Esophageal & extra-esophageal manifestations of GERD - PowerPoint Presentation

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Esophageal & extra-esophageal manifestations of GERD

Dr SM Valizadeh ToosiAssistant Professor of Medical Science facultyImam Khommeni Hospital GI Ward

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DEFINITION 

Gastroesophageal 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

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DEFINITION

Gastroesophageal 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

 

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Clinical manifestations of GERD

Esophageal manifestations

Extraesophageal manifestations

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Esophageal manifestation of GERD

Heartburn

RegurgitationDysphagiaWater

brash

Odynophagia

GERD-related chest pain

Globus

sensation

Nausea & vomiting

Belching

Hiccup

Halitosis or bad

breath

Sour taste, bitter taste

Epigastric pain

Asymptomatic

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Esophageal manifestation of

GERD 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

.

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Esophageal manifestation of

GERD 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

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Esophageal manifestation of

GERD 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

.

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Esophageal manifestation of

GERD 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

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Esophageal manifestation of GERD

Odynophagia 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

.

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Esophageal manifestation of GERD

Water 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

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Esophageal 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.

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Esophageal 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 .

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Esophageal manifestation of GERD

Globus 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

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Esophageal manifestation of GERD

Nausea & 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

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Esophageal manifestation of GERD

BelchingBelching :

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.

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Esophageal manifestation of GERD

hiccup 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.

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Esophageal manifestation of GERD

halitosis 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.

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Esophageal manifestation of GERD

Epigastric pain

Epigastric pain can be the major symptom of GERDAcid-suppressive therapy resolved heartburn and epigastric pain in these patients

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Esophageal manifestation of GERD

AsymptomaticSome 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

.

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exercise-induced gastroesophageal

refluxPhysical 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

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Extra-esophageal manifestations of GERD

Bronchospasm and asthmaChronic coughPharyngitis

Posterior laryngitisRecurrent pneumonitis Dental erosionsGum inflammation SinusitisPulmonary fibrosisRecurrent otitis mediaSleep disturbance

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Extra-esophageal manifestations of GERD

GER 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

.

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extraesophageal 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.

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extraesophageal manifestations of GERD

Asthma

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.

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extraesophageal manifestations of

GERD pulmonary diseases

Other pulmonary diseases associated with GERD include aspiration pneumonia interstitial pulmonary fibrosis chronic bronchitisand

bronchiectasis.

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extraesophageal

manifestations 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.

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extraesophageal 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

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extraesophageal manifestations of GERD

Dental 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 .

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GERD is frequently associated with sleep disturbance

large 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

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The overall definition of gerd

& constituent syndromes

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