GERD Jaspreet Kaur 1488 MD 4

Table of Contents EPIDEMIOLOGY PATHOGENESIS RISK FACTORS COMPLICATIONS SIGNS AND SYMPTOMS CLINICAL FINDINGS LAB DIAGNOSIS PREVENTION TREATMENT

Epidemiology Approximately 10% of adults have GERD daily Approximately 80% of pregnant women have GERD Hiatal hernia present in 70% of people with GERD 10-15% GERD may lead to Barrett’s Esophagus 0.5% of these cases per year many lead to adenocarcinoma

Pathogenesis Transient relaxation and low basal tone of lower esophageal sphincter (LES) Reflux of acid and bile into the distal esophagus Ineffective esophageal clearance of reflux material Impaired gastric emptying Gastric hypersecretion

Gastro-esophageal Reflux Disease (GERD)

Risk Factors Smoking, alcohol Caffeine, greasy and spicy foods, chocolate, peppermint Lying down after eating Pregnancy, over weight, obesity – increased pressure on abdomen Hiatal hernia – lower pressure in esophageal sphincter Certain drugs: Calcium channel blockers, antihistamine, sedatives, antidepressants, painkillers

Complications Esophagitis Esophageal Strictures Anemia Respiratory problems Barrett’s Esophagus Esophageal Cancer

Signs and Symptoms Heart burn Hoarseness of voice Coughing and wheezing Bad breath and bad taste Difficulty or painful swallowing Bloating with belching Nausea / vomiting Tooth erosion

Clinical Findings Non-cardiac chest pain Heartburn, indigestion Nocturnal cough, nocturnal asthma Acid injury to enamel Early satiety, abdominal fullness Regurgitation Barrett's esophagus – depending on severity

Diagnostic Tests Esophageal Endoscopy and Biopsy Twenty-hour esophageal pH monitoring Most accurate procedure to detect acid reflux Record of foods eaten, the time and quantity Manometry – only prior to surgery LES pressure < 10 mm Hg Endoscopy procedure will diagnose GERD if it is moderate to severe

Top - strictures Bottom left hiatal hernia Bottom right ulcer

Prevention and Non-Pharmacological Treatment Diet management Avoid foods that lower LES tone: chocolate, coffee, peppermint, fatty foods, alcohol Avoid drugs that lower LES tone: EtOH, theophylline, Ca-blockers, anti-cholinergics, beta-agonists, alpha-agonists Avoid foods that irritate damaged esophageal lining : citrus fruits and juices, tomato, pepper

Prevention and Non-Pharmacological Treatment Quit smoking and alcohol intake Loose weight if obese Avoid large meals Avoid tight clothing Avoid lying down for two hours after eating and eat dinner at least two hours before bedtime Raise the head of the bed tobacco inhibits saliva production and may also stimulates stomach acid production and relaxes LES

Pharmacological Treatment Short-term Antacids - relieve symptoms of GERD, neutralizes stomach acid OTC Antacids: Maalox, Rolaids, Mylanta H2 Blockers – decrease acid production Cimetidine, Nizatidine, Ranitidine Long-term Proton Pump Inhibitors – lowers parietal cells HCl production Omeprazole, pantoprazole Pro Kinetics - to empty stomach content faster Bethanechol, Metoclopramide Antibiotics - empty stomach faster with lesser side affect Surgery - Fundoplication procedure, gastric wrap around the gastroesophageal junction, increases pressure on LES surgery is recommended if symptoms of GERD don’t improve with lifestyle changes or medicines. 

References http://www.niddk.nih.gov/health-information/health- topics/digestive-diseases/ger-and-gerd-in- adults/Pages/overview.aspx http://www.asge.org/patients/patients.aspx?id=402 http://s3.gi.org/patients/pdfs/UnderstandGERD.pdf Goljan, Edward F. Pathology. 3rd ed. Philadelphia, PA: Mosby/Elsevier, 2010. Print. National Institute of Diabetes and Digestive and Kidney Diseases: "Heartburn, Gastroesophageal Reflux, and Gastroesophageal Reflux Disease (GERD)." Pluta, R. Journal of the American Medical Association, May 18, 2011. American College of Gastroenterology: "Understanding GERD."  http://www.gastrointestinalatlas.com/english/esophagitis.html