms of action
• LAFUTIDINE rapidly binds to gastric cell histamine H2
receptors, results in decreased acid production
