Gastroesophageal Reflux – (GER)

Disease Vs. Disorders

An Integrative Perspective

Dr. Farshid Rahbar MD, FACP, ABIHM

Founder and Practicing Physician

Acknowledgement:

Dr. Michael Erdman, MBBS.

Learning Objectives

• Understand the traditional perspective to GERD

• Definition

• Mechanism of illness

• Symptoms

• Complications

• Traditional treatment models.

• Integrating the above with a holistic mindset/approach.

• Minimizing or avoiding acid reducers.

• Managing refractory cases.

Gastroesophageal reflux disease is a

motility disorder characterized

primarily by heartburn, and caused by

the reflux of gastric contents into the

esophagus.

Definition & Overview

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

GERD is a consequence of the failure of

the normal antireflux barrier to

protect against frequent and abnormal

amounts of refluxed material.

Definition & Overview

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Most patients have no visible mucosal

damage at the time of endoscopy,

whereas others have esophagitis, peptic

strictures, or Barrett's esophagus.

There are approximately 10 million

outpatient clinic visits a year for GERD in

the U.S.

Definition & Overview

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

The Complex Pathogenesis of GERD

Defense of Esophagus

Aggravating stomach factors

Antireflux

barriers

Gastric acidity

Esophageal acid clearance

Stomach volume

Tissue resistance

Duodenal contents

GERD results from an imbalance between

defensive factors protecting the esophagus,

and aggressive factors refluxing from the

stomach.

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Antireflux Barriers

This is an anatomically complex region:

• the intrinsic LES

• diaphragmatic crura

• intra-abdominal location of the LES

• the phrenoesophageal ligaments

• the acute angle of His

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

lower esophageal sphincter - LES

• The LES involves the distal 3 to 4 cm of the esophagus and

at rest is tonically contracted.

• It is capable of preventing reflux even when completely

displaced from the diaphragmatic crura by a hiatal hernia.

• The proximal portion of the LES is normally 2 cm above the

squamocolumnar junction, whereas the distal segment,

about 2 cm in length, lies within the abdominal cavity.

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

• The LES location maintains gastroesophageal competence

during intra-abdominal pressure excursions.

• Resting LES pressure ranges from 10 - 30 mm Hg. There is a

generous reserve capacity because only a pressure of 5 to

10 mm Hg is necessary to prevent GER.

• The LES maintains a high-pressure zone by the intrinsic

tone of its muscle and by cholinergic excitatory neurons.

lower esophageal sphincter - LES

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

LES Vs. Food Nutrients

Increase

LES Pressure

Decrease LES Pressure

Protein

Chocolate

Fat

Peppermint

- Mint

Carbonated beverages

Food preservatives

Processed foods

Green tea

Dietary habits

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

LES Vs. Medications

Increase

LES Pressure

Decrease LES Pressure

Antacids

Barbiturates

Baclofen

Calcium channel blockers

Cisapride

Diazepam

Domperidone

Dopamine

Histamine

Meperidine

Metoclopramide

Morphine

Prostaglandin F

2α

Prostaglandins E

and I

Serotonin

Theophylline

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Important basic concepts

• Overall, gastric acid secretion is normal in patients

with GERD.

• Acid and pepsin are the key ingredients of the gastric

refluxate producing esophagitis.

• The degree of esophageal injury, from nonerosive

GERD to Barrett's esophagus, parallels the increase in

the frequency and duration of acid reflux (pH < 4).

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Important basic concepts

Helicobacter pylori associated gastritis

• Hp antrum-predominant gastritis has been shown to

be associated with hypergastrinemia and gastric

hypersecretion.

• Heartburn and regurgitation often improve

significantly after eradication therapy in patients with

antrum-predominant gastritis.

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Transient Lower Esophageal Sphincter Relaxations

The most frequent mechanism for reflux in

patients with healthy sphincter pressures.

tLESRs

• occur independently of swallowing

• are not accompanied by esophageal peristalsis

• persist longer (>10 seconds) than swallow-induced LESRs

• are accompanied by inhibition of the crural diaphragm.

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Important basic concepts

• Hypotensive Lower

Esophageal Sphincter

Pressure

• Hiatal hernia

Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Important basic concepts