GASTRO-ESOPHAGEAL REFLUX DISEASEBY: ASIA SAID

CLINICAL PHARMACIST

• Gastroesophageal reflux disease

occurs when the amount of gastric

juice that refluxes into the

esophagus exceeds the normal

limit, causing symptoms with or

without associated esophageal

mucosal injury (i.e. esophagitis).

NORMALLY:

We have esophageal defense mechanisms

esophageal

clearancemucosal

resistance

extremely important

factor in preventing

mucosal injury

Lower esophageal

sphincter pressure

• Bicarbonate secretion

• Tissue repair (

epidermal growth

factor secretion within

30 mints of injury)Mechanical

clearance is

achieved with

esophageal

peristalsis

chemical

clearance is

achieved with

saliva (PH=

6.2-7.4)

1. A functional (frequent transient LES relaxation) or mechanical (hypotensive LES)

problem of the LES is the most common cause of GERD.

2. Transient relaxation of the LES can be caused by foods (coffee, alcohol, chocolate,

fatty meals), medications (beta-agonists, nitrates, calcium channel blockers,

anticholinergics), hormones (eg, progesterone), and nicotine.

3. Delayed gastric emptying: an increase in gastric contents resulting in increased

intragastric pressure and, ultimately, increased pressure against the lower

esophageal sphincter

4. Hiatal hernia: is the protrusion (or herniation) of the upper part of the stomach into

the thorax through a tear or weakness in the diaphragm.

5. Obesity: increased BMI and increased prevalence of GERD and its complications.

Hiatal hernia

Esophagitis Stricture

• advanced forms of esophagitis and are caused by circumferential fibrosis due to chronic deep injury

Barrett esophagus

• It is defined by metaplasticconversion of the normal distal squamous esophageal epithelium to columnar epithelium

Barrett’s

esophagitis strictureesophagitis

1. Signs and symptoms.

2. Testing:

• Upper gastrointestinal endoscopy/ esophagogastroduodenoscopy: mandatory

• Esophageal manometry: mandatory

• Ambulatory 24-hour ph monitoring: criterion standard in establishing a diagnosis

of gastroesophageal reflux disease

3. Imaging studies:

• Chest images may also demonstrate a large hiatal hernia, but small hernias can

be easily missed.

atypicalTypical

• Coughing and/or wheezing

• Hoarseness, sore throat

• Otitis media

• Noncardiac chest pain

• Enamel erosion or other dental

manifestations

Uncomplicated:

• Heartburn

• Regurgitation

(usually occurs after large

meals, aggravated by bending

and relieved by antacids )

Complicated:

• Dysphagia

• Anemia

• Hemoptesis

• Weight loss

Upper

gastrointestinal

endoscopy

Esophageal manometry

• It is a test to assess motor function of

the upper esophageal sphincter

(UES), esophageal body and lower

esophageal sphincter (LES).

• Procedure

A technician places a catheter into the

nose and guides it into the stomach.

Once placed, the catheter is slowly

withdrawn, allowing it to detect

pressure changes and to record

information for later review

Ambulatory 24-hour Phmonitoring

• The goals are:

1. To control symptoms.

2. To heal esophagitis.

3. To prevent recurrent esophagitis or other complications.

• The treatment is based on:

(1) lifestyle modification

(2) control of gastric acid secretion through:

• Medical therapy with antacids or PPIs

• Surgical treatment with corrective antireflux surgery

• Losing weight (if overweight).

• Avoiding alcohol, chocolate, citrus juice, and tomato-based products (2005

guidelines from the American college of gastroenterology [ACG] also suggest

avoiding peppermint, coffee, and possibly the onion family).

• Avoiding large meals.

• Waiting 3 hours after a meal before lying down.

• Elevating the head of the bed 8 inches.

Lifestyle modifications are the first line

of management in pregnant women

with GERD.

Antacids

H2 blocker therapy

Proton pump inhibitors

Prokinetic medications and reflux inhibitors

• Antacids were the standard treatment in the 1970s and are

still effective in controlling mild symptoms of GERD.

• Antacids should be taken after each meal and at bedtime.

• Agents:

1.Aluminum hydroxide

2.Magnesium hydroxide

• H2 receptor antagonists are the first-line agents for patients with mild

to moderate symptoms and grades I-II esophagitis.

• Options include:

1. ranitidine (zantac)

2. famotidine (pepcid)

3. nizatidine (axid).

• M.O.A: The H2 receptor antagonists are reversible competitive

blockers of histamine at the H2 receptors, particularly those in the

gastric parietal cells, where they inhibit acid secretion.

• Proton pump inhibitors (PPIs) inhibit gastric acid secretion by inhibition of the

H+/K+ atpase enzyme system in the gastric parietal cells.

• These agents are used in cases of severe esophagitis and in patients whose

conditions do not respond to H2 receptor antagonist therapy.

• Options include:

1. omeprazole (prilosec)

2. lansoprazole (prevacid)

3. rabeprazole (aciphex)

4. esomeprazole (nexium).

• Prokinetic agents, such as metoclopramide (reglan),

• Improve the motility of the esophagus and stomach and

increase the lower esophageal sphincter (LES) pressure to

help reduce reflux of gastric contents.

• They also accelerate gastric emptying.

• Is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia.

• Indications :

1. Patients with symptoms that are not completely controlled by proton pump inhibitors

2. Patients with well-controlled reflux disease who desire definitive, one-time treatment

3. The presence of barrett esophagus

4. The presence of extraesophageal manifestations

5. Young patients

6. Poor patient compliance with regard to medications

7. Postmenopausal women with osteoporosis

8. Patients with cardiac conduction defects

9. Cost of medical therapy

• Immaturity of lower esophageal sphincter function is manifested by

frequent transient lower esophageal relaxations, which result in

retrograde flow of gastric contents into the esophagus.

• S &S:

failure to thrive, feeding or sleeping problems, chronic respiratory

disorders, esophagitis, hematemesis, apnea, and apparent life-threatening

events

• About 70-85 % of infants have regurgitation within the first 2 months of

life, and this resolves without intervention in 95 % of infants by 1 year of

age.

For childrenFor babies

1. Elevate the head of the child's bed.

2. Keep the child upright for at least two

hours after eating.

3. Serve several small meals throughout the

day, rather than three large meals.

4. Make sure your child is not overeating.

5. Limit foods and beverages that seem to

worsen your child's reflux such as high fat,

fried or spicy foods, carbonation, and

caffeine.

6. Encourage your child to get regular

exercise.

1. Elevate the head of the baby's crib or

bassinet.

2. Hold the baby upright for 30 minutes after

a feeding.

3. Thicken bottle feedings with cereal (do not

do this without your doctor's approval).

4. Feed your baby smaller amounts of food

more often.

5. Try solid food (with your doctor's

approval).

Life style modifications

Drug therapy

Drugs to Lessen Gas in

Babies and Children

Drugs to Neutralize or

Decrease Stomach Acid

Drugs to Improve

Intestinal Coordination

• Simethicone

such as Mylicon

• Gaviscon

• Antacids such as:

Maalox

• Histamine-2 (H2)

blockers such As :

Zantac

• Proton-pump inhibitors

such as : Nexium &

Prilosec

Erythromycin. This is

an antibiotic usually

used to treat bacterial

infections. One

common side effect of

erythromycin is that it

causes strong stomach

contractions. This side

effect is advantageous

when the drug is used

to treat reflux

References:

http://www.webmd.com/children/infants-children?page=2

http://emedicine.medscape.com/article/930029-overview

http://emedicine.medscape.com/article/176595-overview