Learn the symptoms of Gastroesophageal Reflux Disease (GERD) and Barrett’s esophagus, and when they may warrant further medical attention. Hear the latest in treatment methods, including radio frequency ablation and endoscopic ultrasound.

1. Gastroesophgeal Reflux
Disease (GERD)
Hazar Michael, M.D.
June 14, 2012

2. GERD Overview
• Reflux occurs when the stomach contents reflux or
back up into the esophagus and/or mouth.

Reflux is a normal process that occurs in healthy individuals

Most episodes are brief and do not cause symptoms or
complications

Mostly after meals, rarely at night

Results from transient relaxation of the muscle sphincter in
lower esophagus
• People with GERD experience symptoms or
complications as a result of the reflux

4. GERD is a Common Problem
80 Males
Females
60
Prevalence (%)
Any episode
of GERD symptoms
40
At least weekly
20 episodes of GERD
symptoms
0
25–34 35–44 45–54 55–64 65–74
Age (years) Locke et al. Gastroenterology 1997

5. Symptoms of GERD
• Typical symptoms

Pain in the upper abdomen

Burning chest pain

Food getting stuck (dysphagia)

Pain upon swallowing (odynophagia)

Taste of acid or food in throat or food or fluid coming up
without effort (regurgitation)
• Atypical symptoms

Persistent sore throat

Sense of a lump in the throat

Waking up with a choking sensation

6. Symptoms of GERD
• Atypical symptoms continue

Persistent laryngitis/hoarseness

Chronic cough, new onset asthma, or asthma only at night

Worsening dental disease

Recurrent Pneumonia

Chronic sinusitis

7. Natural History of GERD
• Majority of patients do very well and only require
symptom control
• Minority will develop serious complications

8. Potential Complications of
GERD
• Severe esophageal inflammation and esophageal
ulcer formation
• Esophageal stricture formation (narrowing diameter)
• Barrett’s esophagus
• Esophageal cancer
• Hoarseness
• Pneumonia which if frequent may lead to permanent
lung damage

9. Barrett’s Esophagus
• Changing in the lining of the esophagus to become
intestine like lining
• Exact number of effected individual is unknown

Overall 1.6%
• 1.4% no GERD symptoms
• 2.3% with GERD symptoms

Risks factors
• Male
• Caucasian
• Smoking
• Hiatal hernia
• Increased visceral fat deposition
Ronkainen J, et al. Prevalence of Barrett's esophagus in the general population: an endoscopic study. Gastroenterology.
2005;129:1825-31.
Bonino JA. Barret’s esophagus. Current opinion in gastroenterology 2006,22:406-411

10. Barrett’s Esophagus and
Esophageal Cancer
• The exact increase risk is unclear

Increased risk by 30-125 folds
• Esophageal cancer is uncommon

Life time risk of developing esophageal cancer 0.4-0.5 per
100 patients per year
• 1% per year in LGD
• 10% per year in HGD
• Risk to progress to HGD is 0.9 per year
• Likely progression from Barrett’s LGD HGD
Ad Ca

~18% in LGD

~ 34% HGD

11. Surveillance for Barrett’s
Esophagus
• Not clear if useful but usually recommended
• At first endoscopy perform extensive biopsy

No dysplasia, confirmed by second endoscopy within 1 year
→ EGD in 3-5 years

LGD EGD in 1 year vs. treatment

HGD In individual with reasonable life
expectancy consider treatment

12. Treatment of Barrett’s
Esophagus
• Control acid and inflammation usually by medication
• Eradication of Barrett’ tissue by heat or cold or other
methods
• Removal of early cancer endoscopically
• For advanced cancer either surgery or chemotherapy
and radiation therapy

13. HALO Device (Barrx Device)
• A device delivers heat to get rid of Barrett’s tissue
• Usually recommended for patients with dysplasia and
few selected patients without dysplasia

About 90% chance of eliminating dysplasia and
Barrett’s esophagus and at least tow fold decrease
in cancer risk

Durable at 5 years but no longer term data

14. When Do I Need to Seek
Medical Care?
• Symptoms are getting worse or inability to control
them
• When you are in doubt if something wrong
• Need to seek immediate medical care
•
Trouble swallowing/chocking or sensation of food being
stuck or lump in throat
•
Unintentional weight loss

Chest pain

Vomiting blood or having bowel movements that are black or
look like tar

15. Diagnosing GERD
• Clinical by history and therapeutic trial
• Endoscopy
• PH testing
• Esophageal manometry
• Radiology

16. Treatment of GERD
• Life style modification
• Medications
• Endoscopic procedure
• Surgery

17. Life Style modification
Not clear if it is effective but usually recommended
• Lose weight (if you are overweight)
• Raise the head of your bed by 6 to 8 inches
• Avoid foods that make your symptoms worse
• Coffee, chocolate, alcohol, peppermint, and fatty foods
• Cut down on the amount of alcohol you drink
• Stop smoking
• Frequent small meal, avoid overeating
• Eat a bunch of small meals each day
• Avoid lying down for 3 hours after a meal

18. Dietary factors that may
aggravate GERD symptoms
• Caffeinated • Spicy foods
products • Citrus fruits and
• Peppermint juices
• Fatty foods • Tomato-based
• Chocolate products
• Alcohol

20. Medications
• Antacids work for mild infrequent episodes of GERD
or as adjuvant to other medication in more severe
case
• Antihistamine work in mild GERD and not very
effective to heal severe esophageal inflammation

21. Medications
• PPI as class are the strongest medication

Heal inflammation over 80%

Most work better if taken before meals

Usually once a day and occasionally twice a day

For symptoms control only initial treatment is 8 weeks
• If symptoms relapse within 3 months usually are needed for long term

Goal of therapy is to use the lowest effective dose of
medication

Usually safe but can lead to decrease bone dentistry and
nutrient absorption and increase risk of infections especially
clostridium difficile

22. My Medications Are Not Working
What Should I Do ?
• If PPI, are you taking it before meal?
• Change to different PPI
• PPI twice a day
• Additional testing
• Consideration for surgery

23. Surgery for GERD
• Goal to increase barrier to acid reflux with minimal impact on the
ability to swallow
• Surgery plays an important role in patients with large hiatus
hernia and those unable or unwilling to take long term
medications
• Majority are done laparoscopically, result depends on surgeon
experience
• Potential complications

Difficulty swallowing (5%)

Sense of bloating and gas

Breakdown of the repair (1 to 2 percent of patients per year)

Diarrhea due to inadvertent injury to the nerves

25. Summary
• GERD is common and in a majority of
cases has benign course
• Use lowest effective dose of medication
• Trouble swallowing, chest pain or
bleeding seek immediate attention
• Barrett’s esophagus in a majority of
cases does not lead to cancer, but
keeping an eye on it is advisable

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