GERD

Dr. Sia Koon Ket

Consultant Gastroenterologist
Definition:

GERD
.thepresence of typical symptoms of
GERD caused by pathological reflux of
intraoesophageal acid, ranging from simple
to erosive to Barretts.

NERD (Non-erosive reflux disease)

Reflux disease in which erosion does not
occur
Range of presentation of
GERD
Typical symptoms
(Heartburn/regurgitation)

With
oesophagitis

Without
oesophagitis
 Range of presentation of
GERD
Atypical symptoms Complications

Chest pain Oesophageal

(visceral erosions
hyperalgesia) and/or ulcers

Hoarseness Stricture
(reflux
laryngitis)

Asthma, Barretts
chronic cough, oesophagus
wheezing

Dental erosions Oesophageal

adenocarcinoma

Nathoo, Int J Clin Pract 2001; 55: 4659.

 GERD
Erosive
30%

Nonerosive
70%
 Los Angeles classification
system for oesophagitis

Grade A Grade B
One or more mucosal One or more mucosal
breaks, no longer than breaks, more than 5
5 mm, that do not mm long, that do not
extend between the extend between the
tops of two mucosal tops of two mucosal
folds folds

Grade C Grade D
One or more mucosal One or more mucosal
breaks, that are breaks, that involve at
continuous between the least 75% of
tops of two or more the oesophageal
mucosal folds, but which circumference
involve less than 75% of
the circumference

Lundell et al., Gut 1999; 45: 17280.

Progression of GERD

Most do not progress over time

Not at risk of developing Barretts oesophagus
If there is progression, usually to low grades of
erosive oesophagitis
Goals of Treatment in GERD

Provide satisfactory acute and long term

symptom control

Prevent symptom relapse

Improve patients health-related quality of

life

Reduce reliance on antireflux treatment

modalities
 GERD Treatment Options

Lifestyle Antacids and

modifications alginates

PPIs Approaches H2RAs

Prokinetic Surgery
motility agents
 Lifestyle Modifications

Reduce weight

Stop smoking Elevate head

of bed

Modifications

Avoid reflux-promoting Eat small meals,

agents (e.g. alcohol, no late meals,
coffee, some foods) reduce fat
(not evidence based)
Antacids

Increases pH of refluxate
Quick relief of mild symptoms
Less effective than PPIs or
H2RA
Adverse effects-diarrhoea,
constipation,accumulation in
renal failure
Prokinetic Agents

Increase LOS and enhance gastric

emptying

Relieve heartburn but not heal

oesophagitis
 GERD Treatment

REMISSION

MAINTENANCE

Continuous Rx Intermittent Rx On demand Rx

Continuous PPI therapy

vs

On-demand PPI therapy

 Definitions
INTERMITTENT Rx
Physician driven
Short, predetermined courses of therapy
when sx occur (1-2 weeks duration)
Duration fixed by physician
ON DEMAND Rx
Patient driven
Patient consumes therapy
when and during periods
that patients desire
Convenient Patients in control

ADVANTAGES OF
ON-DEMAND PPI Rx

Reduced cost to Decrease in the

patients & health rebound of acid
providers secretion
Available PPIs

Lansoprazole
Omeprazole
Esomeprazole
Pantoprazole
Rabeprazole

BUT ARE THEY ALL THE SAME?

Choosing a PPI

Rapid onset of action

Long duration of effect

Stable effect independent of drug-drug

interactions

Predictable therapeutic response

Low risk of adverse events

Who is eligible for on demand
PPI?
Suitable candidates
Symptomatic, nonerosive GERD: up to
70% of GERD
Mild to moderate erosive oesophagitis:70-
85% of erosive oesophagitis patients

Patients who should not use on

demand PPI Rx
Severe erosive oesophagitis
GERD complications (strictures, Barretts)
Extraoesophageal manifestations of GERD