GERD Robert Erickson MD

Definitions Odynophagia – pain on swallowing Dysphagia – symptom resulting from the failure to move a food bolus from the mouth to the stomach

What Factors Contribute to Dysphagia? Inadequate preparation of what is being swallowed Reduced saliva or mastication Neuromuscular disorders Impaired mental function Abnormal muscle strength/function Motility disturbances Esophageal passageway narrowed Mechanical obstruction

Dysphagia (Symptoms Predict Site) Difficulty initiating swallow Oropharyngeal Dysphagia Food stops, “sticks” after swallowing initiated Esophgeal Dysphagia

Disorders Causing Oropharyngeal Dysphagia Anatomical Postcricold web Cervical osteophyte Hypopharyngeal diverticulum Head and neck tumors Neurological Cerebrovascular accidents Poliomyelitis Amyotrophic lateral sclerosis Parkinson’s disease Cerebral palsy Tumors Muscular disease Oculopharyngeal muscular dystrophy Myotonic dystrophy Myasthenia gravis

Oropharyngeal Dysphagia Therapeutic Modalities Speech/Swallowing therapy Retraining Bolus size and consistency adjustment Specific swalowing maneuvers Esophageal dilation Surgical Myotomy NPO with nutrition support (PEG, PEJ or TPN)

Causes of Dysphagia Anatomic Benign Cancer Peptic strictures Rings and webs Caustic scars Cancer Primary esophageal Extrinsic compression

Causes of Dysphagia Neuromuscular Secondary Primary esophageal disease Achalasia Chagas’ disease Other motor disorders Secondary

Achalasia – Loss of Inhibitory Innervation to the LES NORMAL SPHINCTER TONE ACh SP + – VIP NO LES IN CHALASIA VIP NO ACh SP + –

Achalasia: Presenting Symptoms in 133 Patients

Esophageal Dysphagia (Symptoms Suggest Diagnosis) Solids and/or Liquids Solids Only Intermittent Progressive Intermittent Progressive Lower Esophageal Ring Peptic Stricture Or Cancer (espl. if>50y.o. Diffuse Spasm NEMD Nutcracker Achalasia Or Scleroderma

Painful Swallowing

Burning Issues in Gastroesophageal Reflux Disease (GERD)

Pathophysiology of GERD

Common Esophageal Symptoms of GERD Heartburn Regurgitation Belching Water brash

Atypical Presentations of GERD Chest pain Hoarseness/laryngitis Loss of dental enamel Asthma/chronic cough Dyspepsia

Symptoms Associated With Complications of GERD Dysphagia Odynophagia Bleeding

Hiatal Hernias May Contribute to Reflux by Two Mechanisms

Diagnostic Studies Not Needed With Classic History of GERD Heartburn and/or regurgitation, postpradial, postural, decreased with antacid No diagnostic studies needed. Start empiric treatment.

Endoscopy Strengths Esophagitis, Barrett’s epithelium Hiatal hernia, Strictures Biopsy Limitations Operator dependent Cost Endoscopy with biopsy is the best diagnostic Study for evaluating mucosal injury.

Ambulatory pH Monitoring Strengths Quanitfy reflux Physiologic conditions Allows symptom correlation Limitations Availablilty Operator dependent Cumbersome Cost Ambulatory pH monitoring is the best study to confirm GERD.

Life-Style Modifications Are Cornerstone of GERD Therapy Elevate head of bed while speeping (blocks, wedge) No food 3 hours before bedtime Stop smoking Modify diet Decrease fat and volume Avoid peppermint, onions, citrus juice, coffee, tomato Avoid potentially harmful medications OTC medications PRN

Mechanisms by Which Drugs May Effect GERD Decrease LES Pressure Theophylline Anticholinergics Calcium channel blockers Nitrates Injure Mucosa Tetracyclines Quinidine Aspirin/NSAIDs Potassium tablets Iron salts

Acid Suppression Therapy for GERD H2 Receptor Antagonists (H2RAs) Cimetidine Ranitidine Famotidine Nizatidine Proton Pump Inhibitors (PPIs) Omeprazole Lansoprazole

GERD is Chronic Relapsing Condition Effective maintenance therapy is the key!

Barrett’s Esophagus Frequency: 10% to 15% of patients with GERD symptoms who have endoscopic examinations Pathogenesis: GER injures squamous epithelium and promotes repair by columnar metaplasia

Barrett’s Esophagus Cancer Risk Barrett’s esopagus is major risk factor for esophageal adenocarcinoma Cancer risk associated primarily with intestinal metaplasia Incidence of adenocarcinoma in patients with Barrett’s esophagus: ~1% per year

Peptic Esophageal Strictures Frequency: ~10% of patients who have reflux esophagitis Pathogenesis: Ulceration stimulates fibrosis Association: Often associated with NSAIDs Treatments: Aggressive acid suppression Dilatation Surgery