1. Gastroesophageal Reflux Disease ( GERD ) Prof.Dr.Khalid A. Al-Khazraji MBCHB, MD, CAMB, FRCP, FACP 1 2014

2. 2 GERD: is a clinical manifestations of reflux of stomach and duodenal contents into esophagus, with specific symptoms, radiological, endoscopical, and pathological changes. GERD is the most common disorder of the esophagus, and resulting in heartburn affects approximately 10-20 % of general population. Pathophysiology GERD develops when esophageal mucosa exposed to gastroduodenal contents for prolonged periods of time (fail of antireflux mechanisms), resulting in symptoms and, in a proportion of cases, esophagitis. Factors associated with development of GERD: 1- Abnormalities of LES: ( Reduced LES tone, Inappropriate sphincter relaxation). 2- Hiatus hernia. 3- Delayed esophageal clearance ( defective esophageal peristaltic activity). 4- Composition and quantity of reflux materials A- Pepsin and gastric acid. B- Bile salts & pancreatic enzymes both cause more injury than any one alone. 5- Defective gastric emptying. 6- Increased intra-abdominal pressure ( pregnancy, obesity). 7- Dietary and environmental factors ( fat, chocolate, alcohol, coffee: lead to relax LES).

3. 8- Cigarette smoking. 9- Drugs( like anti-muscarinic, calcium channel blockers). 10- Large meal. 11-Abnormal esophagus mucus, swallowed saliva of high bicarbonate content. Esophagus squamous epithelium reacts with reflux by increase basal cell If the reflux was continues Epithelium destroyed Polymorphonuclear leukocyte infiltration and edema, inflammation lamina properia, micro ulcer Submucosal and muscular inflammation and fibrosis Stricture 3

4. Clinical features 1- The two major symptoms are: - Heartburn. - Regurgitation. Usually provoked by ( bending, straining, lying down). 2- Waterbrash. 3- Odynophagia and dysphagia. 4- Atypical chest pain ; mimic angina due to reflux-induced esophageal spasm. (20% of cases admitted to CCU have GERD). But reflux pain: burning, worse on bending, stooping or lying down, seldom radiates to the arms, worse with hot drinks or alcohol, and relieved by antacids. 5- Acid laryngitis. 6- Pulmonary manifestations (recurrent chest infection- pneumonia is unusual without accompanying stricture, Chronic cough. Asthma). 7- Chronic blood loss from hematamesis and iron deficiency anemia. 4

5. Diagnostic Evaluation Indicated for a patient with GERD when:- 1- Heartburn is extremely chronic. 2- Refractory to treatment. 3- accompanied by dysphagia, Odynophagia, or GI bleeding. -Endoscopy (with biopsy when indicated) is the initial procedure. -Barium swallow usually fail to detect most cases of esophagitis or Barrett's. -Esophageal manometry is of minimum use in diagnosis of GERD. -In atypical or complicated cases: 1- Bernstein test ( acid perfusion test). 2- Ambulatory pH monitoring: the principal indication for it is to document persistent excessive acid reflux despite medical or surgical treatment. 5

6. 6 Normal GERD

7. Los Angeles Classification System GRADE A: One or more mucosal breaks no longer than 5 mm, non of which extends between the tops of the mucosal folds

8. GRADE B: One or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds

9. GRADE C: Mucosal breaks that extend between the tops of two or more mucosal folds, but which involve less than 75% of the oesophageal circumference

10. GRADE D: Mucosal breaks which involve at least 75% of the oesophageal circumference

11. Complications: 1- Esophageal stricture. 2- Esophageal ulcer. 3- Barrett’s esophagus. 4- Pulmonary aspiration. 11 Peptic Stricture

12. Treatment 1- Simple (lifestyle) measures: include A- Raise the head of bed 6 to 8 inches by putting blocks under the bedposts. just using extra pillows will not help. B- Avoidance of food or liquids 2-3 hr before bedtime. C- Avoidance of fatty food, spicy food, chocolate, coffee, tea, cola. D- Avoidance of cigarettes, and alcohol. E- Weight reduction (if overweight). F- Wear loose-fitting clothes. G- Liquid antacid ( aluminum hydroxide, magnesium hydroxide). H- H2 receptors blockers (over the counter). 2- Persistent symptoms without esophagitis: A- Alginic acid antacid. B- Promotility drugs (domperidone, metaclopramide). C- H2 receptors blockers ( cimetidine, ranitidine, famotidine, nizatidine). 3- With esophagitis: A- H2 receptor blockers (regular or double dose depending on severity). B- H2 receptor blockers and Promotility agent. C- Proton pump inhibitors (PPI): (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole). PPI are drugs of choice for all but mild cases. D- Antireflux surgery: Nissen fundoplication by laprotomy or laparoscopy. indications include intolerance to medications, the desire for freedom from medications, the expense of therapy and the concern of long-term side effects. - There is no evidence that H.pylori eradication has any therapeutic value. 12

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14. Barrett’s esophagus Is a pre-malignant condition in which the normal squamous lining of lower esophagus is replaced by columnar mucosa, containing areas of intestinal metaplasia. Form segment of “ columnar – lined oesophagus” CLO. It’s a complication of severe GERD, and there is almost always hiatus hernia. -Commonest in middle age men. -0.5-1.0% of Barrett's patients develop adenocarcinoma per year. -It increase chance of developing adenocarcinoma 30 to 125 folds. -Diagnosis : endoscopy with biopsy. Chromoendoscoy magnification and narrow band imaging may aid the diagnosis of metaplasia, dysplasia, and carcinoma. Treatment : Neither potent acid suppression nor anti Reflux surgery induce regression of CLO. Treatment only indicated for symptoms of reflux or complications such as stricture. Endoscopic therapies such as “ argon plasma coagulation, radiofrequency ablation, or photodynamic therapy” can induce regression but remain experimental. 14

15. Atlas of Barrett’s esophagus 15

16. 16 Figure 1 Histological features of low-grade dysplasia in Barrett esophagus Odze, R. D. (2009) Barrett esophagus: histology and pathology for the clinician Nat. Rev. Gastroenterol Hepatol doi:10.1038/nrgastro.2009.103

17. Thank you 17