gastroesophageal reflux disease GERD

1. gastroesophageal reflux diseaseGERD Department of gastroenterology, 1st hospital of jilin university Tongyu Tang

2. Definition • American College of Gastroenterology (ACG) • Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus • Often chronic and relapsing • May see complications of GERD in patients who lack typical symptoms

3. GERD Barrett’s esophagus,BE non-erosive reflux disease, NERD reflux esophagitis, RE

4. Epidemiology • About 44% of the US adult population have heartburn at least once a month • 14% of Americans have symptoms weekly • 7% have symptoms daily • 8.97% in china

5. Pathophysiology • 80% of reflux symptoms occur as a result of transient LES relaxation • Other motility defects • LES incompetence • Gastroparesis • Esophageal body dymotility • Anatomic defects: Hiatal hernia

6. Pathogenesis of GERD Decreased Salivation Impaired Tissue Resistance LES Impaired Esophageal Clearance Hiatal Hernia Decreased LES Resting Tone Duodenum Delayed Gastric Emptying Bile Reflux

7. Clinical Manisfestations • Most common symptoms • Heartburn—retrosternal burning discomfort • Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions

8. Clinical Manisfestations • Dysphagia—difficulty swallowing • Other symptoms include: • Chest pain, water brash, globus sensation, odynophagia, nausea • Extraesophageal manifestations • Asthma, laryngitis, chronic cough

9. Complications Stricture Barrett’s esophagus Bleeding

10. Complications • Esophageal stricture • Result of healing of erosive esophagitis • May need dilation

11. Complications • Barrett’s Esophagus • Columnar metaplasia of the esophagus • Associated with the development of adenocarcinoma

12. Complications • Barrett’s Esophagus • Acid damages lining of esophagus and causes chronic esophagitis • Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells • This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma

13. Diagnostic Tests for GERD Endoscopy Barium swallow Ambulatory pH monitoring Esophageal manometry

14. Esophagogastrodudenoscopy • Endoscopy (with biopsy if needed) • In patients with alarm signs/symptoms • Those who fail a medication trial • Those who require long-term tx • Lacks sensitivity for identifying pathologic reflux • Absence of endoscopic features does not exclude a GERD diagnosis • Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD

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19. LA Classification of Esophagitis From Nayar DS et al. Gastrointest Endosc 2004;60:253-7.

20. 24-Hour Esophageal pH Monitoring Most accurate test for measuring pattern, frequency, and duration of reflux episodes Documents correlation between reflux episodes and symptoms Sensitivity (77-100%) Normal in 25% of esophagitis! Specificity 85-100% Most useful when diagnosis still unclear Dent et al. Gut. 1999;44(suppl 2):S1-S16.

21. Ambulatory 24 hr. pH Monitoring • Physiologic study • Quantify reflux in proximal/distal esophagus • % time pH < 4 • DeMeester score • Symptom correlation

22. Esophageal Manometry Limited role in GERD • Assess LES pressure, location and relaxation • Assist placement of 24 hr. pH catheter • Assess peristalsis • Prior to antireflux surgery

23. A级 B级 D级 C级

24. Treatment Goals for GERD Eliminate symptoms Heal esophagitis Manage or prevent complications Maintain remission

25. Better Living • Lifestyle modifications • Avoid large meals • Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermint • Decrease fat intake • Avoid lying down within 3-4 hours after a meal • Elevate head of bed 4-8 inches • Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS) • Avoid clothing that is tight around the waist • Lose weight • Stop smoking

26. Treatment • Histamine H2-Receptor Antagonists • More effective than placebo and antacids for relieving heartburn in patients with GERD • Faster healing of erosive esophagitis when compared with placebo • Can use regularly or on-demand

27. Treatment AGENT EQUIVALENT DOSAGE DOSAGES Cimetadine 400mg twice daily 400-800mg twice daily Tagamet Famotidine 20mg twice daily 20-40mg twice daily Pepcid Nizatidine 150mg twice daily 150mg twice daily Axid Ranitidine 150mg twice daily 150mg twice daily zantac

28. Treatment • Proton Pump Inhibitors • Better control of symptoms with PPIs vs H2RAs and better remission rates • Faster healing of erosive esophagitis with PPIs vs H2RAs

29. Treatment AGENT EQUIVALENT DOSAGE DOSAGES Esomeprazole 40mg daily 20-40mg daily Nexium Omeprazole 20mg daily 20mg daily Prilosec Lansoprazole 30mg daily 15-10md daily Prevacid Pantoprazole 40mg daily 40mg daily Protonix Rabeprazole 20mg daily 20mg daily Aciphex

30. Endoscopic Treatments • In development with ongoing studies • Most try to improve LES function in some manner • Not quite ready for prime time in community practice

31. Surgical Treatment • Indications • Esophagitis • Stricture • Barrett’s metaplasia • Medication failure • Purpose of surgery  restoration the LES

32. 谢 谢