GERD

What is GERD
A condition that occurs when

the lower esophageal

sphincter (LES) does not
close properly and stomach
contents leak back, or reflux,
into the esophagus.
The LES is a ring of muscle at

the bottom of the esophagus

that acts like a valve between
the esophagus and stomach.

Prevalence of GERD
Approximately 20% of adults have frequent
"classic" symptoms of gastroesophageal reflux
(GER):
Heartburn
Regurgitation.

What causes GERD?

No one knows why

people get GERD.

A hiatal hernia may

contribute.

Other factors that may contribute to GERD

Alcohol use
Overweight
Pregnancy
Smoking

Certain foods can be associated with reflux events

Citrus fruits
Chocolate
Drinks with caffeine
Fatty and fried foods
Garlic and onions
Mint flavorings
Spicy foods
Tomato-based foods, like spaghetti sauce, chili, and pizza

What are the symptoms of GERD

Persistent heartburn and acid

regurgitation.
Belching
Waterbrash (sudden excess of
saliva)
Sour taste in the mouth
Food stuck in throat
Difficulty or pain when swallowing
Chest pain
Hoarseness
Choking or throat tightness.
Chronic sore throat
Dry cough
Bad breath
Inflammation of the gums
Erosion of tooth enamel (the
surface of the teeth)

How is GERD diagnosed?

Review of symptoms and a complete physical

examination, with Special attention to alarming

symptoms.
Duration & severity of symptoms
Anemia
Dysphagia (Difficulty in swollowing)
Weight loss

Diagnosis of supraesophageal Reflux

1.

Heartburn and regurgitation

many of these patients fail to demonstrate the typical symptoms
of heartburn and regurgitation

2.

The response of symptoms to an empirical trial of

antireflux therapy

3.

Ambulatory, esophageal pH monitoring

4.

Upper gastrointestinal endoscopy

Most do not have esophagitis when looked at endoscopically.

A normal upper esophagoscopy

The Los Angeles Classification System for the

endoscopic assessment of reflux oesophagitis
GRADE A:
One or more mucosal breaks no
longer than 5 mm, non of which
extends between the tops of the
mucosal folds

The Los Angeles Classification System for the

endoscopic assessment of reflux oesophagitis

GRADE B:
One or more mucosal
breaks more than 5 mm
long, none of which extends
between the tops of two
mucosal folds

The Los Angeles Classification System for the

endoscopic assessment of reflux oesophagitis

GRADE C:
Mucosal breaks that extend
between the tops of two or more
mucosal folds, but which involve
less than 75% of the
oesophageal circumference

The Los Angeles Classification System for the

endoscopic assessment of reflux oesophagitis

GRADE D:
Mucosal breaks which
involve at least 75% of the
oesophageal circumference

Endoscopic view of GERD complications

Limitations of esophsgeal pH monitoring

Not accepted by patients easily
Optimal site of probe placement (ie, pharyngeal vs upper

esophageal)
What is a normal vs abnormal amount of acid reflux.
False-negatives may occur
A positive test does not prove a causative relationship to the
symptoms
Normal pH testing in the upper and lower esophagus is
strong evidence against acid-related symptoms
Nonacidic reflux may also play a pathophysiologic role in the
symptoms of some patients (which may only resolve with
fundoplication

Catheter-Free pH-Monitoring System

BRAVO Catheter-Free ph Testing

Bravo can be placed during endoscopy
Allows 24-hour or 48-hour pH monitoring

to record more clinical data

Patients maintain normal diet and routine

activities

Minimizes throat and nasal discomfort

associated with transnasal catheters

Transmits data to pager-sized reciever

Uploads easily to pH analysis software

1.

C, DeMeester T, Peters J, et al. Clinical evaluation of the BRAVOTM probe - a catheter-free

ambulatory esophageal pH monitoring system. Gastroenterology. 2001;120:A-35. [Abstract
#177]

Catheter-Free pH-Monitoring System

In a controlled study of only 7 asymptomatic subjects
the small amounts of measured acid reflux appeared comparable to
that obtained with the conventional pH probe.
Additional head-to-head trials of the micro-probe and

conventional catheter systems are needed in symptomatic

patients to determine the accuracy, reliability, and patient
acceptance of this technique.

How is GERD treated?

Lifestyle Changes
Medications
Surgery
Endoscopic options

Lifestyle Changes
If you smoke, stop.
Do not drink alcohol.
Lose weight if needed.
Eat small meals.
Wear loose-fitting clothes.
Avoid lying down for 3 hours after a meal.
Raise the head of your bed 6 to 8 inches by

putting blocks of wood under the bedposts--just

using extra pillows will not help.

Medications
Antacids:
Maalox,
Mylanta
Pepto-Bismol
Rolaids
Foaming agents
Gaviscon
H2 blockers
Cimetidine (Tagamet )
Famotidine (Pepcid)
Nizatidine (Axid)
Ranitidine (Zantac 75)

Magnesium salt can lead to

diarrhea, and aluminum salts can
cause constipation

Medications
Proton pump inhibitors
omeprazole (Prilosec)
lansoprazole (Prevacid)
pantoprazole (Protonix)
rabeprazole (Aciphex)
esomeprazole (Nexium)
Prokinetics
Bethanechol (Urecholine)
Metoclopramide (Primpran)
Domperidone (Motilium)

Surgery
Nissen
Fundoplication

Nissen Fundoplication

Endoscopic view of Nissen Fundoplication

Long-term complications of GERD?

Inflammation of the esophagus
Bleeding or ulcers
strictures
Barrett's esophagus and adenoarcinoma
Supraesphageal manafestations
Asthma
chronic cough
pulmonary fibrosis
ENT manafestations

Endoscopic pictures of GERD

Extraesophageal disorders in GERD

Extraesophageal manifestations of gastroesophageal reflux disorder
(GERD) are frequent, and consist broadly of
Noncardiac chest pain
pulmonary diseases
Asthma
chronic cough
recurrent bronchitis
sleep apnea
pulmonary fibrosis
laryngeal diseases
Laryngitis
subglottic stenosis
laryngeal cancer
other ENT (ear, nose, throat) disorders
Sinusitis
Otitis media
Pharyngitis
dental erosion

Noncardiac chest pain is associated with GERD

Among patients with angina-like chest pain

30% will have normal coronary arteries; of these, 40% to 50% have objective

evidence of GERD by endoscopy or ambulatory pH monitoring

Prevalence of GERD symptoms is 23% to 100%

Esophagitis is seen in 0% to 47%
Abnormal ambulatory pH recordings noted in 20% to 63%
Empiric trial of PPI
78% sensitivity and 86% specificity , for diagnosing GERD association with

noncardiac chest pain.

GERD and Chronic Cough

Direct mucosal injury and/or
Triggering vagally mediated mechanisms
Increased airway secretions
Bronchospasm

Nonacid Gastroesophageal Reflux

Reflux of gastric contents
Food
Nonacidic material.
Symptoms that fail to respond to aggressive therapy with

proton-pump inhibitors may still improve after antireflux

surgery
Traditional pH testing (which detects reductions in

intraesophageal pH from a baseline of pH 6-7) cannot

detect nonacidic reflux.

Nonacid Gastroesophageal Reflux

Nonacidic reflux was seen in both normal (healthy controls) subjects and

GERD patients

Measured by multichannel intraluminal impedance (MII) monitoring

Accounted for one third of all reflux events
Occurred more commonly after meals and in recumbency
Only 4% of nonacidic reflux events were due to bile reflux
Three fourths of bile reflux episodes occurred in conjunction with acid reflux
Compared with acid reflux events, nonacidic reflux typically did not extend as

far proximally and was cleared more quickly from the esophagus.

importance of nonacidic reflux

The true importance of nonacidic reflux in the

pathogenesis of both esophageal and extraesophageal

symptoms remains to be established.

may be a factor in:

Functional heartburn (ie, heartburn with normal esophageal pH
measurements)
Nonerosive reflux disorders
Extraesophageal disorders, whose symptoms persist despite
aggressive proton-pump inhibitor therapy.
MII may be used to test for nonacidic reflux

GERD and Chronic Cough

The mechanisms remain controversial.
Microaspiration
Stimulation of a vagally mediated esophageal-bronchial

reflex. That may also involve brainstem centers.

GERD and Chronic Cough

Establishing a definite cause-and-effect relationship

between GER and chronic cough is difficult.

A normal esophageal pH study argues against acid GER as

a cause of chronic cough

An abnormal pH study does not prove that acid reflux is the
cause of chronic cough.
Only a minority of patients with proven GER have

improvement of cough after proton-pump inhibitor therapy.

GERD and Chronic Cough

Empirical trial of high-dose therapy with PPI
Uncontrolled trials
70% to 100% improvement
The only published placebo-controlled trial reported
35% response rate.

GERD and Chronic Cough

75 patients with chronic cough prospectively evaluated
GER symptoms in 72%
abnormal pH testing in 56% (42 of 75)
20/42 had minimal or no reflux symptoms.

Omeprazole was given to a subset of patients (n = 55)

with either GER symptoms and/or abnormal pH testing.

After 3-6 months, significant improvement was noted 45%

No symptom or pH parameter was predictive of

improvement.

Garrigues V, Bastida G, Bau I, et al. Gastroenterology. 2001;120:A-430. [Abstract #2195]

GERD and Chronic Cough

Conclusions
ambulatory esophageal pH testing still is of limited utility in the evaluation of patients

with chronic cough.

A normal pH study with a low SI (symptom index) , probably excludes acid-related

cough, but a positive pH study does not prove a causal relationship.

Many clinicians may choose to treat all patients with chronic cough with an empirical

trial of high-dose proton-pump inhibitors (eg, omeprazole 40 mg twice daily), even if

symptoms of reflux are absent.

Cough usually responds within 2 weeks of therapy.

An empirical trial is more cost-effective than formal evaluation with manometry and pH

testing.

Coclusions
Gastroesophageal reflux is extremely common and may

manifest with typical and atypical symptoms.

At present it is extremely difficult to establish a definite

diagnosis of extraesophageal GERD.

Typical esophageal symptoms (heartburn, regurgitation)

may be absent in a large number of patients.

Neither the type of ENT symptoms nor the ENT findings

are of predictive value in determining underlying GER.

Coclusions
Although interesting new modalities for reflux testing are available

(capsule pH monitoring, impedance testing) it remains to be seen

whether these modalities improve diagnostic accuracy

Currently, the most cost-effective approach for most patients with

suspected reflux-related symptoms is a trial of a high-dose protonpump inhibitor for 3 monthes.

pH testing reserved to confirm adequate acid suppression in those

with refractory symptoms.

Although improvement in cough symptoms may be evident within 2

weeks of treatment, improvement in other ENT disorders may require

3 or more months of therapy.

The place of Fundoplication is yet to be defined

Thank you