GERD

Robert Erickson MD

Definitions

•Odynophagia – pain on swallowing

•Dysphagia – symptom resulting from the failure to move a food bolus from the mouth to the stomach

What Factors Contribute to Dysphagia?• Inadequate preparation of what is being

swallowed– Reduced saliva or mastication– Neuromuscular disorders– Impaired mental function

• Abnormal muscle strength/function– Neuromuscular disorders– Motility disturbances

• Esophageal passageway narrowed– Mechanical obstruction

Dysphagia(Symptoms Predict Site)

Difficulty

initiating

swallow

Oropharyngeal

Dysphagia

Food stops,

“sticks” after

swallowing initiated

Esophgeal

Dysphagia

Disorders CausingOropharyngeal Dysphagia

• Anatomical– Postcricold web

– Cervical osteophyte

– Hypopharyngeal diverticulum

– Head and neck tumors

• Neurological– Cerebrovascular accidents

– Poliomyelitis

– Amyotrophic lateral sclerosis

– Parkinson’s disease

– Cerebral palsy

– Tumors

• Muscular disease– Oculopharyngeal muscular

dystrophy– Myotonic dystrophy– Myasthenia gravis

Oropharyngeal DysphagiaTherapeutic Modalities

• Speech/Swallowing therapy– Retraining– Bolus size and consistency adjustment– Specific swalowing maneuvers

• Esophageal dilation• Surgical Myotomy

• NPO with nutrition support (PEG, PEJ or TPN)

Causes of Dysphagia

• Anatomic– Benign

• Peptic strictures• Rings and webs• Caustic scars

– Cancer• Primary esophageal• Extrinsic compression

Causes of Dysphagia

• Neuromuscular– Primary esophageal disease

• Achalasia• Chagas’ disease• Other motor disorders

• Secondary

Achalasia – Loss of InhibitoryInnervation to the LES

NORMAL SPHINCTER TONE

VIPNO

VIPNO

ACh

SP

ACh

SP

+

–

–

+

LES IN CHALASIA

Achalasia: PresentingSymptoms in 133 Patients

Esophageal Dysphagia(Symptoms Suggest Diagnosis)

Solids OnlySolids and/or

Liquids

Intermittent Progressive Intermittent Progressive

Lower

Esophageal

Ring

Peptic Stricture

Or

Cancer

(espl. if>50y.o.

Diffuse Spasm

NEMD

Nutcracker

Achalasia

Or

Scleroderma

Painful Swallowing

Burning Issues inGastroesophageal Reflux

Disease (GERD)

Pathophysiology of GERD

Common EsophagealSymptoms of GERD

• Heartburn

• Regurgitation

• Belching

• Water brash

Atypical Presentations of GERD

• Chest pain

• Hoarseness/laryngitis

• Loss of dental enamel

• Asthma/chronic cough

• Dyspepsia

Symptoms Associated WithComplications of GERD

• Dysphagia

• Odynophagia

• Bleeding

Hiatal Hernias May Contribute toReflux by Two Mechanisms

Diagnostic Studies Not NeededWith Classic History of GERD

Heartburn and/or regurgitation,

postpradial, postural,

decreased with antacid

No diagnostic studies needed.

Start empiric treatment.

Endoscopy

•Strengths

– Esophagitis,

Barrett’s epithelium

– Hiatal hernia,

Strictures

– Biopsy

•Limitations

– Operator dependent

– Cost

Endoscopy with biopsy is the best diagnostic

Study for evaluating mucosal injury.

AmbulatorypH Monitoring

• Strengths– Quanitfy reflux– Physiologic

conditions– Allows symptom correlation

• Limitations– Availablilty– Operator dependent– Cumbersome– Cost

Ambulatory pH monitoring is the best

study to confirm GERD.

Life-Style Modifications AreCornerstone of GERD Therapy

• Elevate head of bed while speeping (blocks, wedge)• No food 3 hours before bedtime• Stop smoking• Modify diet

– Decrease fat and volume– Avoid peppermint, onions, citrus juice,

coffee, tomato

• Avoid potentially harmful medications• OTC medications PRN

Mechanisms by WhichDrugs May Effect GERD

• Decrease LES Pressure– Theophylline– Anticholinergics– Calcium channel blockers– Nitrates

•Injure Mucosa• Tetracyclines

• Quinidine

• Aspirin/NSAIDs

• Potassium tablets

• Iron salts

Acid Suppression Therapyfor GERD

• H2 Receptor Antagonists

(H2RAs)

– Cimetidine

– Ranitidine– Famotidine– Nizatidine

• Proton Pump Inhibitors

(PPIs)

– Omeprazole

– Lansoprazole

GERD is ChronicRelapsing Condition

Effective maintenance

therapy is the key!

Barrett’s Esophagus

• Frequency: 10% to 15% of patients with GERD symptoms who have endoscopic examinations

• Pathogenesis: GER injures squamous epithelium and promotes repair by columnar metaplasia

Barrett’s EsophagusCancer Risk

• Barrett’s esopagus is major risk factor for esophageal adenocarcinoma

• Cancer risk associated primarily with intestinal metaplasia

• Incidence of adenocarcinoma in patients with Barrett’s esophagus: ~1% per year

Peptic Esophageal Strictures

• Frequency: ~10% of patients who have reflux esophagitis

• Pathogenesis: Ulceration stimulates fibrosis• Association: Often associated with NSAIDs• Treatments:

– Aggressive acid suppression– Dilatation– Surgery