Download GERD

GERD
Ahmad Shavakhi.MD
Associate professor of gastroenterology
Isfahan university of medical sciences
GERD
• Definition :
• "a condition that develops when the reflux of
stomach contents causes troublesome
symptoms and/or complications“
• at least weekly heartburn and/or acid
regurgitation
• "clinically significant" :occurring ≥ twice
weekly
CLINICAL MANIFESTATIONS
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Heartburn
Regurgitation
Dysphagia
Other symptoms
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chest pain
water brash
globus sensation
Odynophagia
nausea
Case
history
• A 32-year- old woman with :
• heart burn and acid regurgitation from 1 year
ago
• Commonly occur within 60 minutes of eating
and while lying recumbent
• Relieved by drinking water or using antacid
but can occur frequently
• 4 times in week
• She is smoker and obese
She denied
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Weight loss
Dysphagia
GIB
Vomiting
• P/E:
• Unremarkable
What is the treatment?
Life style modification
Dietary modification
• Should not be routinely recommended in all
• selective elimination of
• fatty foods
• caffeine
• Chocolate
• spicy foods
• food with high fat content
• carbonated beverages, and peppermint)
• correlation with symptoms and an improvement
with elimination
• Avoidance of tight-fitting garments
• Promotion of salivation through chewing gum to
neutralize refluxe
• Avoidance of tobacco and alcohol
• reduce LES pressure
• smoking also diminishes salivation
• ●Abdominal breathing exercise
• to strengthen the anti-reflux barrier of LES
Treatment strategy
•Step-up
• Step-down
Step-up
• Mild and intermittent symptoms
• fewer than two episodes per week
• No evidence of erosive esophagitis on
upper endoscopy
• incremental changes at two- to four-week
intervals
• low-dose H2RA concomitant antacids
H2 blocker
• The different H2 receptor antagonists
have equivalent efficacy if drug dose is
adjusted for potency
• An increased dose , prolonged course of
H2RA is unlikely to produce relief for
patients who continue to have heartburn
after six weeks
• H2RAs are ineffective in patients with
severe esophagitis
• tachyphylaxis within two to six weeks of
initiation of H2RAs
Step-down
• Erosive esophagitis
• frequent symptoms (two or more episodes
per week)
• And/or severe symptoms that impair
quality of life
• standard-dose PPI once daily for eight
weeks in addition to lifestyle and dietary
modification
Maintenance PPI therapy
• Severe erosive esophagitis
• Barrett's esophagus
• If recurrent symptoms occur within three
months after therapy was discontinued
intermittent (on-demand)
therapy )
• Continuous therapy provided better
symptom control, quality of life, and higher
endoscopic remission rates
PPI
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The PPIs are comparably effective
omeprazole (20 mg/d)
lansoprazole (30 mg/d)
pantoprazole (40 mg/d)
esomeprazole (40 mg/d)
rabeprazole (20 mg/d)
proton pump inhibitor
• complete relief from heartburn occurred at
a rate of 11.5 percent per week with a
proton pump inhibitor compared to 6.4
percent per week with an H2 receptor
antagonist
• dose-response curve for healing highgrade esophagitis
Differences in proton pump
inhibitors
• magnitude of differences has been small
and of uncertain clinical importance
Side effect of PPI
• Hypomagnesemia :
• More than 1 year
• With other drug like digoxin or diuretics
• Hip fracture
• More than 50 years
• Smokers or exsmokers
• B12 deficiency
• Iron deficiency : not appear to be of clinical significance
• Atrophic gastritis: uncertain significance
• Acute interstitial nephritis
Taper the PPI
• ● GERD are considered for a taper after being asymptomatic for a
minimum of three months
• ● treated for acute duodenal and gastric ulcers for four to eight
weeks do not require a taper
• ● PPI as part of a course of treatment for H. pylori do not require a
taper.
• ●For patients on a moderate- to high-dose PPI (eg, omeprazole 40
mg daily or twice daily), cut the dose by 50 percent every week (for
patients on twice daily dosing, or decreasing the dosing to once in
the morning until the patient is on the lowest dose of the
medication.
• Once on the lowest dose for one week, the patient is instructed to
stop the medication
PROKINETIC DRUGS/REFLUX
INHIBITORS
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bethanechol,
metoclopramide,
Cisapride
tegaserod
can potentially be useful adjuncts in the
treatment
• increasing lower esophageal sphincter pressure,
enhancing gastric emptying, or improving
peristalsis
• However, the currently available promotility
agents are not ideal for monotherapy
TREATMENT OF HELICOBACTER
PYLORI INFECTION
• Mild worsening of GERD in patients with
corpus dominant gastritis
• improvement in those with antralpredominant gastritis
•
most authorities would advocate eradication
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•
•
10 percent lifetime risk of developing peptic ulcer disease
two to three times higher incidence of gastric adenocarcinoma.
The mild increase in reflux associated with eliminating
corpus gastritis does not outweigh these risks
• the overall impact that H. pylori may have on the risk of
esophageal adenocarcinoma is insignificant
• She was better with life style modification
and ranitidine 150 mg BID for 8 weeks
• But symptoms recurred 2 months later
• what is the next step?
RECURRENT SYMPTOMS AND
MAINTENANCE THERAPY
• Two-thirds of NERD
• Nearly all patients with erosive
esophagitis (EE)
Relapse when acid
suppression is discontinued
Indication for surgery
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Failed optimal medical management
Noncompliance with medical therapy
High volume reflux
Severe esophagitis by endoscopy
Benign stricture
Barrett's columnar-lined epithelium
(without severe dysplasia or carcinoma
Pregnancy and lactation
Pregnant
with GERD
GERD in
lactation
Sucralfete
sucralfate
H2 RA
PPI
H2RA