1. GERD
Robert Erickson MD

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

3. 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

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

5. 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

6. 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)

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

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

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

10. Achalasia: Presenting Symptoms in 133 Patients

11. 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

12. Painful Swallowing

13. Burning Issues in Gastroesophageal Reflux Disease (GERD)

14. Pathophysiology of GERD

15. Common Esophageal Symptoms of GERD
Heartburn
Regurgitation
Belching
Water brash

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

17. Symptoms Associated With Complications of GERD
Dysphagia
Odynophagia
Bleeding

18. Hiatal Hernias May Contribute to Reflux by Two Mechanisms

19. 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.

20. 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.

21. 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.

22. 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

23. 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

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

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

26. 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

27. 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

28. 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