GASTROESOPHAGEAL GASTROESOPHAGEAL REFLUX DISEASE (GERD)REFLUX DISEASE (GERD)

Fall 2014

Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease (GERD) (GERD)

Gastroesophageal reflux (GER) is defined as the retrograde Gastroesophageal reflux (GER) is defined as the retrograde passage of gastric contents from the stomach into the esophagus. passage of gastric contents from the stomach into the esophagus. It is primarily the result of transient relaxation of the LES.It is primarily the result of transient relaxation of the LES.

Gastroesophageal reflux is a normal physiologic phenomenon Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux meal. Gastroesophageal reflux disease disease (GERD) occurs when the (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis). esophageal mucosal injury (ie, esophagitis).

GERD should be defined as symptoms or GERD should be defined as symptoms or complications resulting from the reflux of gastric complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral contents into the esophagus or beyond, into the oral cavity (including larynx) or lung. cavity (including larynx) or lung.

GERD can be further classified as the presence ofGERD can be further classified as the presence of

symptoms without erosions on endoscopic symptoms without erosions on endoscopic examination (non-erosive disease or examination (non-erosive disease or NERDNERD) or ) or GERD symptoms with erosions present (GERD symptoms with erosions present (ERDERD).).

Locke et al. Gastroenterology 1997;112:1148.Locke et al. Gastroenterology 1997;112:1148.

High Prevalence of Gastroesophageal High Prevalence of Gastroesophageal Reflux Symptoms Reflux Symptoms

19.8%

59%

0%10%20%30%40%50%60%

Weekly Monthly

Frequency of heartburn and/or regurgitation

EpidemiologyEpidemiologyGERD is a chronic disease that affects patients across all age groups with equal distribution between men and women. The prevalence of GERD appears to be greater in the Western population with patients presenting with more clinically important disease and complications than in Eastern countries (especially Asian populations) where GERD is uncommon.

It has also been estimated that 7% of the U.S. population have complicated GERD associated with erosive esophagitis.

Up to 75% of patients who undergo endoscopic procedures due to symptoms associated with GERD have normal esophageal findings. These patients are identified as having functional heartburn, NERD, or endoscopy-negative reflux disease (ENRD).

Childhood GERD appears to continue into adolescence and adulthood. Although most infants develop physiological regurgitation, or spitting up, the majority (95%) will have abatement of symptoms by 1.0 to 1.5 years of age. infants with persisting symptoms beyond 2 years of age are at risk of developing complicated GERD.

• Complications associated with GERD include esophageal Complications associated with GERD include esophageal erosions (5%), strictures (4%–20%), and Barrett's erosions (5%), strictures (4%–20%), and Barrett's metaplasia (8%–20%). Male gender and advancing age metaplasia (8%–20%). Male gender and advancing age (men and women) are associated with an increase in the (men and women) are associated with an increase in the prevalence of esophageal complications, presumably due prevalence of esophageal complications, presumably due to refluxed acidic contents damaging the mucosa over to refluxed acidic contents damaging the mucosa over time. No sexual predilection exists. time. No sexual predilection exists.

• The prevalence of GERD increases in people older than 40 The prevalence of GERD increases in people older than 40 years.years.

• Approximately 50% of patients with gastric reflux develop Approximately 50% of patients with gastric reflux develop esophagitis.esophagitis.

PathophysiologyPathophysiologyAbnormal gastroesophageal reflux is caused by the Abnormal gastroesophageal reflux is caused by the abnormalities of one abnormalities of one

or more or more of the following protective mechanisms:of the following protective mechanisms:

• 1) Transient Relaxations of the Lower Esophageal Sphincter. 1) Transient Relaxations of the Lower Esophageal Sphincter.

• The LES, when in a resting state, remains at a high pressure (10–30 The LES, when in a resting state, remains at a high pressure (10–30 mmHg) to prevent the gastric contents from entering into the mmHg) to prevent the gastric contents from entering into the esophagus. esophagus.

• Pressures are lowest during the day and with meals and highest at Pressures are lowest during the day and with meals and highest at night. night.

• Transient relaxations of the LES are short periods of sphincter Transient relaxations of the LES are short periods of sphincter relaxation that are different from those that occur with swallowing or relaxation that are different from those that occur with swallowing or peristalsis. They occur due to vagal stimulation in response to gastric peristalsis. They occur due to vagal stimulation in response to gastric distension from meals (most common), gas, stress, vomiting, or distension from meals (most common), gas, stress, vomiting, or coughing and can persist >10 seconds. These transient relaxations of coughing and can persist >10 seconds. These transient relaxations of the LES are associated with virtually all GER events in healthy the LES are associated with virtually all GER events in healthy individuals but account for 50% to 80% of occurrences in patients individuals but account for 50% to 80% of occurrences in patients with pathogenic GERDwith pathogenic GERD

• 2) Esophageal Acid Clearance and Buffering Capabilities.2) Esophageal Acid Clearance and Buffering Capabilities.

• Peristalsis is the primary mechanism by which acid refluxate is Peristalsis is the primary mechanism by which acid refluxate is removed from the esophagus. Other mechanisms include swallowing, removed from the esophagus. Other mechanisms include swallowing, esophageal distension in response to refluxate, and gravity (which is esophageal distension in response to refluxate, and gravity (which is only effective when the patient is in an upright position).only effective when the patient is in an upright position).

• Saliva plays an important role in the neutralization of gastric acid Saliva plays an important role in the neutralization of gastric acid within the esophagus. Its bicarbonate-rich content buffers the residual within the esophagus. Its bicarbonate-rich content buffers the residual acid that remains in the esophagus after peristalsisacid that remains in the esophagus after peristalsis

• The reduction of swallowing that occurs during sleep is associated The reduction of swallowing that occurs during sleep is associated with nocturnal GERD. Patients with decreased saliva production (e.g., with nocturnal GERD. Patients with decreased saliva production (e.g., elderly, patients taking medication with anticholinergic effects, and elderly, patients taking medication with anticholinergic effects, and those with certain medication conditions such as xerostomia or those with certain medication conditions such as xerostomia or Sjogren's syndrome) may also be at increased risk of developing Sjogren's syndrome) may also be at increased risk of developing GERDGERD

• 3) Anatomic Abnormalities.3) Anatomic Abnormalities.

• 4) Gastric Emptying4) Gastric Emptying

• 5) Mucosal Resistance5) Mucosal Resistance

• 6) Aggressive Factors Associated With 6) Aggressive Factors Associated With Esophageal DamageEsophageal Damage

Clinical Presentations of GERDClinical Presentations of GERD

• Classic (Typical) GERD Classic (Typical) GERD

• Extraesophageal (Atypical) GERDExtraesophageal (Atypical) GERD

• Complicated GERDComplicated GERD

Extraesophageal Manifestations Extraesophageal Manifestations of GERDof GERD

PulmonaryPulmonaryAsthmaAsthmaAspiration pneumoniaAspiration pneumoniaChronic bronchitisChronic bronchitisPulmonary fibrosisPulmonary fibrosis

OtherOther Chest painChest pain Dental erosionDental erosion

ENTENTHoarsenessHoarsenessLaryngitisLaryngitisPharyngitisPharyngitisChronic coughChronic coughGlobus sensationGlobus sensationDysphoniaDysphoniaSinusitisSinusitisSubglottic stenosisSubglottic stenosisLaryngeal cancerLaryngeal cancer

Potential Oral and Laryngopharyngeal Signs Potential Oral and Laryngopharyngeal Signs Associated with GERDAssociated with GERD

• Edema and hyperemia of Edema and hyperemia of larynxlarynx

• Vocal cord erythema, Vocal cord erythema, polyps, granulomas, polyps, granulomas, ulcersulcers

• Hyperemia and lymphoid Hyperemia and lymphoid hyperplasia of posterior hyperplasia of posterior pharynx pharynx

• Interarytenyoid changesInterarytenyoid changes

• Dental erosionDental erosion

• Subglottic stenosisSubglottic stenosis

• Laryngeal cancerLaryngeal cancer

Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.344.

Gastroesophageal reflux disease (GERD) can Gastroesophageal reflux disease (GERD) can cause typical (esophageal) symptoms or cause typical (esophageal) symptoms or atypical (extraesophageal) symptoms.atypical (extraesophageal) symptoms.

However, a diagnosis of gastroesophageal However, a diagnosis of gastroesophageal reflux disease (GERD) based on the reflux disease (GERD) based on the presence of typical symptoms is correct in presence of typical symptoms is correct in only 70% of patients. only 70% of patients. Therefore, GERD Therefore, GERD cannot be confirmed solely based on cannot be confirmed solely based on clinical symptoms.clinical symptoms.

When to Perform Diagnostic TestsWhen to Perform Diagnostic Tests

• Uncertain diagnosisUncertain diagnosis

• Atypical symptomsAtypical symptoms

• Symptoms associated with complicationsSymptoms associated with complications

• Inadequate response to therapy Inadequate response to therapy

• Recurrent symptomsRecurrent symptoms

• Prior to anti-reflux surgeryPrior to anti-reflux surgery

Diagnostic Tests for GERDDiagnostic Tests for GERD

• Barium swallowBarium swallow

• EndoscopyEndoscopy

• Ambulatory pH monitoringAmbulatory pH monitoring

• Esophageal manometryEsophageal manometry

Barium SwallowBarium Swallow– A barium esophagogram is particularly A barium esophagogram is particularly

important for patients with important for patients with gastroesophageal reflux disease (GERD) gastroesophageal reflux disease (GERD) who experience dysphagia due to:who experience dysphagia due to:

– Stricture (location, length)Stricture (location, length)– Mass (location, length)Mass (location, length)– Bird’s beakBird’s beak– Hiatal hernia (size, type).Hiatal hernia (size, type).

• LimitationsLimitations– Detailed mucosal exam for erosive Detailed mucosal exam for erosive

esophagitis, Barrett’s esophagusesophagitis, Barrett’s esophagus

EndoscopyEndoscopy

• Indications for endoscopy Indications for endoscopy – Alarm symptomsAlarm symptoms– Empiric therapy failureEmpiric therapy failure– Preoperative evaluationPreoperative evaluation– Detection of Barrett’s Detection of Barrett’s

esophagusesophagus

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

• Physiologic studyPhysiologic study

• Quantify reflux in Quantify reflux in proximal/distal proximal/distal esophagusesophagus

– % time pH < 4% time pH < 4

– DeMeester scoreDeMeester score

• Symptom correlationSymptom correlation

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

NormalNormal

GERDGERD

Wireless, Catheter-Free Esophageal pH Monitoring

• Improved patient Improved patient comfort and acceptancecomfort and acceptance

• Continued normal work, Continued normal work, activities and diet studyactivities and diet study

• Longer reporting periods Longer reporting periods possible (48 hours)possible (48 hours)

• Maintain constant probe Maintain constant probe position relative to SCJposition relative to SCJ

Potential AdvantagesPotential Advantages

Esophageal ManometryEsophageal Manometry

• Assess LES pressure, Assess LES pressure, location and relaxationlocation and relaxation– Assist placement of 24 hr. Assist placement of 24 hr.

pH catheterpH catheter

• Assess peristalsisAssess peristalsis– Prior to antireflux surgery Prior to antireflux surgery

Limited role in GERDLimited role in GERD

Treatment Goals for GERDTreatment Goals for GERD

• Eliminate symptomsEliminate symptoms

• Heal esophagitisHeal esophagitis

• Manage or prevent complicationsManage or prevent complications

• Maintain remissionMaintain remission

Step-wise progression of GERD therapyStep-wise progression of GERD therapy

Phase IPhase I: Mild/occasional symptoms. Do not seek medical help. : Mild/occasional symptoms. Do not seek medical help.

Phase II aPhase II a: Persistent symptoms, mucosal damage.: Persistent symptoms, mucosal damage.

Phase II bPhase II b: Severe mucosal damage.: Severe mucosal damage.

Phase III: Phase III: Refractory disease.Refractory disease.

The following table summarizes the pharmacologic treatments The following table summarizes the pharmacologic treatments for the different phases.for the different phases.

• Phase II aPhase II a: Persistent symptoms, mucosal damage.: Persistent symptoms, mucosal damage.

• Cimitidine 400 mg bid, ranitidine 150 mg bid, famotidine Cimitidine 400 mg bid, ranitidine 150 mg bid, famotidine 20 mg bid, nizatidine 150 mg bid.20 mg bid, nizatidine 150 mg bid.

• Metoclopramide 10-20 mg ac and HSMetoclopramide 10-20 mg ac and HS

• Phase II bPhase II b: severe mucosal damage.: severe mucosal damage.

• Cimitidine 800 mg bid or 400 mg qid, ranitidine 150 mg Cimitidine 800 mg bid or 400 mg qid, ranitidine 150 mg qid, famotidine 40 mg bid, nizatidine 150 mg qidqid, famotidine 40 mg bid, nizatidine 150 mg qid

• Metoclopramide 10-20 mg ac and HSMetoclopramide 10-20 mg ac and HS

• PPIPPI

• Phase III: refractory disease. Anti-reflux surgery.Phase III: refractory disease. Anti-reflux surgery.

• PPI bid for a short period of time. If no improvement, consider PPI bid for a short period of time. If no improvement, consider surgery.surgery.

• Approximately 80% of patients have a recurrent but Approximately 80% of patients have a recurrent but nonprogressive form of gastroesophageal reflux disease nonprogressive form of gastroesophageal reflux disease (GERD) that is controlled with medications. Identifying the (GERD) that is controlled with medications. Identifying the 20% of patients who have a progressive form of the disease is 20% of patients who have a progressive form of the disease is important, because they may develop severe complications, important, because they may develop severe complications, such as strictures or Barrett esophagus. For patients who such as strictures or Barrett esophagus. For patients who develop complications, surgical treatment should be considered develop complications, surgical treatment should be considered at an earlier stage to avoid the sequelae of the disease that can at an earlier stage to avoid the sequelae of the disease that can have serious consequences.have serious consequences.

Indications for fundoplication include the Indications for fundoplication include the following:following:   

Patients with symptoms that are not completely controlled by Patients with symptoms that are not completely controlled by PPI therapy can be considered for surgery. Surgery can also PPI therapy can be considered for surgery. Surgery can also be considered in patients with well-controlled be considered in patients with well-controlled gastroesophageal reflux disease (GERD) who desire gastroesophageal reflux disease (GERD) who desire definitive, one-time treatment.definitive, one-time treatment.

The presence of Barrett esophagus is an indication for The presence of Barrett esophagus is an indication for surgery. Whether acid suppression improves the outcome or surgery. Whether acid suppression improves the outcome or prevents the progression of Barrett esophagus remains prevents the progression of Barrett esophagus remains unknown, but most authorities recommend complete acid unknown, but most authorities recommend complete acid suppression in patients with histologically proven Barrett suppression in patients with histologically proven Barrett esophagus.esophagus.

The presence of extraesophageal manifestations of The presence of extraesophageal manifestations of gastroesophageal reflux disease (GERD) may indicate gastroesophageal reflux disease (GERD) may indicate the need for surgery. These include the following: (1) the need for surgery. These include the following: (1) respiratory manifestations (eg, cough, wheezing, respiratory manifestations (eg, cough, wheezing, aspiration); (2) ear, nose, and throat manifestations (eg, aspiration); (2) ear, nose, and throat manifestations (eg, hoarseness, sore throat, otitis media); and (3) dental hoarseness, sore throat, otitis media); and (3) dental manifestations (eg, enamel erosion).manifestations (eg, enamel erosion).

Young patientsYoung patients Poor patient compliance with regard to medicationsPoor patient compliance with regard to medications Postmenopausal women with osteoporosisPostmenopausal women with osteoporosis Patients with cardiac conduction defectsPatients with cardiac conduction defects Cost of medical therapyCost of medical therapy

TreatmentTreatment• AntacidsAntacids

– Over the counter acid Over the counter acid suppressants and antacids suppressants and antacids appropriate initial therapyappropriate initial therapy

– Approx 1/3 of patients with Approx 1/3 of patients with heartburn-related symptoms heartburn-related symptoms use at least twice weeklyuse at least twice weekly

– More effective than placebo More effective than placebo in relieving GERD symptomsin relieving GERD symptoms

Antacids: work within 5-15 minutes. Duration of relief 1-3 hours. An adult dose is about 40-80 mEq acid-neutralizing capacity (ANC) taken 4-5 times daily.Sodium BicarbonateCalcium CarbonateAluminum HydroxideMagnesium HydroxideMagnesium-Aluminum HydroxidesPossible interactions with tetracyclines, quinolone antibiotics, iron supplements, digoxin, azithromycin.

• Alginic acid: works by forming sodium Alginic acid: works by forming sodium alginate which is a viscous solution that alginate which is a viscous solution that floats on the surface of gastric contents so floats on the surface of gastric contents so that when reflux occurs, sodium alginate that when reflux occurs, sodium alginate rather than acid is refluxed and irritation is rather than acid is refluxed and irritation is minimized.minimized.

• Tablets should be chewed and taken with a Tablets should be chewed and taken with a full glass of water.full glass of water.

• Should be taken when patients are in an Should be taken when patients are in an upright position. NOT at bedtime.upright position. NOT at bedtime.

Common Alginic Acid Products

Treatment: H-2 BlockersTreatment: H-2 Blockers Histamine H2-receptor antagonists are the first-line agents for Histamine H2-receptor antagonists are the first-line agents for

patients with mild to moderate symptoms and grades I-II patients with mild to moderate symptoms and grades I-II esophagitis. Histamine H2 receptor antagonists are effective for esophagitis. Histamine H2 receptor antagonists are effective for healing only mild esophagitis in 70-80% of patients with healing only mild esophagitis in 70-80% of patients with gastroesophageal reflux disease (GERD) and for providing gastroesophageal reflux disease (GERD) and for providing maintenance therapy to prevent relapse. maintenance therapy to prevent relapse. Tachyphylaxis has been Tachyphylaxis has been observed, suggesting that pharmacologic tolerance can reduce observed, suggesting that pharmacologic tolerance can reduce the long-term efficacy of these drugs.the long-term efficacy of these drugs.

Additional H2 blocker therapy has been reported to be useful in Additional H2 blocker therapy has been reported to be useful in patients with severe disease (particularly those with Barrett patients with severe disease (particularly those with Barrett esophagus) who have nocturnal acid breakthrough.esophagus) who have nocturnal acid breakthrough.

More effective than placebo and antacids for relieving heartburn in More effective than placebo and antacids for relieving heartburn in patients with GERDpatients with GERD

Faster healing of erosive esophagitis when compared with placeboFaster healing of erosive esophagitis when compared with placebo Can use regularly or on-demand.Can use regularly or on-demand.

TreatmentTreatment

AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESCimetadine 400mg twice daily 400-800mg twice dailyCimetadine 400mg twice daily 400-800mg twice dailyTagametTagamet

Famotidine 20mg twice daily 20-40mg twice dailyFamotidine 20mg twice daily 20-40mg twice dailyPepcidPepcid

Nizatidine 150mg twice daily 150mg twice dailyNizatidine 150mg twice daily 150mg twice dailyAxidAxid

Ranitidine 150mg twice daily 150mg twice dailyRanitidine 150mg twice daily 150mg twice dailyzantaczantac

Treatment: PPITreatment: PPI

• Proton Pump InhibitorsProton Pump Inhibitors– Better control of symptoms with PPIs vs Better control of symptoms with PPIs vs

H2RAs and better remission ratesH2RAs and better remission rates– Faster healing of erosive esophagitis with PPIs Faster healing of erosive esophagitis with PPIs

vs H2RAsvs H2RAs

TreatmentTreatmentAGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESEsomeprazole 40mg daily 20-40mg dailyEsomeprazole 40mg daily 20-40mg dailyNexiumNexium

Omeprazole 40mg daily 20mg dailyOmeprazole 40mg daily 20mg dailyPrilosecPrilosec

Lansoprazole 30mg daily 15-10md dailyLansoprazole 30mg daily 15-10md dailyPrevacidPrevacid

Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg dailyProtonixProtonix

Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg dailyAciphexAciphex

Newest PPI on the marketNewest PPI on the market

Dexlansoprazole (trade names Kapidex, Dexilant) is a proton pump inhibitor that is

marketed by Takeda Pharmaceuticals. Chemically, it is an enantiomer of lansoprazole.

The compound was launched in the US for use in the treatment and maintenance of patients with

erosive oesophagitis and non-erosive gastro-oesophageal reflux disease.

Dexlansoprazole was approved by the U.S. Food and Drug Administration (FDA) on January 30,

2009

OTC PPI ProductsOTC PPI ProductsOTC PPI strengths and dosage forms:

Omeprazole 20 mg delayed release tablets.Omeprazole and sodium bicarbonate 20/1100 mg immediate release capsules.Lansoprazole 15 mg delayed release capsules.

TreatmentTreatment

• H2RAs vs PPIsH2RAs vs PPIs– 12 week freedom from symptoms12 week freedom from symptoms

• 48% vs 77%48% vs 77%

– 12 week healing rate12 week healing rate• 52% vs 84%52% vs 84%

– Speed of healingSpeed of healing• 6%/wk vs 12%/wk6%/wk vs 12%/wk

Effectiveness of Medical Therapies for Effectiveness of Medical Therapies for GERDGERD

TreatmentTreatment ResponseResponse

Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %

HH22-receptor antagonists-receptor antagonists 50 %50 %

Single-dose PPI Single-dose PPI 80 %80 %

Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %

Figure 26-5 Management of gastroesophageal reflux disease. H2RA, H2-receptor antagonist; PPI, proton pump inhibitor.

Summary of Treatment Algorithm for GERD

If Initial Treatment Fails, the Following If Initial Treatment Fails, the Following Should be Considered:Should be Considered:

• Improve complianceImprove compliance

• Optimize pharmacokineticsOptimize pharmacokinetics

– Adjust timing of medication to 15 – 30 minutes Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime)before meals (as opposed to bedtime)

– Allows for high blood level to interact with Allows for high blood level to interact with parietal cell proton pump activated by the mealparietal cell proton pump activated by the meal

• Consider switching to a different PPI Consider switching to a different PPI

GERD is a Chronic Relapsing ConditionGERD is a Chronic Relapsing Condition

• Esophagitis relapses quickly after cessation Esophagitis relapses quickly after cessation of therapyof therapy– > 50 % relapse within 2 months> 50 % relapse within 2 months– > 80 % relapse within 6 months> 80 % relapse within 6 months

• Effective maintenance therapy is imperativeEffective maintenance therapy is imperative

Brain Storming! (2-slides)Brain Storming! (2-slides)

Can PPIs be co-adminstered with antacids / Can PPIs be co-adminstered with antacids / H2 blockers? What should be the patient’s H2 blockers? What should be the patient’s instructions?instructions?

Why is omperazole 10 mg capsules Rx only Why is omperazole 10 mg capsules Rx only while 20 mg tablets is OTC?while 20 mg tablets is OTC?

Since 95% of the proton pumps will be Since 95% of the proton pumps will be permanently inactivated within 5 days of permanently inactivated within 5 days of single daily use of a full-dose PPI, what is single daily use of a full-dose PPI, what is the rationale for twice daily dosing?the rationale for twice daily dosing?

Several weeks after daily dosing of a PPI, Several weeks after daily dosing of a PPI, patients usually complain of breakthrough patients usually complain of breakthrough heartburns. Why is that? How can this be heartburns. Why is that? How can this be managed?managed?

A patient did not get a full relief with A patient did not get a full relief with omeprazole 40 mg daily. Should we omeprazole 40 mg daily. Should we increase the dose to 80 mg or change into increase the dose to 80 mg or change into another PPI?another PPI?

What are the main differences in What are the main differences in indications and use instructions between indications and use instructions between OTC and Rx PPI products?OTC and Rx PPI products?

Complications of GERDComplications of GERD

• Erosive/ulcerative esophagitisErosive/ulcerative esophagitis

• Esophageal (peptic) strictureEsophageal (peptic) stricture

• Barrett’s esophagusBarrett’s esophagus

• AdenocarcinomaAdenocarcinoma

Erosive EsophagitisErosive Esophagitis

Peptic StricturePeptic Stricture

Barium SwallowBarium Swallow EndoscopyEndoscopy

Esophageal Stricture: Dilating DevicesEsophageal Stricture: Dilating Devices

TTS Balloon Dilation of a Peptic StrictureTTS Balloon Dilation of a Peptic Stricture

Barrett’s EsophagusBarrett’s Esophagus

Esophageal CancerEsophageal Cancer

Barium SwallowBarium Swallow EndoscopyEndoscopy