GERD Questions & Answers: Insights from Iranian College of Internal Medicine

2. Gastroesophageal Reflux Disease (GERD)Questions & Answers Iranian College of Internal Medicine Hamid Kalantari MD Professor of Gastroenterology Isfahan University of Medical Sciences

3. Gastroesophageal reflux goes by several names: GERD Reflux Heart­burn Indigestion

4. Definition of GERD • When the reflux of gastric content causes troublesome symptoms or complications.

5. Diagnosis • GERD presents with typical signs and symptoms, such as heartburn or acid regurgitation, that are responsive to antisecretory therapy.

6. Montreal classification of GERD

7. Who should have endoscopy? • Individuals who: • Fail to respond to therapy. • Have alarm symptoms or signs such as: dysphagia, weight loss, anemia, gastrointestinal bleeding, persistent heartburn. • Require continuous maintenance medical therapy to rule out Barrett's esophagus.

8. What are the goals of endoscopy? • Detection of erosive esophagitis. • Complications such as: • Peptic stricture • Barrett's esophagus and cancer of esophagus. • Excludes conditions that can mimic GERD, such as eosinophilic esophagitis.

9. Nonerosive gastroesophageal reflux disease (NERD) • The majority of patients with typical symptoms of GERD do not have esophagitis.

10. NERD • Normal levels of esophageal acid: Esophageal hypersensitivity • Assessed by a 24-hour pH monitoring study. • Abnormal levels of esophageal acid. • heartburn not attributable to acid reflux: “Functional heartburn" • Groups (A, B), but not the Group C may respond to antisecretory therapy. • Proton pump inhibitors were associated with more effective symptom relief than placebo or H2 receptor antagonists in such patients

11. Treatment of esophageal hypersensitivity • Pain modulators such as: • Tricyclic antidepressants • Trazodone • Selective serotonin reuptake inhibitors (Improve esophageal pain in patients with noncardiac chest pain (by acting at the central nervous system and/or sensory afferents level)

12. Can I have GERD without any symptoms? Yes, GERD can occur with "silent" symptoms.

13. Silent GERD Silent GERD" is one of the most difficult conditions to diagnose • Sleep disruption (A diagnosis of GERD with complaints of difficulty sleeping) • Persistent cough • Asthma attacks • Hoarseness • Dental erosions (may be the first symptom) • Bad breath • Water brash

14. Is there a difference between day time and night time GERD? • The major difference between day and night GERD management is in your body position.

15. Can GERD cause changes in my voice? • Repeated acid damage of the voice box can cause growths (polyps) to develop and can increase your risk of cancer.

16. Whatare alarm signs of GERD?(1) • Do you experience GERD or heartburn 3 or more times per week? • Is the pain in your chest from heartburn or reflux debilitating? • Does the pain radiate to your arm or cause you to become short of breath? • Does the pain wake you from sleep or prevent you from getting a full night's rest?

17. What are alarm signs of GERD?(2) • Have these symptoms been ongoing for more than 6 months? • Do you have a persistent and unexplained cough? • Is your asthma difficult to control with conventional medications? • Has the reflux caused you to lose weight over the past few months?

18. What are alarm signs of GERD?(3) • Do you have pain after you eat? • Do you have any difficulty swallowing? • Do you wake up from sleep coughing, choking, or short of breath? • Do you have unexplained repeated episodes of bronchitis or pneumonia?

19. Pregnancy & GERD • Lifestyle modifications or antacids should be first-line therapy. • H2 receptor antagonists ranitidine and cimetidine, which appear to be safe during pregnancy. • Proton pump inhibitors. (Less experience) No significant difference in the risk for major congenital birth defects, spontaneous abortions, or preterm delivery.

20. Do children get GERD? • Irritable after eating • Repeatedly belch or vomit • Persistent coughing Infants may exhibit symptoms different from adults • Poor feeding • Impaired weight gain or colic or

21. Does GERD affect one gender more than the other? Females are slightly more affected by GERD

22. Can GERD happened out of patient’s control? • Factors out of a patient's control include: • Genetics • Personal background

24. How can I improve my symptoms of GERD?

25. How can I improve my symptoms of GERD? • Mild symptoms: lifestyle and dietary modifications along with antacids and histamine-2 (H2) receptor antagonists. • Debilitating symptoms: acid-suppressive therapy. • Between these extremes: • “Step up" approach. • “Step down" approach.

26. Lifestyle modifications

27. Aims of Lifestyle modifications • Enhancing esophageal acid clearance. • Minimizing the incidence of reflux.

28. Does my bed make a difference in nighttime symptoms? Head of bed elevation: • 6- to 8-inch (it is important for individuals with nocturnal or laryngeal symptoms). Night symptoms: • Heartburn • Regurgitation with coughing, aspiration and pneumonia • Choking • Gasping for air • Bitter taste in your mouth or excessive drooling

29. What kind of foods can make GERD worse? Alcohol Colas Red wine Orange juice • High-fat foods • Spicy foods • Carbonated beverages • Chocolate • Mint

30. What kind of foods should I eat if I Have GERD? • Smaller and lighter meals • Most food and vegetables • High protein diet • Low fat diet

31. Foods can make GERD worse (Mechanism) Reduce lower esophageal sphincter pressure: • Fatty foods • Chocolate • Peppermint • Excessive alcohol Acidic pH can exacerbate symptoms: A number of beverages include: • Colas • Red wine • Orange juice (pH 2.5 to 3.9).

32. Can smoking cause GERD? Smoking does not directly cause GERD, it can exacerbate GERD symptoms. Smoking is deleterious in part because it diminishes salivation. Promotion of salivation by either chewing gum or use of oral lozenges.

33. Can stress increase GERD symptoms? • Some people do experience heartburn in times of stress. • Stress hormones cause stomach relaxation • Stress hormones may increase stomach acid production.

34. Can medicines exacerbate GERD? • Relaxes the LES of the esophagus. • Irritates and directly damages the lining of the esophagus. • Can cause the body's digestive system to slow down, which leads to food lingering in and more acid production in the stomach.

35. Medications that May Cause Reflux or Heartburn(1)

36. Medications that May Cause Reflux or Heartburn(2)

37. Medications that can Cause Direct Damage to the Esophagus Medication (1)

38. Medications that can Cause Direct Damage to the Esophagus Medication (2)

39. How can I avoid GERD problems if I have to take my pills?

40. Can exercise affect my reflux?

41. Does GERD get worse with age?

42. Can my weight affect my GERD?

43. Obesity Risk factor for: • GERD • Erosive esophagitis • Esophageal adenocarcinoma

45. Aims of Acid-Suppressive Medications: Reduce gastric acid secretion The goal being to raise the intragastric pH above 4

46. Reduce gastric acid secretion • The most common and effective treatment of peptic esophagitis or symptomatic GERD: • H2 blocker • Proton pump inhibitor These therapies do not prevent reflux, but they reduce the acidity of the refluxate.

47. The H2 receptor antagonists: 10 to 24 percent. The proton pump inhibitors: 57 to 74 percent. Therapeutic gain relative to the placebo for healing esophagitis

48. Complete relief from heartburn per week • Proton pump inhibitor (11.5 percent). • H2 receptor antagonist (6.4 percent).

49. Acid-suppressive Medications H2 receptor antagonists: • Cimetidine (Tagamet) • Ranitidine (Zantac) • Famotidine (Pepcid) • Nizatidine (Axid)

50. What do you do? • Patients who continue to have heartburn after six weeks of treatment with a standard dose of an H2 antagonist.