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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