Lecture notes for MBBS

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2. Learning Objectives

3. Learning Objectives:GORD/GERD
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction
• Gastroesophageal reflux disease (GERD), is
defined as a condition in which the stomach
contents reflux into the esophagus or
beyond (oral cavity, larynx, or the lungs),
causing troublesome symptoms and
complications.
• Reflux esophagitis is defined as
inflammation of the esophageal mucosa
secondary to gastroesophageal reflux
disease.

6. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

7. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

8. Etiology
• Reflux of gastric contents into the
esophagus due to weak lower esophageal
sphincter (LES) function,
• Impaired esophageal clearance
– Esophageal dysmotility
– Presence of hiatal hernia,
– Impairment in the tone of the lower esophageal
sphincter (LES),
– Transient LES relaxation,
– Poor gastric emptying

9. Etiology
• Obesity
• Smoking
• Alcohol,
• Caffeine
• Lack of physical activity
• Anxiety/depression
• Stress
• Eating habits (large meals,
eating before bed)
• Diabetes
• Age 50 years or older
• Connective tissue
disorders Scleroderma
• High dietary fat
• Drugs
• Microbiome alteration
• Pregnancy
• Tobacco chewing
• Nonalcoholic fatty liver
disease.
• Zollinger-Ellison
syndrome causing
increased acid secretion

10. Etiology:Drugs induced
• Angiotensin-
converting enzyme
inhibitors
• Anticholinergics
• Calcium channel
blockers
• Narcotics
• Nitrates
• Progesterone
• Sedatives or
tranquilizers (eg,
benzodiazepines)
• Statins
• Theophylline
• Tricyclic
antidepressants (eg,
amitriptyline)
•

11. Etiology
• Protective role of H.Pylori remains
controversial.

12. Pathophysiology

13. Pathophysiology
Mechanism of LES
–Intrinsic distal esophageal muscles –
tonically contracted.
–Angle of His
–Muscular Sling fibers of the gastric cardia.
–Diaphragmatic crura.
–Transmitted pressure of the abdominal
cavity.
–Phreno-esophageal membrane

14. Pathophysiology
• Reflux occurs in healthy individuals also
cleared by-
1. Clearance by esophageal peristaltic movement
2. Neutralization of the small acidic residue by weakly
alkaline swallowed saliva.

15. Pathophysiology
• Pepsin” in the reflux contents
• Strong acid (pH < 2), however, can cause
mucosal damage independent of the
presence of pepsin.
• The presence of bile in reflux

16. Pathophysiology
• Transient relaxation of the lower esophageal sphincter or a
low resting lower esophageal sphincter pressure
• Presence of a hiatus hernia
• Increased intra-abdominal fat, as is the case in obesity, and
increased intra-abdominal pressure, such as in pregnancy
and patients with ascites
• Impairment of the normal defense mechanisms, including
esophageal peristalsis (dysregulation of esophageal
peristalsis)
• Impairment of saliva production due to several causes,
including chronic inflammation of the salivary glands
• Impairment of esophageal mural defense mechanisms.

17. Clinical Features
•

18. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

19. Demography

20. Demography
• 10-20% of healthy adult Americans experienced
symptomatic GERD at least once a month. Severe disease
in6%.
• 5%in Asians.
• White individuals have higher prevalence of severe grades
of esophagitis
• Reflux esophagitis is equally prevalent among men and
women.However, the predominance of esophagitis and
Barrett esophagitis in men compared to women is 3:1 and
10:1, respectively.
• Incidence of gerd increased in the autumn and winter
• Incidence of reflux esophagitis has doubled over a period
of 10 years.
• Gastroesophageal reflux exists universally in preterm
infants.

21. Symptoms
• .

22. Symptoms
Esophageal and Extraesophageal
• Esophageal
– Heartburn
– Acid dyspepsia
– Regurgitation
– Chest pain.
• Exraesophageal symptoms-

23. Symptoms
• Exraesophageal symptoms-
– Chronic Cough
– Dental erosions,,
– Asthma
– Throat pain
– Aspiration pneumonia,
– Globus sensation
– Hoarseness due to pharyngitis, laryngitis, or
sinus problems.

24. Symptoms
• However, some patients with severe
esophagitis or Barrett esophagus may be
symptom-free and have no heartburn

25. Complications

26. Complications
• Upper gastrointestinal bleeding,
• Anemia,
• Stricture,
• Barrett esophagus
• Dysplasia
• Malignancy

27. Alarming Signs & Symptoms
• Dysphagia
• Early satiety
• GI bleeding
• Odynophagia
• Vomiting
• Weight loss
• Iron deficiency anemia

28. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germ line Testing and Molecular Analysis
• Diagnostic Laparotomy.

29. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

30. Diagnostic Studies
Imaging Studies
• X-Ray –Barium swallow
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

31. Diagnostic Studies
• Esophagogastroduodenoscopy (EGD) (or,
upper gastrointestinal [GI] endoscopy) with
biopsy,
• 24-hour ambulatory pH study,
• Manometry,
• Barium contrast study,
• Gastric emptying study.

32. Diagnostic Studies
• According to the diagnostic guidelines
established by American College of
Gastroenterology (ACG) for GERD, if a
patient’s history is typical for
uncomplicated GERD, an initial trial of
empirical therapy is appropriate, without
further investigation.

33. Classification
• Based on endoscopic and histopathologic
appearance, GERD is classified into three
different phenotypes:
1. Non-erosive reflux disease (NERD),
2. Erosive esophagitis (EE)
3. Barrett esophagus (BE)

34. Grades of Esophagitis
•

35. Grades of Esophagitis
The Savary-Miller grading system
• Grade 1: single or multiple erosions on a
single fold. ...
• Grade 2: multiple erosions affecting
multiple folds. ...
• Grade 3: multiple circumferential erosions.
• Grade 4: ulcer, stenosis or oesophageal
shortening.
• Grade 5: Barrett's epithelium.

36. Diagnostic Studies
• The endoscopic findings in
gastroesophageal reflux disease (GERD)
range from normal esophageal mucosa to
erosions and ulcerations

37. Pathology
Microscopy
• Squamous (basal) cell hyperplasia,
elongation of vascular papillae, presence of
intraepithelial inflammatory cells, dilated
intercellular spaces (intercellular edema),
ballooning degeneration of squamous cells
(due to accumulation of intracellular plasma
proteins), vascular lakes (dilated small
blood vessels in superficial lamina
propria/vascular papillae), acanthosis,
mucosal erosions and ulcerations

38. Barrett's epithelium.
• Replacement of squamous
epithelium with gastric columnar
epithelium

39. Differential Diagnosis

40. Differential Diagnosis
• Coronary artery disease
• Infectious esophagitis
• Eosinophilic esophagitis
• Peptic ulcer disease
• Biliary colic
• Esophageal motor disorders
• Esophageal stricture
• Esophageal cancer
• Dyspepsia
• Dysphagia
• Rumination syndrome
• Radiation and chemotherapy-induced esophagitis

41. Complications

42. Complications
• Barrett esophagus,
• Dysplasia,
• Malignancy

43. Management
•

44. Management
• The treatment is based on-
1 Lifestyle modification
2 Control of gastric acid secretion through
• A. Medical therapy with-
– Antacids
– PPIs
B.Surgical treatment with corrective antireflux
surgery

45. Lifestyle Modifications
•

46. Lifestyle Modifications
• Losing weight (if overweight)
• Avoiding alcohol, chocolate, citrus juice,
and tomato-based products peppermint,
coffee, and possibly the onion
• Avoiding large meals
• Waiting 3 hours after a meal before lying
down
• Elevating the head of the bed by 8 inches

47. Operative Therapy

48. Minimally invasive Therapy
Laparoscopic fundoplication
• Complete mobilization of the fundus of the
stomach with division of the short gastric
vessels
• Reduction of the hiatal hernia
• Narrowing of the esophageal hiatus
• Creation of a 360° fundoplication over a
large intraesophageal dilator (Nissen
fundoplication)

49. Operative Therapy
• Indications for fundoplication include the
following:
– Patients with symptoms that are not completely
controlled by PPI therapy
– Barrett esophagus
– extraesophageal manifestations Young patients
– Poor patient compliance with regard to
medications
– Postmenopausal women with osteoporosis
– Patients with cardiac conduction defects
– Cost of medical therapy

50. Myths
• Heartburn chest pain should not be first
managed as GERD. First angina must be
excluded.

51. Futuristic
• Endoscopic antireflex surgery.

52. Controversies
• Surgery or PPIs

53. Take home messages
• Gastroesophageal reflux disease (GERD) is
a common clinical problem, affecting
millions of people worldwide.
• Patients are recognized by both classic and
atypical symptoms.
• Acid suppressive therapy provides
symptomatic relief and prevents
complications in many individuals with
GERD.
• Fundoplication is surgical treatment.

54. MCQs
• A diagnosis of gastroesophageal reflux
disease implies that a patient has which
of the following functional abnormalities?
A.Compression of the esophagus from a
double aortic arch
B.Cricopharyngeal incoordination
C.Denervation of esophageal muscle
D.Lower esophageal sphincter incompetence

55. MCQs
• A diagnosis of gastroesophageal reflux
disease implies that a patient has which
of the following functional abnormalities?
A.Compression of the esophagus from a
double aortic arch
B.Cricopharyngeal incoordination
C.Denervation of esophageal muscle
D.Lower esophageal sphincter incompetence

56. MCQs
• A patient who has symptoms of
gastroesophageal reflux disease (GERD) is
prescribed a trial of proton pump inhibitors.
One month later the symptoms have not
improved despite treatment, and findings on
endoscopy are unremarkable. Which of the
following is the most appropriate next step in
management?
• A.Barium swallow x-ray study
• B.Esophageal manometry
• C.Repeat endoscopy in one month
• D.24-hour pH testing

57. MCQs
• A patient who has symptoms of
gastroesophageal reflux disease (GERD) is
prescribed a trial of proton pump inhibitors.
One month later the symptoms have not
improved despite treatment, and findings on
endoscopy are unremarkable. Which of the
following is the most appropriate next step in
management?
• A.Barium swallow x-ray study
• B.Esophageal manometry
• C.Repeat endoscopy in one month
• D.24-hour pH testing

58. MCQs
• Which of these is considered an "alarm symptom"
suggestive of complicated GERD?
A. Excessive belching/flatulence
B. Epigastric pain
C. Nausea
D. Odynophagia

59. MCQs
• Which of these is considered an "alarm symptom"
suggestive of complicated GERD?
A. Excessive belching/flatulence
B. Epigastric pain
C. Nausea
D. Odynophagia

60. MCQs
• which is most accurate regarding the workup for
GERD?
A. Barium radiography is routinely recommended in
the diagnosis of GERD
B. A presumptive diagnosis of GERD can be made
and empirical proton pump inhibitor (PPI)
therapy initiated in the setting of typical
symptoms of heartburn and regurgitation without
additional studies
C. Upper endoscopy is required for diagnosis of
GERD in all patients
D. Specific diagnosis of GERD can only be made
with biopsies obtained from the distal esophagus

61. MCQs
• which is most accurate regarding the workup for
GERD?
A. Barium radiography is routinely recommended in
the diagnosis of GERD
B. A presumptive diagnosis of GERD can be made
and empirical proton pump inhibitor (PPI)
therapy initiated in the setting of typical
symptoms of heartburn and regurgitation without
additional studies
C. Upper endoscopy is required for diagnosis of
GERD in all patients
D. Specific diagnosis of GERD can only be made
with biopsies obtained from the distal esophagus

62. MCQs
• Which of these is most commonly
recognized as an "alarm symptom" that
suggests potentially serious complications
associated with GERD?
A. Dysphagia
B. Constipation
C. Epigastric pain
D. Foul-smelling gas

63. MCQs
• Which of these is most commonly
recognized as an "alarm symptom" that
suggests potentially serious complications
associated with GERD?
A. Dysphagia
B. Constipation
C. Epigastric pain
D. Foul-smelling gas

64. MCQs
• Which of these is best established as a risk
factor for GERD?
A. Epilepsy
B. Diabetes
C. Male sex
D. Use of beta-blockers

65. MCQs
• Which of these is best established as a risk
factor for GERD?
A. Epilepsy
B. Diabetes
C. Male sex
D. Use of beta-blockers

66. MCQs
• Which of these medications is most likely to
increase acid reflux and worsen GERD
symptoms?
A. Metformin
B. Levothyroxine
C. Amitriptyline
D. Warfarin

67. MCQs
• Which of these medications is most likely to
increase acid reflux and worsen GERD
symptoms?
A. Metformin
B. Levothyroxine
C. Amitriptyline
D. Warfarin

68. MCQs
• In addition to upper gastrointestinal (GI)
endoscopy, which of these is most routinely
a part of the workup for GERD?
A. Nuclear medicine gastric emptying study
B. CT
C. Manometry
D. Ultrasonography

69. MCQs
• In addition to upper gastrointestinal (GI)
endoscopy, which of these is most routinely
a part of the workup for GERD?
A. Nuclear medicine gastric emptying study
B. CT
C. Manometry
D. Ultrasonography

70. MCQs
• Which is most accurate about GERD
treatment?
A. Lifestyle changes remain the cornerstone of GERD
management
B. PPIs are now preferred to histamine 2–receptor
antagonists as first-line therapy for most patients with
mild to moderate GERD symptoms and grade I-II
esophagitis
C. Chocolate has been found to be beneficial when included
in the diet of patients with GERD
D. Cardiac conduction defects are a contraindication to
surgical intervention for GERD

71. MCQs
• Which is most accurate about GERD
treatment?
A. Lifestyle changes remain the cornerstone of GERD
management
B. PPIs are now preferred to histamine 2–receptor
antagonists as first-line therapy for most patients with
mild to moderate GERD symptoms and grade I-II
esophagitis
C. Chocolate has been found to be beneficial when included
in the diet of patients with GERD
D. Cardiac conduction defects are a contraindication to
surgical intervention for GERD

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