Dr SM Valizadeh Toosi Assistant Professor of Medical Science faculty Imam Khommeni Hospital GI Ward DEFINITION Gastroesophageal reflux GER Physiologic reflux typically occur postprandial ID: 912427
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Slide1
Esophageal & extra-esophageal manifestations of GERD
Dr SM Valizadeh ToosiAssistant Professor of Medical Science facultyImam Khommeni Hospital GI Ward
Slide2DEFINITIONGastroesophageal reflux (GER ) : Physiologic reflux typically occur postprandial
are short-lived asymptomatic rarely occur during sleepdoes not lead to complications detectable by intra-esophageal pH monitoring
Slide3DEFINITIONGastroesophageal reflux
( GERD): Pathologic reflux consensus of the Montreal Classification defines: GERD as a condition that develops when the reflux of stomach contents to esophagus causes :troublesome symptoms
and/or complications
Esophageal manifestations
Extraesophageal manifestations
Slide5Esophageal manifestation of GERDHeartburn
RegurgitationDysphagiaWater
brash
Odynophagia
GERD-related chest pain
Globus
sensation
Nausea & vomiting
Belching
Hiccup
Halitosis or bad
breath
Sour taste, bitter taste
Epigastric pain
Asymptomatic
Slide6Esophageal manifestation ofGERD Heartburn
burning sensation in the retrosternal area most commonly experienced in the postprandial period.radiating toward the neck, throat, and occasionally the back.It occure after large meals or after ingesting spicy foods, citrus products, fats, chocolates, and alcohol.
The
supine position and bending over may exacerbate heartburn
.
Slide7Esophageal manifestation ofGERD Heartburn
Heartburn has high specificity (89%) but low sensitivity (38%) for GERD as diagnosed by 24-hour esophageal pH testingGERD is usually diagnosed symptomatically by the occurrence of heartburn one, two or more days a week
Slide8Esophageal manifestation ofGERD regurgitation
the perception of flow of refluxed gastric content into the mouth or hypopharynx The effortless regurgitation of acidic fluid, is highly suggestive of GERD. This symptom more difficult to treat medically than classic heartburn
.
Slide9Esophageal manifestation ofGERD Dysphagia
common in the setting of longstanding heartburn Dysphagia is reported by more than 30% of individuals with GERD.The most common causes are peptic stricture Schatzki's
ring
but other etiologies include severe esophageal inflammation alone, peristaltic dysfunction, and esophageal cancer arising from Barrett's esophagus
Slide10Esophageal manifestation of GERDOdynophagia Odynophagia may be seen with severe ulcerative esophagitis.
Its presence should raise the suspicion of an alternative cause of esophagitis, especially infections or injury from impacted pillsOdynophagia is an unusual symptom of GERD
,
usually indicates an esophageal ulcer
.
Slide11Esophageal manifestation of GERDWater brash
Water brash is the sudden appearance in the mouth of a slightly sour or salty fluid. It is not regurgitated fluid, but rather secretions from the salivary glands in response to acid reflux.Water
brash
or
hyper-salivation
is a relatively unusual
symptom
Slide12Esophageal manifestation of GERD
GERD-related chest painGERD-related chest
pain:
may mimic angina pectoris, as squeezing or burning, located
substernally
and radiating to the back, neck, jaw, or
arms
lasting from minutes to hours, and resolving either spontaneously or with antacids.
It usually occurs after meals, awakens patients from sleep, and may be exacerbated by emotional stress
Patients with reflux-induced chest pain may also have typical reflux symptoms.
Slide13Esophageal manifestation of GERD
GERD-related chest painThe mechanism for GERD-related chest pain is poorly understood and is probably multifactorial, related to
H
+
ion
concentration
volume
, and
duration
of acid
reflux
secondary esophageal
spasm
However
, it is often difficult to differentiate chest pain due to
GERD
and chest pain due to heart disease.
all chest pain evaluated IMMEDIATELY by cardiologist .
Slide14Esophageal manifestation of GERDGlobus sensationGlobus sensation is the almost constant perception of a lump in the throat (irrespective of swallowing), which has been related to GERD in some studies.
One study suggested that globus was associated with a hypertensive upper esophageal sphincter rather than with reflux
Slide15Esophageal manifestation of GERDNausea & vomitingNausea and vomiting is infrequently reported with
GERD but a diagnosis of GERD should be considered in patients with otherwise unexplained nausea. In one report, nausea resolved after therapy for GERD in 10 patients who previously had intractable symptoms
Slide16Esophageal manifestation of GERDBelchingBelching :
Belching is as common and as severe in patients with dyspepsia as it is in patients with GERD. Belching and heartburn in GERD patients are more likely correlated with episodes of pathological acid reflux. ambulatory pH monitoring should be considered to elucidate the relationship of belching to acid reflux in patients with dyspepsia or GERD.
Slide17Esophageal manifestation of GERDhiccup Hiccup is a spasmodic, involuntary contraction of the inspiratory muscles
There are numerous causes of hiccup, including diseases of the gastrointestinal tract. Hiccup is reported to represent an atypical manifestation GERD.
Slide18Esophageal manifestation of GERDhalitosis or bad breath GERD increases the risk of halitosis in both edentulous and dentate subjects.
Because of the increasing prevalence of overweightness and obesity, which are associated with GERD, this may be of increasing public health relevance.
Slide19Esophageal manifestation of GERDEpigastric pain
Epigastric pain can be the major symptom of GERDAcid-suppressive therapy resolved heartburn and epigastric pain in these patients
Slide20Esophageal manifestation of GERDAsymptomaticSome patients with GERD are
asymptomatic. This is particularly true in the older adults Many older adult patients present first with complications of GERD perhaps because of decreased acidity of the reflux material in some or decreased pain perception in others
.
Slide21exercise-induced gastroesophagealrefluxPhysical exercise may induce symptoms of
GERD in patients who have no/minimal symptoms at other time Gastroesophageal reflux can cause episodes of chest pain that resemble ischemic cardiac pain, without accompanying heartburn or regurgitation
Slide22Extra-esophageal manifestations of GERDBronchospasm and asthmaChronic coughPharyngitis
Posterior laryngitisRecurrent pneumonitis Dental erosionsGum inflammation SinusitisPulmonary fibrosisRecurrent otitis mediaSleep disturbance
Slide23Extra-esophageal manifestations of GERDGER may cause a wide spectrum of conditions including
asthma, posterior laryngitis, chronic cough, recurrent
pneumonitis
, and even
dental
erosion
.
Some
of these patients have classic reflux
symptoms
but many are “
silent
refluxers
,” contributing to problems in making the diagnosis
.
Slide24extraesophageal manifestations of GERD Furthermore, it may be difficult to establish a causal relationship even
if GER can be documented by testing (e.g., pH studies) because individuals may simply have two common diseases without a cause-and-effect relationship.
Slide25extraesophageal manifestations of GERDAsthma
The prevalence of GERD in asthmatics is estimated between 34% and 89% in different studies GERD should be considered in asthmatics who present in adulthood those without an extrinsic (allergic
)
component
and
those
not responding to bronchodilators or
glucocorticoids
.
Proposed
mechanisms of reflux-induced asthma include
aspiration
of gastric contents into the lungs with secondary bronchospasm and activation of a
vagal
reflex
from the esophagus to the lungs causing bronchoconstriction.
Slide26extraesophageal manifestations ofGERD pulmonary diseases
Other pulmonary diseases associated with GERD include aspiration pneumonia interstitial pulmonary fibrosis chronic bronchitisand
bronchiectasis.
Slide27extraesophagealmanifestations of GERDent DISORDERS
GERD may be associated with a variety of laryngeal symptoms and signs, of which “reflux laryngitis” is the most common.
These patients present with
hoarseness
,
globus
sensation, frequent throat
clearing
, recurrent
sore
throat
ENT
signs attributed to GERD include
posterior laryngitis
vocal cord ulcers and
granulomas
leukoplakia, and even carcinoma.
Slide28extraesophageal manifestations of GERDchronic cough
GERD has been postulated to be a leading cause of chronic cough (after sinus problems and asthma).Potential
causal mechanisms of reflux cough, reflux laryngitis
,
include
direct
(aspiration) or
indirect
(
neurally
mediated) effects of
gastroesophageal
reflux
Slide29extraesophageal manifestations of GERDDental erosion
Dental erosion, the loss of tooth structure by nonbacterial chemical processes and gum inflammation can be caused by GER in healthy subjects and patients with bulimia .
Slide30GERD is frequently associated with sleep disturbancelarge general population survey found that GER occurred
during the sleep period in 25% of patients with reflux diseaseThis night-time symptoms and sleep disturbance improved by PPI and or anti-Reflux surgery
Slide31The overall definition of gerd& constituent syndromes
Slide32