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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.

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GERD

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  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

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