Erosive esophagitis

Responsible for 40-60% of GERD symptoms

Severity of symptoms often fail to match severity of erosive esophagitis

Esophageal stricture

Result of healing of erosive esophagitis

May need dilation

Common in the distal esophagus and are generally 1 to 2 cm length.

Barrett’s Esophagus

Columnar metaplasia of the esophagus,i.e replacement of the squamous epithelial lining of the esophagus by specialized columnar- type epithelium

Associated with the development of adenocarcinoma

Have a greater chance (30%) of developing esophageal stricture

Barrett’s Esophagus

Acid damages lining of esophagus and causes chronic esophagitis

Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells

This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma

3 CLASSES OF SYMPTOMS

TYPICAL SYMPTOMS

May be aggravated by activities that worsen gastroesophageal reflux such as recumbent position, bending over, or eating a meal high in fat.

Heartburn—retrosternal burning discomfortRegurgitation—effortless return of gastric contents into the pharynx without nausea,

retching, or abdominal contractionsWater brash (hyper salivation)

Belching

Atypical symptoms

In some cases, these extra esophageal symptoms may be the only symptoms present, making it more difficult to recognize GERD as the cause, especially when endoscopic studies are normal.

Nonallergic asthma

Hoarseness

Pharyngitis

Chest pain

Dental erosions

ALARM SIGNS/SYMPTOMS

These symptoms may be indicative of complications of GERD such as Barrett’s esophagus, esophageal strictures, or esophageal cancer

Dysphagia

Early satiety

GI bleeding

Odynophagia

Vomiting

Unexplained Weight loss

Iron deficiency anemia

Choking

Continual pain

If classic/typical symptoms like heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated

H2RA or PPI

Expect response in 2-4 weeks

If no response

Change from H2RA to PPI

Maximize dose of PPI

If PPI response inadequate despite maximal dosage

Confirm diagnosis

EGD(Esophagogastrodudenoscopy)

24 hour pH monitor

Endoscopy (with biopsy if needed)

In patients with alarm signs/symptoms

Those who fail a medication trial

Those who require long-term treatment

Important in distinguishing between esophagitis and Barret’s metaplasia

Absence of endoscopic features does not exclude a GERD diagnosis

Confirmation can be achieved by provocative tests such as an acid perfusion test(Bernstein test), standard acid reflux test etc.