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Gastroesophageal Reflux Disease(GERD)

Dr. Agus Mulyadi Sp.B-KBDRSU BANYUMAS

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What Is Gastroesophageal Reflux?Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return.

Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus

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The Digestive System

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In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus.

Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach's contents to flow up into the esophagus.

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Acid reflux involves inflammation and irritation of the lower oesophagus due to the reflux of food and gastric acid. This reflux of gastric contents is spontaneous and involuntary.

Below is an endoscopic image showing ulceration of the lower end of the oesophagus caused by the refluxed gastric acid.

Inflamed oesophagus due to GORD.

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Epidemiology

• About 44% of the adult population have heartburn at least once a month

• 14% of adults have symptomps weekly• 7% have symptoms daily

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Pathophysiology

• Primary barrier to gastroesophageal reflux is the lower esophageal sphincter

• LES normally works in conjunction with the diaphragm

• If barrier disrupted, acid goes from stomach to esophagus

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Gastroesophageal Reflux Disease

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Gastroesophageal Reflux Disease

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Gastroesophageal Reflux Disease

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What Are the Symptoms of Heartburn?

Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.

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Heartburn is Classic Symptom of GERD

• Substernal burning and/or regurgitation

• Postprandial• Aggravated by change

in position• Prompt relief by

antacids

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Heartburn is Classic Symptom of GERD

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The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating.

Lying down or bending over can also result in heartburn.

Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.

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Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences.

Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.

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How Common Is Heartburn and GERD?

More than 60 million American adults experience heartburn at least once a month, and about 25 million adults suffer daily from heartburn.

Twenty-five percent of pregnant women experience daily heartburn.

Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing, and other respiratory problems.

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Predisposing Factors• Obesity• Cigarette smoking• High caffeine intake (e.g. coffee, tea or chocolate);• Excess alcohol ingestion;• Eating large meals (especially late at night) or meals high in

fat;• Pregnancy;• Hiatus hernia;• Family history: There is some genetic predisposition to

reflux, and • Some drugs (particularly those used to treat high blood

pressure and angina)

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What Is the Treatment for GERD?

Doctors recommend lifestyle and dietary changes for most people needing treatment for GERD.Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.

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Treatment

• Goals of therapy– Symptomatic relief– Heal esophagitis– Avoid complications

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Avoiding foods and beverages that can weaken the LES is recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages.

Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided.

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Decreasing the size of portions at mealtime may also help control symptoms.

Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially.

Being overweight often worsens symptoms. Many overweight people find relief when they lose weight.

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Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus.

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Antacids taken can help neutralize acid in the esophagus and stomach and stop heartburn. An antacid combined with a foaming agent helps some people.

These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occurring.

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Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 3 weeks, a doctor should be consulted.

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For chronic reflux and heartburn, the doctor may recommend medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. H2 blockers include: cimetidine, famotidine, and ranitidine.

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Another type of drug, the proton pump (or acid pump) inhibitor inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. Some proton pump inhibitors include

Esomeprazole Lansoprazole Omeprazole Pantoprazole

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Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs metoclopramide .

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Treatment

• Antireflux surgery– Failed medical management– Patient preference– GERD complications– Medical complications attribute to a large hiatal

hernia– Atypical symptomps with reflux documented on

24-houe pH monitioring

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Principles of Anti-Reflux Surgery

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Complications

• Erosive esophagitis• Stricture• Barrett’s esophagus

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• Erosive esophagitis– Responsible for 40-60% of GERD symptoms– Severity of symptoms often fail to match severity

of erosive esophagitis

Complications

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• Esophageal stricture– Result of healing of erosive esophagitis– May need dilation

Complications

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Peptic Stricture

Barium Swallow Endoscopy

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Esophageal Stricture: Dilating Devices

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TTS Ballon Dilation of a Peptic Stricture

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Complications

• Barrett’s Esophagus– Columnar metaplasia

of the esophagus– Associated with the

development of adenocarcinoma

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Barrett’s Esophagus

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Complications

• Barrett’s Esophagus– Acid damages lining of

esophagus and causes chronic esophagitis

– Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells

– This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma

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Complications

• Barrett’s Esophagus– Manage in same manner as GERD– EGD every 3 years in patient’s without dysplasia– In patient with dysplasia annual to shorter interval

surveillance

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Complications

• Patient’s who need EGD– Alarm symptoms– Poor therapeutic response– Long symptom duration

• “Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice

• Many patients with Barrett’s are asymptomatic

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Esophageal Cancer

Barium Swallow Endoscopy

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TERIMA

KASIH

For UMY 5 - 2013