GastroEsophageal Reflux Disease

(GERD)

Objectives:
● Understand the Pathophysiology of reflux esophagitis.
● Know clinical features of reflux esophagitis.
● Describe the pathology (gross and microscopic features) of reflux esophagitis.
● Know the complications of reflux esophagitis.

Important note:​
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Pathology Edit​.

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Introduction
Lower esophageal sphincter (LES):
Anatomy:
The LES ​
(abdominal part)​
is a bundle of muscles at the low end of the esophagus, where it meets the
stomach and maintains the tonic contraction.

Physiology:
● Primary barrier​ to gastroesophageal reflux is the lower esophageal sphincter.
● LES normally works in conjunction with the diaphragm.
● If barrier disrupted, acid goes from stomach to esophagus.
● Stratified squamous epithelium ​ (in esophagus) ​
is resistant to abrasion1 of the foods and sensitive to
acid.
● Submucosal glands contribute the mucosal ​ (acid) ​
protection by secreting both mucin and
bicarbonate.
● LES tone prevents the acidic gastric reflux under positive pressure.

Gastroesophageal reflux:
Is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal.

1
​
The process of scraping or wearing away.
2
Gastroesophageal Reflux Disease (GERD):​
(‫)ﺣﺮﻗﺎﻥ‬
Definition:​ ​
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​.

​
Pathophysiology:​
1. Impaired lower esophageal sphincter (low pressures →
hypotonia → relaxation).
2. Hypersecretion of acid.
3. Decreased acid clearance resulting from impaired
peristalsis or abnormal saliva production.
4. Delayed gastric emptying and duodenogastric reflux of
bile2 .
5. Salts and pancreatic enzymes.
These caused by two mechanisms:
1. Decrease in LES tone.
2. Increase abdominal pressure.

Abnormal lower esophageal sphincter Increase abdominal pressure

​ecrease in LES tone​
(D )

The most common causes:

● Functional (frequent transient LES relaxation) Obesity.
● Mechanical (hypotensive LES) Pregnancy.
Increased gastric volume
Decrease the tone of LES​
: (e.g by suddenly eating too much food).
● Foods (eg, coffee, alcohol, ​
Tobacco​ ),
● Medications (​ Central nervous system depressants​ eg, Delayed gastric emptying.
calcium channel blockers, ​alpha and beta blockers,
anticholinergic, antipsychotic ...etc​
),

​
hiatal hernia3
Location:​

2
​
Occurs when bile flows upward from the small intestine into the stomach. Bile reflux is caused by damage to the pyloric valve.
3
Hiatal hernia is characterized by separation of the right and left ​
crus of the ​
diaphragm and protrusion of the stomach into the
thorax through the resulting gap.
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Clinical Manifestations:
​ypical symptoms ​
● T (Most common)
- Heartburn​ :​retrosternal burning discomfort (more frequent).
- Regurgitation​ :​effortless return of gastric contents into the pharynx without
nausea, retching4, or abdominal contractions.
- Dysphagia: ​ (more frequent).
● Atypical symptoms:
- Coughing, chest pain, and wheezing hoarseness/laryngitis.
● Extraesophageal manifestations:
- Otolaryngol​:​hoarseness and laryngitis. ​
​ o​
to=ear: these symptoms are due the connection between the
ear and the pharynx (eustachian tube)​
.
Non-cardiac chest pain (mimics cardiac chest pain). ​
​
● Other:​ (not every chest pain is angina)

Diagnostic Evaluation​
:
alarm symptoms5​
If classic symptoms of heartburn and regurgitation exist in the absence of “​ ” the
diagnosis of GERD can be made ​clinically​
and treatment can be initiated.

1- Esophagogastroduodenoscopy6​
:
*Device with 2 arms: one for camera other biopsy handle. When doctor sees
an area not looking good (bleeding,ulcer,polyp) take biopsy and send it to lab.
Endoscopy with biopsy is needed:
- In patients with alarm signs/symptoms.
- Those who fail a medication trial.
- Those who require long-term treatment.
Allows the detection, and management of ​ esophageal injury​
or
complications of GERD.
The procedure lacks sensitivity for identifying pathologic
reflux
and ​absence of endoscopic features does not exclude a GERD
diagnosis.
If you find nothing with the endoscopy you go with the pH procedure.

2- pH: ​
pass tube through nose→ put a machine→ for 24h→ check PH.
● 24-hour pH monitoring.
● Transnasal catheter or a wireless, capsule shaped device.​ ​
used for establishing or excluding
presence of GERD for those patients who do not have mucosal changes.

4
e.g Gagging ( repeated unsuccessful attempts to vomit ).
5
Alarm symptoms include: dysphagia, odynophagia (painful swallowing), bleeding, anemia and weight loss.
6
Endoscopic examination of the upper alimentary tract using a video instrument.
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Complications:
1. Erosive 7 esophagitis: ​
Inflammation of the esophagus.
2. Stricture:​Caused by inflammation → fibrosis → esophagus becomes narrow → increase risk of
choking with food.
3. Barrett’s esophagus:

Barrett’s Esophagus
Erosive esophagitis Esophageal stricture (main risk factors)

– Responsible for 40-60% of GERD Result of ​

healing ​
of erosive Intestinal ​metaplasia​
of
symptoms esophagitis. the esophageal mucosa
– Severity of symptoms often fail to match from​ ​
stratified squamous
epithelium changes into
severity of erosive esophagitis.
non ciliated columnar
epithelium with goblet
cells (it can be
premalignant).

Associated with the

development of
adenocarcinoma.
May need dilation ​
(procedure).
Risk factors:
male, smoker, age, obese.

Microscopic shows​ :
1. elongation of lamina propria papilia.
2. basal zone hyperplasia.
3. eosinophils and neutrophils .

Pathophysiology of Barrett’s Esophagus:

- Acid damages​ lining of esophagus and causes​chronic esophagitis​.
- Damaged area tries to heal in a​metaplastic process​ and ​
damaged squamous cells are replaced by
metaplastic columnar cells​ defined by the presence of ​
goblet cells ​
(intestinal metaplasia).
- This specialized intestinal metaplasia can progress to dysplasia and ​
adenocarcinoma​ ​
(Columnar can
handle acidity but stratified squamous can’t so it gets converted to columnar).

‫ ﺗﺂﻛﻞ‬7
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 - Many patients with Barrett’s are asymptomatic.

Gross Microscopic

● The risk of cancer in Barrett's esophagus is estimated to be 40 to 100 times. ​

Not everyone develops
cancer.
● Endoscopic surveillance8 is recommended for all patients with Barrett's esophagus.
● Endoscopy is performed ​
every 2 years​
, and biopsies are taken from the area of abnormal mucosa.

If the biopsies reveal:

→​
- Low-grade dysplasia​ The frequency of endoscopies is increased. ​
​ Check every six months to see if
the patient developed a higher grade​
.
- High-grade dysplastic changes are seen →​ Then the risk of subsequent ​
​ adenocarcinoma​
is greater
than 25%, and surgical resection should be considered.

Barrett’s esophagus Dysplasia adenocarcinoma

‫ ﻣﺮﺍﻗﺒﺔ‬8
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Difference between Physiologic and Pathologic GER:

Physiologic GER Pathologic GERD

Asymptomatic. Symptoms
Postprandial ​(after meal)​. Mucosal injury
Short lived ​
(for a period of time)​
. Nocturnal symptoms ​
(problems while
No nocturnal symptoms. sleeping at night)

Treatment:
● H2 receptor Blockers.
● Proton pump inhibitors.
● Antireflux surgery.
Will be discussed more in details in the pharmacology lecture.

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Summary:

8
MCQ’s
1- A 55 years old male known to have sever migraine presented to his physician with frequent
cough, and difficulty in eating, and recently he noticed some changes in his voice.
What is the most likely cause of his condition?
A. Obesity
B. Ranitidine (H2 blocker)
C. Diclofenac sodium ( NSAIDs)
D. Helicobacter pylori

2- A pregnant woman presented with difficulty in swallowing and a night waking heartburn. What is
the most likely cause of her condition?
A. Analgesics
B. H.pylori
C. Hiatal hernia
D. Antidepressants

3- A 50 years old woman complaining of heartburn and regurgitation was diagnosed with GERD,
what is the first step management for her?
A. Endoscopy
B. pH monitoring
C. Antacid medications (no alarm symptoms )
D. Antireflux surgery

4- A 60 years old salesman noticed to have a cancer of his lower esophagus. He is a nonsmoker and
occasionally drinks alcohol. Which of the following is most likely cell type?

A. Sarcoma
B. Adenocarcinoma
C. Squamous cell carcinoma
D. Metastasis

5- A 58 year-old man presents with dysphagia for solids for three months. He complains of weight
loss and loss of appetite. There is no other relevant medical history apart from indigestion
symptoms and heartburn for the previous five years. He has endoscopy which shows an esophageal
stricture which indicates:
A. Peptic ulcers
B. Esophagitis
C. Intestinal metaplasia
D. Dysplasia

6- Which is not a predisposing factor for GERD?

A. High fatty food intake
B. Cholinergic drugs
C. Caffeine
D. Nicotine
E. Gastric outlet obstruction
Answers:​
1-C , 2-C , 3-C , 4-B , 5-B , 6-B.

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SAQ’s
A 42-year-old policeman has been seen by his family physician for a 5 years history of "heartburn",
he has been intermittently taking Ranitidine – a H2 blocking agent – with some relief.
An upper endoscopic examination that was performed recently revealed some reddish
discoloration and friability of the lower esophageal region. A biopsy was performed, and the
microscopic examination revealed Columnar cells containing goblet cells.

Q1. What is the most likely diagnosis?

Barrett's esophagus
- Intestinal metaplasia -
Q2.What is a long term complication of this process?
Adenocarcinoma.
Q3. What are the risk factors of Barrett's esophagus?
Male gender – Smoking – Age – obesity – family history - GERD.
Q4. What is the most likely mechanism of this process?
Repeated acid reflux (GERD) from the stomach to the lower esophagus leading to metaplasia of the normal
squamous epithelium into columnar epithelium.
Q5. What are the other complications of GERD?
Odynophagia - dysphagia - GI bleeding – Anemia – vomiting - weight loss - Erosive esophagitis –Strictures.

Online Quizzes:
http://patient.info/education/gastro-oesophageal-reflux-disease-gord/mcq
http://www.medicinenet.com/gerd_gastroesophageal_reflux_disease_quiz/quiz.htm

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