1. GASTRO-ESOPHAGEAL REFLUX DISEASE
BY: ASIA SAID
CLINICAL PHARMACIST

2. • Gastroesophageal reflux disease
occurs when the amount of gastric
juice that refluxes into the
esophagus exceeds the normal
limit, causing symptoms with or
without associated esophageal
mucosal injury (i.e. esophagitis).

3. NORMALLY:
We have esophageal defense mechanisms
esophageal
clearance
mucosal
resistance
extremely important
factor in preventing
mucosal injury
Lower esophageal
sphincter pressure
• Bicarbonate secretion
• Tissue repair (
epidermal growth
factor secretion within
30 mints of injury)
Mechanical
clearance is
achieved with
esophageal
peristalsis
chemical
clearance is
achieved with
saliva (PH=
6.2-7.4)

4. 1. A functional (frequent transient LES relaxation) or mechanical (hypotensive LES)
problem of the LES is the most common cause of GERD.
2. Transient relaxation of the LES can be caused by foods (coffee, alcohol, chocolate,
fatty meals), medications (beta-agonists, nitrates, calcium channel blockers,
anticholinergics), hormones (eg, progesterone), and nicotine.
3. Delayed gastric emptying: an increase in gastric contents resulting in increased
intragastric pressure and, ultimately, increased pressure against the lower
esophageal sphincter
4. Hiatal hernia: is the protrusion (or herniation) of the upper part of the stomach into
the thorax through a tear or weakness in the diaphragm.
5. Obesity: increased BMI and increased prevalence of GERD and its complications.

5. Hiatal hernia

6. Esophagitis Stricture
• advanced forms
of esophagitis
and are caused
by
circumferential
fibrosis due to
chronic deep
injury
Barrett
esophagus
• It is defined by
metaplastic
conversion of the
normal distal
squamous
esophageal
epithelium to
columnar
epithelium

7. Barrett’s
esophagitis
strictureesophagitis

8. 1. Signs and symptoms.
2. Testing:
• Upper gastrointestinal endoscopy/ esophagogastroduodenoscopy: mandatory
• Esophageal manometry: mandatory
• Ambulatory 24-hour ph monitoring: criterion standard in establishing a diagnosis
of gastroesophageal reflux disease
3. Imaging studies:
• Chest images may also demonstrate a large hiatal hernia, but small hernias can
be easily missed.

9. atypicalTypical
• Coughing and/or wheezing
• Hoarseness, sore throat
• Otitis media
• Noncardiac chest pain
• Enamel erosion or other dental
manifestations
Uncomplicated:
• Heartburn
• Regurgitation
(usually occurs after large
meals, aggravated by bending
and relieved by antacids )
Complicated:
• Dysphagia
• Anemia
• Hemoptesis
• Weight loss

10. Upper
gastrointestinal
endoscopy

11. Esophageal manometry
• It is a test to assess motor function of
the upper esophageal sphincter
(UES), esophageal body and lower
esophageal sphincter (LES).
• Procedure
A technician places a catheter into the
nose and guides it into the stomach.
Once placed, the catheter is slowly
withdrawn, allowing it to detect
pressure changes and to record
information for later review

13. Ambulatory
24-hour Ph
monitoring

14. • The goals are:
1. To control symptoms.
2. To heal esophagitis.
3. To prevent recurrent esophagitis or other complications.
• The treatment is based on:
(1) lifestyle modification
(2) control of gastric acid secretion through:
• Medical therapy with antacids or PPIs
• Surgical treatment with corrective antireflux surgery

15. • Losing weight (if overweight).
• Avoiding alcohol, chocolate, citrus juice, and tomato-based products (2005
guidelines from the American college of gastroenterology [ACG] also suggest
avoiding peppermint, coffee, and possibly the onion family).
• Avoiding large meals.
• Waiting 3 hours after a meal before lying down.
• Elevating the head of the bed 8 inches.
Lifestyle modifications are the first line
of management in pregnant women
with GERD.

16. Antacids
H2 blocker
therapy
Proton pump
inhibitors
Prokinetic
medications and
reflux inhibitors

17. • Antacids were the standard treatment in the 1970s and are
still effective in controlling mild symptoms of GERD.
• Antacids should be taken after each meal and at bedtime.
• Agents:
1.Aluminum hydroxide
2.Magnesium hydroxide

18. • H2 receptor antagonists are the first-line agents for patients with mild
to moderate symptoms and grades I-II esophagitis.
• Options include:
1. ranitidine (zantac)
2. famotidine (pepcid)
3. nizatidine (axid).
• M.O.A: The H2 receptor antagonists are reversible competitive
blockers of histamine at the H2 receptors, particularly those in the
gastric parietal cells, where they inhibit acid secretion.

19. • Proton pump inhibitors (PPIs) inhibit gastric acid secretion by inhibition of the
H+/K+ atpase enzyme system in the gastric parietal cells.
• These agents are used in cases of severe esophagitis and in patients whose
conditions do not respond to H2 receptor antagonist therapy.
• Options include:
1. omeprazole (prilosec)
2. lansoprazole (prevacid)
3. rabeprazole (aciphex)
4. esomeprazole (nexium).

20. • Prokinetic agents, such as metoclopramide (reglan),
• Improve the motility of the esophagus and stomach and
increase the lower esophageal sphincter (LES) pressure to
help reduce reflux of gastric contents.
• They also accelerate gastric emptying.

21. • Is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia.
• Indications :
1. Patients with symptoms that are not completely controlled by proton pump inhibitors
2. Patients with well-controlled reflux disease who desire definitive, one-time treatment
3. The presence of barrett esophagus
4. The presence of extraesophageal manifestations
5. Young patients
6. Poor patient compliance with regard to medications
7. Postmenopausal women with osteoporosis
8. Patients with cardiac conduction defects
9. Cost of medical therapy

23. • Immaturity of lower esophageal sphincter function is manifested by
frequent transient lower esophageal relaxations, which result in
retrograde flow of gastric contents into the esophagus.
• S &S:
failure to thrive, feeding or sleeping problems, chronic respiratory
disorders, esophagitis, hematemesis, apnea, and apparent life-threatening
events
• About 70-85 % of infants have regurgitation within the first 2 months of
life, and this resolves without intervention in 95 % of infants by 1 year of
age.

24. For childrenFor babies
1. Elevate the head of the child's bed.
2. Keep the child upright for at least two
hours after eating.
3. Serve several small meals throughout the
day, rather than three large meals.
4. Make sure your child is not overeating.
5. Limit foods and beverages that seem to
worsen your child's reflux such as high fat,
fried or spicy foods, carbonation, and
caffeine.
6. Encourage your child to get regular
exercise.
1. Elevate the head of the baby's crib or
bassinet.
2. Hold the baby upright for 30 minutes after
a feeding.
3. Thicken bottle feedings with cereal (do not
do this without your doctor's approval).
4. Feed your baby smaller amounts of food
more often.
5. Try solid food (with your doctor's
approval).
Life style modifications

25. Drug therapy
Drugs to Lessen Gas in
Babies and Children
Drugs to Neutralize or
Decrease Stomach Acid
Drugs to Improve
Intestinal Coordination
• Simethicone
such as Mylicon
• Gaviscon
• Antacids such as:
Maalox
• Histamine-2 (H2)
blockers such As :
Zantac
• Proton-pump inhibitors
such as : Nexium &
Prilosec
Erythromycin. This is
an antibiotic usually
used to treat bacterial
infections. One
common side effect of
erythromycin is that it
causes strong stomach
contractions. This side
effect is advantageous
when the drug is used
to treat reflux

26. References:
http://www.webmd.com/children/infants-children?page=2
http://emedicine.medscape.com/article/930029-overview
http://emedicine.medscape.com/article/176595-overview