Gastroesophageal

Reflux Disorder 
Dr. Hira Salman 
 ◦A condition which results due to
reflux of gastric content and leads
GERD  to initiating symptoms and
complications
 most common cause is inappropriate relaxation of Lower esophageal sphincter.
LES is not a true anatomical Structure, it is created by the different response of
the smooth muscle cells in the distal esophagus, so there are many factors that
can cause decreased tone or loosening of this sphincter like use of nicotine,
alcohol, caffeine, peppermint, chocolate, calcium channel blockers and nitrates.
Obesity is also one of the common causes of GERD, Pathophysiology in obesity
includes esophageal motor disorder, Lower esophageal sphincter abnormalities, a
trend toward development of hiatal hernia, increased intragastric gastric
pressure & increased gastric capacity.

Cause Acid hypersecretion from Zollinger Ellison Syndrome.

s:
Hiatal hernia can only worsen reflux. It is found in 1/4 of patients with non-
erosive GERD, 3/4 of patients with severe erosive esophagitis and over 90% of
patients with Barrett esophagus.

Anticholinergic medications, Sjogren's syndrome and oral radiation therapy may

exacerbate GERD due to impaired Salvation.
 To summarize broadly we can say
pathophysiology of GERD mainly include:

Dysfunction of
Irritant effects of
the Gastroesophag
refluxate
eal junction

Abnormally
esophageal Delayed emptying 
clearance
 CLINICAL
FINDINGS:
 Most common:
epigastric
Sign and burning pain
Symptoms
Heartburn is
called pyrosis
 Investigations:
Initiate PPI if no
improvement then
Most accurate
Clinical diagnosis increases the
diagnostic test: 24
is sufficient doses of PPI two
hour's pH monitor
times daily for 4 to
8 weeks.

Esophageal
If no improvement
manometry ( study
then goes for
 of esophageal
endoscopy.
motility)
Absolute indications of endoscopy:

Heartburn accompanied by red flags:

Persistent reflux symptoms after therapeutic trial of 4 to 8

weeks of PPI 2 times daily

History suggests dysphagia

High risk for Barrett esophagus (like Male more than 50

years of age, obese, white, tobacco use, long history of
symptoms)
Repeat endoscopy after 6 to 8 weeks of PPI
therapy in case of the severe esophagitis
because it can mask Barrett esophagus or
symptoms. 
Indications Of Esophageal Manomt
ery
(Study of Esophageal motility) 
Patients who have a normal gastroscopy but with
chest pain or dysphagia
It is done to diagnose abnormal peristalsis /
decreased LES tone but cannot detect presence of
reflux. 

Mainly used to rule out scleroderma /Achalasia. 

 Angina pectoris

Eosinophilic esophagitis

Differenti
al Esophageal motility disorder (Scleroderma/ Achalasia)

Diagnosis
  Peptic Ulcer

Reflux erosive esophagitis may be confused with pill induced

damage, eosinophilic esophagitis or infections (CMV,
Herpes, Candida)
TREATMENT
Treatment of Mild intermittent
symptoms: cut down citrus
tomatoes, coffee, spicy
foods, food that
lifestyle modifications precipitate reflux like
fatty food,
chocolate peppermint, al
cohol and cigarettes

patients should be avoid

weight loss lying down within 3 hours
after meal.

for nocturnal symptoms Patient with infrequent

elevate the head of the heartburn should revise
bed on 6-inch block or a antacids or oral H2
foam wedge to reduce receptor antagonist.
reflux and it also helps Duration of action of
increase esophageal antacids is less than 2
clearance. hours.
TROUBLESOM
E SYMPTOMS
 A: Initial Therapy:

Those who have known

complications of
If symptoms are
GERD like erosive
not relieved, then
esophagitis, Barett
increase the dose to
esophagus,
twice daily 30 minutes
stricture:  once daily oral
before meal for 4-8
proton pump inhibitors
weeks.
30 minutes before
breakfast for 4-8 weeks.
 Patients who require twice-daily
Proton pump inhibitors therapy
B: Long Term Thearpy should be maintained on long-
term therapy with once or twice
daily.
 Esophageal impedance PH testing , oropharyngeal pH
C:  Extra esophageal testing may be performed in patients with
reflux manifestations : extraesophageal symptoms persist after 3 months of PPI
therapy.
 For unresponsive patient which are about 5%
these patients undergo endoscopy for
D:  Unresponsive detection of severe, in adequately treated
disease Reflux oesophagitis and for other
gastroesophageal lesions that may mimic
GERD.
 Surgical Surgical fundoplication afford good to excellent  relief of
symptoms and healing of esophagitis in our 85% of

treatment: properly selected patients.  It is performed by

laparoscopically.
 Typical GERD do not respond with twice-daily
PPI for 4-8 weeks. 
Patient with suspected extraesophageal
GERD symptoms that do not resolve with 3
When to refer: months of twice daily PPI use.
Patient with significant dysphagia or other
alarm symptoms for upper endoscopy.

patient with Barrett oesophagus

surgical fundoplication is considered

GOOD LUCK!