GASTRO ESOPHAGEAL REFLUX DISEASE

GASTRO ESOPHAGEAL REFLUX DISEASE  

INTRODUCTION:

GERD refers to a symptomatic clinical condition that results episodes of gastric esophageal reflux.
GERD is the retrograde movements of gastric content from stomach to esophagus. Prolonged GERD
leads to erosion of squamous epithelium-erosive esophagitis which requires ENDOSCOPY.GERD
is associated with defective lower esophageal sphincter pressure (LES). 

Complications include GER, esophagitis, esophageal strictures, barrettes esophagus, Adeno carcinoma
of esophagus. Relaxation of esophagus is due to esophageal distension, vomiting, belching and
retching. An increase in abdominal pressure occurring due to straining, bending over, coughing,
eating or Valsalva maneuver may occur over a LES and leads to reflux.

DEFINITION:

Gastroesophageal reflux disease (GERD) refers to symptoms or mucosal damage resulting from the
abnormal retrograde movement of gastric contents from the stomach into the esophagus. When the
esophagus is repeatedly exposed to refluxed material for prolonged periods, inflammation of the
esophagus (reflux esophagitis) can occur and in some cases it progresses to erosion of the squamous
epithelium (erosive esophagitis). Severe reflux symptoms associated with normal endoscopic findings
are referred to as “symptomatic GERD,” nonerosive reflux disease, or endoscopy-negative reflux
disease.

PATHOPHYSIOLOGY:

The pathogenesis of GERD is a complex and involves changes in reflux exposure, epithelial resistance,
and visceral sensitivity. The gastric refluxate is a noxious material that injures esophagus and elicits
symptoms.

The key factor in the development of GERD is the abnormal reflux of gastric contents from the
stomach into the esophagus.

 • In some cases, Gastroesophageal reflux is associated with defective lower esophageal sphincter
(LES) pressure or function. Patients may have decreased LES pressures related to spontaneous
transient LES relaxations, transient increases in Intra abdominal pressure, or an atonic LES.
A variety of foods and medications may decrease LES pressure (Table 24-1). 

• Problems with other normal mucosal defense mechanisms may also contribute to the development
of GERD, including prolonged acid clearance time from the esophagus, delayed gastric emptying,
and reduced mucosal resistance. 

• Aggressive factors that may promote esophageal damage upon reflux into the esophagus include
gastric acid, pepsin, bile acids, and pancreatic enzymes. The composition and volume of the refluxate
and the duration of exposure are the most important aggressive factors in determining the
consequences of Gastroesophageal reflux.

Foods and Medications That May Worsen Gastroesophageal Reflux Disease Symptoms:

FOODS	MEDICATIONS
Fatty meal Garlic Carminatives (peppermint, spearmint) Chocolate Coffee, cola, tea Onion Chilli peppers	Anticholenergics Barbiturates  Caffeine Dihydropyridine Dopamine Oestrogen Ethanol Nicotine (Tobacco) Nitrates Progesterone Tetracycline Theophylline

DIAGNOSIS:

The most useful tool in the diagnosis of Gastroesophageal reflux is the clinical history, including both
presenting symptoms and associated risk factors. Patients with mild, typical reflux symptoms do not
usually require invasive evaluation; a clinical diagnosis of GERD can be assumed in patients who
respond to appropriate therapy.

 • Further diagnostic evaluation should be performed in those who do not respond to therapy, who
present with alarm symptoms (e.g., dysphasia, weight loss), or who have long-standing GERD
symptoms. 

• Endoscopy is the preferred technique for assessing the mucosa for esophagitis and complications
such as Barrett’s esophagus. It enables visualization and biopsy of the esophageal mucosa, but the
mucosa may appear relatively normal in mild cases of GERD. 

• A camera-containing capsule swallowed by the patient is a new technology for visualizing the
esophageal mucosa (PillCam ESO). The procedure is less invasive than endoscopy and takes about
20 minutes to perform in the clinician’s office. Images of the esophagus are downloaded through
sensors placed on the patient’s chest that are connected to a data collector. The camera-containing
capsule is passed in the stool.

 • Barium radiography is less expensive than endoscopy but lacks the sensitivity and specificity
needed to accurately determine the presence of mucosal injury or to distinguish Barrett’s esophagus
from esophagitis. 

• Twenty-four-hour ambulatory pH monitoring is useful in patients who continue to have symptoms
without evidence of esophageal damage, patients who are refractory to standard treatment, and patients
who present with atypical symptoms (e.g., chest pain or pulmonary symptoms). The test helps to
correlate symptoms with abnormal esophageal acid exposure, documents the percentage of time the
intra esophageal pH is low, and determines the frequency and severity of reflux. 

• Omeprazole given empirically in standard or double doses as a “therapeutic trial” for diagnosing
GERD may be as beneficial as ambulatory pH monitoring while also being less expensive, more
convenient, and more readily available. However, there is no standard dosing regimen; standard dose
or double-dose omeprazole has been used. 

• Esophageal manometry to evaluate motility should be performed in any patient who is a candidate
for antireflux surgery. It is useful in determining which surgical procedure is best for the patient.

THERAPEUTIC INTERVENTIONS:

SYMPTOMS:

Typical:

• Heart burn
• Water bash
• Belching
• Regurgitation

Atypical:

• Non-allergic asthma
• Chronic asthma
• Hoarseness
• Chest pain
• Dental erosion

Complicated:

• Continuous pain
• Dysphasia
• Odynodysphasia
•  Bleeding
• Unexplained weight loss
• Choking

TREATMENT:

Phase-I: intermittent heart burn

1. Life style changes 
2. Antacids
3. Low dose H2 receptor antagonists for two weeks

• CIMETIDINE 200MG BD
• RANITIDINE 75MG BD
• FAMOTIDINE 10MG BD
• NIZATIDINE 75MG BD 

4. Proton pump inhibitors

• OMEPRAZOLE 20MG OD

Phase-II: symptomatic relief of GERD

1. Life style changes 
2. H2 receptor antagonists for 6-12 weeks

• CIMETIDINE 400MG BD
• RANITIDINE 150MG BD
• FAMOTIDINE 20MG BD
• NIZATIDINE 150MG BD 

3. Proton pump inhibitors for 4-8 weeks

• ESOMEPRAZOLE 20MG OD
• LANSOPAZOLE 15MG OD
• OMEPRAZOLE 20MG OD
• PANTOPRAZOLE 20MG OD
• RABEPRAZOLE 20MG OD

Healing of erosive esophagitis or treatment of patients with moderate to severe symptoms or
complications.

1. Life style changes 
2. PPI’s for 4-16 weeks BD
3. H2 receptor antagonists for 6-12 weeks

• CIMETIDINE 400MG QID
• RANITIDINE 150MG QID
• FAMOTIDINE 40MG BD
• NIZATIDINE 150MG QID

Phase-III: this is a critical phase where patient needs Anti-reflex surgery or endoluminal therapy.

MUCOSAL PROTECTANTS:

Sucralfate is a non absorbable aluminium salt of sucrose octasulfate that has limited value and is not
routinely recommended for treatment of GERD.

COMBINATION THERAPY:

 Combination therapy with an acid-suppressing agent and a prokinetic agent or mucosal protectant
seems logical, but data supporting such therapy are limited. This approach should be reserved for
patients who have esophagitis plus concurrent motor dysfunction or for those who have failed
high-dose PPI therapy.

MAINTAINANCE THERAPY:

• Although healing and/or symptomatic improvement may be achieved via many different therapeutic

modalities, 70% to 90% of patients relapse within 1 year of discontinuation of therapy. 

• Long-term maintenance therapy should be considered to prevent complications and worsening of

esophageal function in patients who have symptomatic relapse after discontinuation of therapy or

dosage reduction, including patients with complications such as Barrett’s esophagus, strictures, or

haemorrhage. 

• • Most patients require standard doses to prevent relapses. H2RAs may be an effective maintenance

therapy in patients with mild disease. The PPIs are the drugs of choice for maintenance

treatment of moderate to severe esophagitis. Usual once-daily doses are omeprazole 20 mg,

lansoprazole 30 mg, Rabeprazole 20 mg, or esomeprazole 20 mg. Lower doses of a PPI or

alternate-day regimens may be effective in some patients with less severe disease. 

• • “On-demand” maintenance therapy, by which patients take their PPI only when they hav

symptoms, may be effective for patients with endoscopy negative GERD.

Lifestyle modifications:

• Weight loss
• Elevation of the head
• Eating smaller meals and avoid eating 3hrs prior to the bed
• Avoid food or medication that exacerbate GERD
• Smoking cessation and avoid alcohol

  --Shaik Rafijani.

  5th year Pharm.D

  Clinosol -Vizag branch.