GERD | Clinical Medicine

Page 1: Introduction to GERD

Overview

• Gastroesophageal reflux disease (GERD) is the condition where stomach contents, including hydrochloric acid, flow back into the esophagus.

• Symptoms include heartburn and dyspepsia, which can occur after meals and worsen when lying down.

Symptoms

• Heartburn: Burning retrosternal chest pain post-meals, aggravated when supine.

• Dyspepsia: Burning pain in the epigastric region, often described as discomfort in the upper abdomen. includes: discomfort, bloating, and fullness in the upper chest region

Page 2: Complications of GERD

Esophageal Damage

• The acid can lead to inflammation and potential ulceration of the esophagus, resulting in:

  • Esophagitis: Inflammation of the esophagus leading to pain.

  • Odynophagia: Pain upon swallowing.

Stricture Formation

• Chronic inflammation may cause a fibrotic response, narrowing the esophagus (stricture).

Aspiration Risks

• Acid can reach the airway, leading to:

  • Laryngitis: Resulting in voice changes.

  • Bronchitis: Worsening symptoms in asthma patients.

GI Bleeding and Cancer Risk

• Persistent ulcers can erode blood vessels, leading to GI bleeding, often presenting as:

  • Anemia or fatigue.

• Chronic GERD increases the risk of esophageal cancer, particularly adenocarcinoma.

Page 3: Pathophysiology of GERD

Cell Transformation

• Normal esophageal lining: stratified squamous epithelium that adapts due to chronic acid exposure.

• Metaplasia: Transformation from squamous to columnar cells, often leading to conditions like Barrett's esophagus.

• Dysplasia: Further progression to neoplastic cells, indicating increased risk of malignancy (adenocarcinoma).

Page 4: Causes of GERD

Mechanisms Leading to GERD

1. Low Lower Esophageal Sphincter Tone: Relaxes allowing acid reflux.

2. Hiatal Hernia: Displacement of the esophagus above the diaphragm increases GERD risk.

3. Increased Hydrochloric Acid Production: Higher acid levels exacerbate symptoms.

4. High Intragastric Pressure: Causes gastric contents to reflux into the esophagus.

Page 5: Decreased Lower Esophageal Sphincter Tone

Lifestyle Factors

• Triggers:

  • Smoking

  • Alcohol

  • Caffeine

Hiatal Hernias

• Most commonly associated type with GERD: Sliding Hernnias.

Page 6: Increased Intragastric Pressure and Acid Production

Contributing Factors to Intragastric Pressure

• Pregnancy: Increased abdominal volume.

• Obesity: Excessive abdominal weight can elevate pressure.

• Large Meals: Volume overload in the stomach.

• Gastroparesis: Delayed gastric emptying contributing to high pressure.

Increased Hydrochloric Acid Production Causes

• NSAIDs, Alcohol, Smoking

• Zollinger-Ellison Syndrome: Rare condition with a gastrin-secreting tumor leading to excessive stomach acid.

Page 7: Diagnostic Approach to GERD

Clinical Diagnosis

• Primarily clinical, but caution necessary:

  • Heartburn mimicking chest pain, requiring ECG to rule out myocardial infarction.

Diagnostic Procedures

1. Empiric PPI Trial: Initiate trial of proton pump inhibitors; if symptoms improve, likely GERD.

2. Alarm Symptoms: Presence of dysphagia, vomiting, anemia, or weight loss may indicate complications requiring EGD.

3. Esophageal Manometry and pH Monitoring: Additional tests if PPI trial is ineffective, to evaluate motility and acid exposure.

Page 8: Treatment of GERD

General Treatment Strategy

• Suppress acid production; manage lifestyle factors and underlying causes.

Proton Pump Inhibitors (PPIs)

• Starting treatment for severe GERD. Recommended for at least 8 weeks then reevaluate based on symptoms.

H2 Blockers

• Alternative for mild GERD without complications; avoid PPIs due to potential side effects.

Surgical Intervention

• Nissen Fundoplication: Considered for refractory GERD unresponsive to medical therapy—reinforcing the lower esophageal sphincter.

Page 9: Cancer Surveillance

Risk Management

• Chronic GERD patients require regular surveillance, particularly with any alarm symptoms to detect dysplasia or malignancy.

• In absence of dysplasia: EGD every 3-5 years to monitor changes.

Conclusion

• A comprehensive understanding of GERD's pathophysiology, complications, diagnostic strategies, and treatment options is crucial for effective management and prevention of serious consequences.

LOs for GERD:

Important: How to locate epigastric region, What are the possible organs involved in heartburn and how, Function of lower sophageal sphincture, Whats endoscopy, Whats histopatjology, Whats biopsy, Anatomical surface features of esophagus and stomach, Whys is esophagus and mucus red and why are there neutrophils during gerd.

Deinfe Heartburn

difference between esophagitis and GERD

Functions of stomach

symptomps associated with gerd

treatments for gerd

pathogenesis of gerd

factors associated with high affect of gerd