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Gastroesophageal reflux disease

(GERD)

Gao Hong

Department of Gastroenterology

Zhongshan Hospital Fudan University

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Outline

• Treatment

• Key points

• Q & A

• Definition and classification

• Pathogenesis

• Pathology

• Manifestation

• Diagnosis and differentiation diagnosis

• Diagnostic approach

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Definition

• GERD is a condition which develops

when the reflux of stomach contents

causes troublesome symptoms and/or

complications.

The Montreal Definition and Classification of Gastroesophageal Reflux

Disease

Am J Gastroenterol 2006;101:1900–1920

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Prevalence of GER symptoms

10.3%

20-40%

25－38%

8.97%

17％

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Beijing10.19%

Xi’an 16.9%

Shanghai7.76%

Prevalence of GER symptoms in China

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Iceberg Phenomenon

Others 54.4%

OTC 27.24%

visit doctor 18.62%

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GERD Classification

1. Reflux esophagitis

2. Non-erosive reflux disease(NERD)

3. Barrett Esophagus

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Physiological

•after meal •short period •seldom at night •seldom causes symptoms

•frequent •long period •in the daytime and/or at night •can cause symptoms and/or esophageal lesion

Pathological

Gastric acid (pH 1.5-2.0) Esophogus(pH 6.0-7.0)

Gastroesophageal reflux (GER)

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Pathogenesis

Defense from reflux

Anti-reflux barrier: LES, Diaphragm

Esophagus scavenging : peristalsis, saliva

Esophageal mucosa

Damage to esophagus

Incompetent barrier-tLESR

Gastric contents

UES

Aorta

left main

bronchus

Esophagus

LES

Diaphragm

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Pathogenesis

HCl

Pepsin

Bile

Pancreatic enzyme

Low

Esophageal

Sphincter

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Pathology

Proliferation of

squamous

epithilium

Extension of

papillary

Metaplasia

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Typical symptoms of reflux

Heartburn, regurgitation

Irritation of reflux to esophagus

Chest pain(NCCP), dysphagia,

Odynophagia, etc.

Extra-esophageal symptoms

Cough, Pharyngitis, asthma, bolus, etc.

Manifestation of GERD

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The Montreal Definition and Classification of Gastroesophageal Reflux Disease

Am J Gastroenterol 2006;101:1900–1920

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• Complications

upper gastrointestinal bleeding

esophageal stricture

carcinoma

Manifestation of GERD

Notes:1. symptoms～severity 2. 2/3 regurgitation without symptoms

×

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Diagnostic approachs

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Aim of diagnostic approach

• To clarify mucosal injury

• To quantify reflux

• To clarify the pathophysiology

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Diagnotic approach

• Esophago-gastroendoscopy

• Barium swallow

• Bernstein test

• 24-h pH monitoring

• Esophageal manometry

• 24-h impedance monitoring

•Questionnaire： RDQ, GerdQ

•PPI therapy

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Esophagoscopy

• To identify mucosal lesion

• To judge the severity of esophagitis

• To determine complication(stricture, carcinoma)

• To perform dilation if stricture exists

Note: GERD cannot be excluded without mucosal

lesion

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Normal esophagus

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LA-A(Mild esophagitis)

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LA-B(mild esophagitis)

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LA-C(moderate esophagitis)

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LA-D(severe esophagitis)

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24-h pH monitoring

• To identify acid reflux

• % of pH＜4 is of importance

• GERD cannot be excluded with less

acid reflux

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pH wireless monitoring—

Bravo capsule

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Ambulatory 24-h pH-MII monitoring

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阻抗

pH 7

4

0

60 秒

pH>4 ‘非酸性’ 反流

疼痛

反流

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How to make a diagnosis

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• With typical symptoms

esophageal lesion

response to PPI therapy

positive findings with 24-h pH and/or

impedance monitoring

How to make a diagnosis

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• With atypical or extraesophageal

symptoms

Comprehensive analysis with

endoscopy, pH/impedance monitoring,

PPI therapy, etc.

Note: non-reflux esophagitis, carcinoma should be differentiated.

How to make a diagnosis

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Differentiation

• Other esophageal disease

• Peptic ulcer

• Functional gastrointestinal disease

• Heart diseases

• Lung diseases

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Treatment

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1.To release symptoms

Heartburn

regurgitation

Chest pain

Goals

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Goals

2. To heal esophagitis

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3. To improve quality of life

Goals

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GERD治疗目标

4. To treat and prevent complications

Goals

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Therapy methods

• To modify life style and dietary

• Drugs

• Endoscopy

• Surgery

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To modify life style • Weight reduction, elevate the head of

bed

• To avoid certain foods and drugs

• To eliminate the factors that increase

abdominal pressure

• Don’t smoke

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Drugs

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Main drugs

Antisecretory agents are of importance

• PPIs (proton pump inhibitors)

- omeprazole, Lansoprazole,

rabeprazole, esomeprazole

• H2 receptor blocking agents

- cimetidine, ranitidine, famotidine

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PPI

• A therapeutic trial (twice a day) provide

strong support for the diagnosis

• PPIs are of most effective drugs

• Comparably expensive

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H2RA

• Antisecretory effectiveness

duration for pH>4: 8 hours

cannot inhibit acid secretion after meal

• Clinical effectiveness

twice a day

suitable for mild or moderate cases

useful for NERD, less effective for RE

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Others

Antiacid drugs-to relieve symptoms

-sucralfate、Hydrotalcite

Prokinetic drugs-for mild patients

-Domperidone, mosapride, itopride

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regimens

• Down-step therapy

• Maintenance therapy is needed for some

patient. On-demand therapy is recommended.

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Antireflux surgery

• Laparoscopic fundoplication

• Patients who have the evidence of

reflux and response to PPIs have better

results.

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Special treatment

• Esophageal stricture：dilator/surgery +

drug maintenance

• Barrett esophgus：

surveillance esophagoscopy

drugs

esophagectomy

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Key points

• The characteristic manifestations

are heartburn and regurgitation

• Atypical and extraesophageal

symptoms are common

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• Endoscope can diagnose esophagitis,

while 2/3 GERD patients are NERD.

• PPIs are main drugs to treat GERD.

• Some patients need maintenance

therapy.

Key points

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