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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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