Gastro Esophageal Reflux Disease
(GERD)
Dr Raed Altiti
SECRETARY GENERAL OF PLAESTINIAN
GASTROENTEROLOGY ASSOCIATION
Jericho –Palestine
2012
The Montréal definition and Classification of GERD
A Global Evidence-Based Consensus
What is GERD?
“GERD is a condition which develops
when the reflux of stomach contents
causes troublesome symptoms and/or
complications”
Vakil N et al. Am J Gastroenterol 2006;101:1900-1920
GASTROESOPHAGEAL REFLUX
DISEASE
DIAGNOSED BY
1- CLINICAL PICTURE
2-UPPER ENDOSCOPY
3- PH METRY
4- MANOMETRY?
5- The impedance metry
UPPER ENDOSCOPY
Upper endoscopy should be the initial
evaluation of suspected GERD
because it provides a mechanism for
detecting, stratifying, and managing
the esophageal manifestations of
GERD
Not indicated in every patient
What can We Detect by EGD
• 1- FROM THE LARYNX
• 2- FROM THE ESOPHAGUS
• 3- FROM STOMACH
Laryngopharyngeal reflux, or LPR
• laryngeal hyperemia
• posterior commissure
hypertrophy.
Thick endolaryngeal mucus.
• some persons with LPR do suffer from
heartburn or esophagitis (12%), most persons
with LPR do not.
• The reason for this is that the refluxate spends
very little time in the esophagus and does
most of its damage in the larynx.
• The anatomic abnormality in patients with LPR
is thought to exist at the level of the upper
esophageal sphincter
ESOPHAGUS
• NERD 60-70 % so BIOPSIES ARE NEEDED
• GERD
The GERD symptom pattern is similar in patients with
and without esophagitis
Heartburn
(100%)
Regurgitation
Epigastric pain
Nausea
Belching
Bloating
without
esophagitis
with esophagitis
Abdominal pain
Scale=% of patients with symptom
Carlsson et al 1998b
Endoscopic Severity of GERD
Non-erosive Reflux Disease (NERD)
Mild reflux esophagitis (LA grade A/B)
Severe reflux esophagitis (LA grade C/D)
~1%
~10%
~30%
~30%
~60%
In referral center
LA: Los Angeles Classification
~70%
In community
Labenz, Malfertheiner. World J Gastroenterol 2005
Ronkainen et al. Scand J Gastroenterol 2005
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Biopsies should target any areas of suspected:
metaplasia,
dysplasia, or, in the
normal mucosa
eosinophilic esophagitis
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So biopsies are needed for many reasons:
1- For diagnosis of NERD
2- For excluding Esinophilic Esophagitis
3- For Diagnosis and staging of Barrett’s
Histology
• . NERD =The most consistently observed histologic
finding is dilation of the intercellular spaces seen
on transmission electron microscopy. This finding
is also present in patients with reflux esophagitis.
• GERD=Cellular injury stimulates cell proliferation,
the morphologic equivalent of which is thickening
of the basal cell layer and elongation of the
papillae of the epithelium
• Other histologic features include the presence of
neutrophils and eosinophils, dilated vascular
channels in papillae of the lamina propria, and
distended, pale squamous ("balloon") cells.
However, none of these findings is specific for
GERD.
Dilated intercellular space in NERD
MACROSCOPICAL APEARANCE
• Los Angeles classification —
• The Los Angeles classification grades esophagitis severity
by the extent of mucosal abnormality, complications
recorded separately.
• Grade A – one or more mucosal breaks each ≤5 mm in
length
• Grade B – at least one mucosal break >5 mm long, but not
continuous between the tops of adjacent mucosal folds
• Grade C – at least one mucosal break that is continuous
between the tops of adjacent mucosal folds, but which is
not circumferential
• Grade D – mucosal break that involves at least threefourths of the luminal circumference .
Stricture of the esophagus
DEFINITION of BARRETT’S
Barrett's esophagus is the condition in
which an abnormal columnar epithelium
replaces the stratified squamous epithelium
that normally lines the distal esophagus.
It is a consequence of chronic (GERD) and
predisposes to the development of
adenocarcinoma of the esophagus.
Barrett’s Esophagus
BARRETT’S CAN BE
1- With no DYSPLASIA.
2 – With low Dysplasia.
3- With high Dysplasia.
• For patients without dysplasia, the risk of
esophageal adenocarcinoma is approximately
0.5 % per year
• For patients with low-grade dysplasia, the risk
of esophageal adenocarcinoma is
approximately 0.6 % per year
• For patients with high-grade dysplasia, the
rate of cancer development is 4 to 6 % per
year.
WHAT WE SEE BY RETROGRADE
FELXION FROM THE STOMACH
Ambulatory esophageal pH monitoring
• Transnasally placed catheter or a wireless,
capsule-shaped device that is affixed to the
distal esophageal mucosa
• The catheter type pH electrode is positioned 5
cm above the manometrically defined upper
limit of the lower esophageal sphincter.
• In the case of the wireless device, the pH
capsule is attached 6 cm proximal to the
endoscopically defined squamocolumnar
junction
• the percentage time with the intraesophageal
pH below 4 as the most useful outcome
measure in discriminating between
physiologic and pathologic esophageal reflux
INDICATIONS FOR PH -METRY
• 1---To document abnormal esophageal acid
exposure in an endoscopy-negative patient being
considered for surgical antireflux repair .
• 2---To evaluate patients after antireflux surgery
who are suspected to have ongoing abnormal
reflux
• 3- To evaluate patients with either normal or
equivocal endoscopic findings and reflux
symptoms that are refractory to PPI therapy .
• Is possibly indicated to detect refractory reflux in
chest pain patients after cardiac evaluation using
a symptom reflux association scheme, preferably
the symptom association probability calculation .
• Is possibly indicated to evaluate a patient with
suspected LPR manifestations (laryngitis,
pharyngitis, chronic cough) of GERD after
symptoms have failed to respond to at least 4
weeks of PPI therapy .
• possibly indicated to document concomitant
GERD in an adult onset, non-allergic asthmatic
suspected of having reflux induced asthma
exacerbations .
Esophageal manometry
• Esophageal manometry should be considered in
patients with symptoms of GERD and normal upper
endoscopy, especially if there is any associated
dysphagia, even though esophageal manometry is of
minimal use in the diagnosis of GERD.
• Useful in identifying alternative diagnoses such as
achalasia, the symptoms of which sometimes closely
mimic those of GERD .
• The evaluation of peristaltic function to exclude major
motor disorders is also important before antireflux
surgery, and it can also be used to ensure that
ambulatory pH probes are placed correctly .
Combined Multichannel intraluminal
impedance and pH testing
• All patients with persistent GERD symptoms
despite PPI therapy require multichannel
intraluminal impedance and pH testing.
• Combined multichannel intraluminal
impedance and pH (MII-pH) monitoring is
based upon detection of changes in resistance
to electrical currents.
• retrograde bolus movement causes the
electrical resistance changes
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This techinc provides information on:
The number of acid and non-acid reflux episodes
Number of liquid, gas, and mixed reflux episodes
Proximal extent of reflux episodes
Bolus contact time (ie, percentage of time bolus
was present at 5 cm above the lower esophageal
sphincter [LES])
• Acid contact time (ie, percentage of time pH <4.0
at 5 cm above the LES)
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CONTINUE TO BE PATIENT RR
WHY NO RESPONSE
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Differences in Bioavailability (change the drugs)
Food
Differences in metabolism gentetic (change the drug)
Dose interval
(split the dose)
Gastric acid secretion
Esphageal hypersensitivity (increase the dose)
Esinophillic esophagitis
Bilereflux
(considere sucralfate )
Other drugs
• Medical therapy is the first line of
management for GERD.
• +++Esophagitis will heal in approximately 90%
of cases with intensive medical therapy.
• ---- medical management does not address
the etiology; thus symptoms recur in more
than 80% of cases within one year of drug
withdrawals.
• ---- mucosal injury may continue due to
ongoing alkaline reflux .
• ----may be required for life.
• ----The cost
• ----Psychological burden of a life time of
medication dependence,
----Undesirable life style changes,
• Chronic medical management may be most
appropriate for patients with limited life
expectancy or comorbid conditions which
would prohibit safe surgical intervention.
• young people.
• "Long-term control of chronic GERD can be
very effectively obtained with either
maintenance esomeprazole or laparoscopic
antireflux surgery,
• "Both treatments are safe and well
tolerated."
• Proton pump inhibitors (PPIs) are just as
effective as laparoscopic surgery for patients
with chronic gastroesophageal reflux disease,
results of a multicenter clinical trial suggest.
• After five years of follow-up, 92% of patients
treated with the PPI esomeprazole remained
in remission, compared with 85% of patients
who had antireflux surgery.
• But clinical relevance is questionable
SURGERY
• The most frequent indication for antireflux
surgery has traditionally been severe GERD
unresponsive to optimal medical therapy,
which consists of both drug therapy and
lifestyle modifications .
Surgical management of
gastroesophageal reflux in adults
Gastrointestinal indications
• Failed optimal medical management
• Noncompliance with medical therapy
• High volume reflux
• Severe esophagitis by endoscopy
• Benign stricture
• Barrett's columnar-lined epithelium (without
severe dysplasia or carcinoma)
Non gastrointestinal indications
• About one-half of patients with GERD report
upper respiratory symptoms including
hoarseness, laryngitis, wheezing, nocturnal
asthma, cough, aspiration, or dental erosion .
Relief of respiratory symptoms is usually
achievable by fundoplication in patients who
also have typical reflux symptoms; however, the
outcome is less favorable in the substantial
minority of patients in whom respiratory
symptoms occur in association with
abnormalities of esophageal motility
Asthma
• Consensus has not been achieved on the role of surgery in
patients with asthma that is thought to be related to GERD.
A systematic review that included 24 reports (mostly case
series and uncontrolled trials) suggested that surgery
improved asthma symptoms in 79 , asthma medication use
88, and pulmonary function in, 27 percent of patient.
• A dramatic reduction in steroid dependency
postoperatively was documented in another study .
• Medical therapy is associated with an improvement in
symptoms and reduction in asthma medication use in 60 to
70 percent of patients .
• Improvement in pulmonary function has not been
documented after medical or surgical therapy .
Laryngeal disease
• There is no role for considering surgery as a
first-line treatment for posterior laryngitis.
However, it is reasonable to consider surgery
for patients who have abnormal pharyngeal
acid on a double probe pH study when
medical therapy has been maximized, is not
tolerated, or is impractical.
• A controlled trial suggested that surgery was
not consistently effective in patients who were
unresponsive to aggressive PPI therapy
• ; thus, failure to respond to a PPI should serve
as a warning that symptoms may not be
relieved with surgery
What to do for refractory cases
• CONSIDER OTHER DIAGNOSIS or GERD
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complications
Split the doses
Increase the dose
Use compound therapy
Change the drug
surgery