1. Gastro-Esophageal
Reflux Disease

2. Gastro-Esophageal Reflux Disease (GERD):
Definitions
Gastro-Esophageal Reflux Disease (GERD):
It is a chronic disorder which describes any symptomatic or histopathologic alteration resulting from episodes of gastro-esophageal reflux into the esophagus and/or adjacent organs

3. ERD NERD Erosive Reflux Disease Non Erosive Reflux Disease 2/3
Definitions
ERD
Erosive
Reflux
Disease
1/3
NERD
Non
Erosive
Reflux
Disease
2/3

4. Typical: Symptoms Heartburn Acid regurgitation > 2x/week
> 4 to 8 weeks

5. Symptoms-Atypical Esophageal: Pulmonary: Non-cardiac chest pain
Non-obstructive dysphagia
Globus hystericus
Pulmonary:
Asthma
Chronic cough
Hemoptysis
Bronchitis
Broncheictasis
Recurrent pneumonia

6. Symptoms-Atypical Otorhinolaryngological: Oral
Hoarseness
Throat cleaving laryngitis
Sinusitis
Otolagia
Oral
Etching of dental enamel
Halitosis

7. Epidemiolgy

8. Shubbar & Taka

9. Increasing Prevalence:% %

10. Pathogenesis Transient lower esophageal sphincter (LES) relaxation
Hypotensive LES
Delayed Esophageal clearance
Delayed gastric emptying
Salivary function
Tissue resistance

11. Diagnosis

12. 1-History Age Alarm features Nocturnal reflux Dysphagia Odynophagia
Weight loss
GI bleeding
Nausea &/or vomiting
Family history of cancer
Nocturnal reflux

13. -ve endoscopy is seen in 2/3 of GERD
Useful in:
Grading
Hiatus hernia
Ulcer or stenosis
Barrett’s Esophagus
Indications:
Age over 40 years-old
Alarm features
Atypical symptoms
-ve endoscopy is seen in 2/3 of GERD

14. 24 hrs pH Recording Indications: Atypical symptoms
NERD who do not respond to PPI
When esophagitis is not demonstrated in the pre-operative endoscopic examination

15. Management

16. Symptoms
Antacids/Alginates
Proton pump inhibitor
Full dose
Poor response
Consider pH
Monitoring
Reconsider
diagnosis
Normal
Fundoplication
Maintenance dose
Good response
H2 receptor
Antagonists
Antacids

17. Behavioral modifications in the treatment of GERD
Special care with at risk medications: anticholinergics, theophylline, tricyclic antidepressants, Ca channel blockers, B-Adrenergic agonists, alendronate.
Avoidance of lying down for 2 hrs after meals
Avoidance of large meals
Drastic reduction in, or cessation of, smoking.
Reduction of body weight if overweight

18. Surgical treatment Indications:
No response to medical treatment including atypical symptoms.
Continuous maintenance treatment is required especially in patients younger than 40 year old.
Financial impediment

19. Complications
Barrett’s esophagus
Stenosis
Ulcer
Bleeding

20. Barrett's Esophagus
is the condition in which an abnormal columnar epithelium that is predisposed to malignancy replaces the stratified squamous epithelium that normally lines the distal esophagus. Barrett's esophagus is a consequence of chronic gastroesophageal reflux disease (GERD), which damages the esophageal squamous epithelium and causes it to heal through a metaplastic process in which columnar cells replace reflux- damaged squamous cells. The columnar-lined esophagus causes no symptoms, and the condition has clinical importance only because it is a risk factor for esophageal adenocarcinoma, a tumor whose frequency has increased more than six-fold over the past several decades.
Barrett's esophagus is diagnosed by endoscopic examination, and two criteria must be fulfilled. First, the endoscopist must ascertain that columnar-appearing epithelium lines the distal esophagus( Endoscopically, columnar epithelium has a reddish color and velvet- like texture that can be distinguished readily from normal esophageal squamous epithelium, which is pale and glossy). Second, biopsy specimens of that columnar-appearing epithelium must show evidence of metaplasia.

21. Achalasia
Achalasia is characterized by impaired LES relaxation with swallowing, and aperistalsis in the smooth muscle esophagus. The resting LES pressure is elevated in about 60% of cases. If there are nonperistaltic, spastic contractions in the esophageal body, the disease is referred to as vigorous achalasia or, more recently, spastic achalasia.
Clinical manifestations of achalasia may include dysphagia starting for fluid then solid, regurgitation, chest pain, hiccups, halitosis, weight loss, aspiration pneumonia, and heartburn. All patients have solid food dysphagia; the majority of patients also have variable degrees of liquid dysphagia. The onset of dysphagia is usually gradual, with the duration of symptoms averaging two years at presentation.
Characteristic barium swallow findings are proximal esophageal dilatation with the tapering of distal esophagus at the gastroesophageal junction.
ENDOSCOPY and Esophageal Manometry help dx,
Rx: Pharmacologic treatments, calcium channel blockers, are not very effective, making them more appropriate as temporizing maneuvers than definitive therapies. The definitive treatments of achalasia are disruption of the LES either surgically (Heller myotomy) or with a pneumatic dilator.