1 / 83

GERD

GERD. Thomas A Judge, M.D. Definition. Definition. “A condition which develops when the reflux of stomach contents causes troublesome symptoms or complications.”. The Montreal definition and classification of GERD 2006. Am J Gastroenterol 2006;101(8):1900–20. Epidemiology. Epidemiology.

forest
Download Presentation

GERD

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. GERD Thomas A Judge, M.D.

  2. Definition

  3. Definition “A condition which develops when the reflux of stomach contents causes troublesome symptoms or complications.” The Montreal definition and classification of GERD 2006 Am J Gastroenterol 2006;101(8):1900–20.

  4. Epidemiology

  5. Epidemiology Gut 2005;54:710–7

  6. Epidemiology Gut 2005;54:710–7

  7. Epidemiology N.S. Am J Gastroenterol 2008;103:12–19

  8. Cost of GERD GASTROENTEROLOGY 2002;122:1500-1511

  9. Global prevalence of heartburn Gut 2005;54:710–7

  10. Factors associated with GERD Gut 2005;54:710–7

  11. Genetic factors in GERD Gut 2003;52:1085–9.

  12. Genetic factors in GERD Gut 2003;52:1085–9.

  13. Factors that can precipitate or exacerbate GERD symptoms Foods     Caffeine     Chocolate     Peppermint     Alcohol (red wine pH = 3.25)     Carbonated beverages (cola pH = 2.75)     Citrus fruits (orange juice pH = 3.25)     Tomato-based products (tomato juice pH = 3.25)     Vinegar (pH = 3.00) Lifestyle factors     Weight gain     Smoking     Eating prior to recumbency

  14. Demographic factors in GERD FactorEffect Sex none Age none* Obesity (BMI) >25 OR 1.3 >30 OR 2.8 * Age >55 more likely to have esophagitis Pharm Res 2001;18:1367–72. (Georgia medicaid database) Ann Med 1995;27:67–70 (Olmstead Cty)

  15. Obesity and GERD N Engl J Med 2006;354:2340-8

  16. Behavior Factors in GERD Pharm Res 2001;18:1367–72. (Georgia medicaid database)

  17. Behavior Factors in GERD Pharm Res 2001;18:1367–72. (Georgia medicaid database)

  18. Nutritional Factors and GERD NUTRITION AND CANCER 2000; 38(2), 186–191

  19. Pathophysiology of GERD

  20. Pathophysiology of GERD • Anti-Reflux Barrier • Esophageal Contact Time • Gastric contents

  21. Esophageal Hiatus Right crus Left crus

  22. Anti-Reflux Barrier

  23. Transient LES Relaxation Baseline Air infusion

  24. Elongation of Esophageal Hiatus by Abdominal Pressure

  25. Hiatal Hernia

  26. Anti-Reflux Barrier Gastroenterol Clin N Am 37 (2008) 827–843

  27. Diaphragmatic Augmentation

  28. Esophageal Acid Contact • Impaired esophageal motility • - Dysfunctional peristalsis (aging) • - Poor emptying (hiatal hernia) • Salivary function • - Decreased salivation in sleep • - Cigarette use <60% saliva HCO3

  29. Gastric refluxate • Hydrochloric acid • 40-70% Z-E patients have severe esophagitis • No difference in basal acid levels in GERD / esophagitis • Best treatment results with acid suppression Rx • Pepsin, bile, pancreatic enzymes • Can injure experimental esophagus tissue • Effects either limited by acid or too low concentration • Role of bile reflux in refractory GERD controversial • Acid rebound after PPI therapy • Effect of H. pylori eradication ???

  30. GERD: Clinical features

  31. Diagnosis • Barium esophagram: 20% normals have reflux • Endoscopy: useful for mucosal assessment • Only 10-25% pts have any mucosal injury with NCCP • <10% with (+)pH test have Barrett's • 24 hour ambulatory pH testing • Catheter • Wireless • Impedance monitor: detect non-acidic reflux • Most useful combined with pH monitor • Sensor may be “blinded” by food debris

  32. Los Angeles Classification GradeDescription N Normal mucosa M Minimal change (erythema/turbidity) A Non-confluent mucosal break <5 mm B Non-confluent mucosal break >5 mm C Confluent breaks < 75% circumferential D Confluent breaks > 75% circumferential Gastroenterology 1996; 111: 85–92.

  33. GERD pathology Normal NERD American Journal of Gastroenterology (2005) 100, 2299–2306

  34. Treatment

  35. Proton Pump Inhibitors

  36. Medical management of GERD • Erosive esophagitis • PPI once daily heals 83-96% EE pts at 8 weeks • Higher LA grade requires longer duration Rx • Healing correlates with %time with pH>4.0 • % heartburn relief ALWAYS lower than healing rate

  37. Medical management of GERD • Non-erosive reflux disease • PPI symptom relief only 37% long-term • Longer time to relief than EE pts (3x longer) • Response same to full dose or half-dose PPI • Reason: Functional heartburn ~50% of NERD pts

  38. Continuous Rx vs. On-demand Rx • Continuous maintenance Rx • 80% EE pts relapse within 1 year off Rx • Single trial for NERD pts: PPI better than placebo • On-demand Rx • As effective as continuous Rx in NERD pts trials • Not as effective with EE pts • Probably not best for elderly (more risk of EE) • Most patients use PPI on-demand regardless of advise

  39. Refractory GERD • 30% pts on daily PPI report Rx failure • Compliance • Bioavailability vary considerably between PPIs • Food / concomitant antacid use affects PPI absorption • Lack of food intake within 30-60 mins of dose • “Refractory”: 25% pts failing PPI bid • NERD / functional heartburn • Infectious esophagitis / neoplasia • pH testing (on-meds vs. off-meds) • Baclofen trial

More Related