We hope that you will find the following
information useful when caring for your patients with GERD.
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I have strived to provide information that can be helpful in your diagnostic
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Farivar, MD, FACP, FACG
GERD is the most common condition encountered
by pediatric and adult gastroenterologists. Millions of Americans suffer from
daily heartburn, and millions more have other GERD
related syndromes. The cost of relieving heartburn in the US is several billion
dollars per year - a major public health expenditure. No wonder
why drug companies allocate expensive resources to the development and marketing
of newer anti-GERD medications.
often poorly informed about dietary restrictions and over-the-counter self-medication.
Primary Care Doctors treat most patients empirically with the strongest medication that
they have been detailed about, and they are often not sure when to refer patients
with GERD to specialist or when to stop or modify treatment.
in turn have their own problem in dealing with GERD.
GERD can present itself in a variety of ways from esophageal to supra and peri-esophageal syndromes. Less
than 50% of patients with GERD complain about heartburn. There is no “Gold
Standard” test for diagnosis of GERD. Endoscopy indications are not well defined
(Indications for Endoscopy in GERD).
Not all endoscopist report the degree of damage that they see in a systematic
Slides) or Los Angeles classification. This grading is very important and
should be adopted by endoscopists. It provides a blue print for comparison
when further endoscopy follow-up is indicated, and it has important therapeutic
implications (Grades C and D of EE according to the LA criteria rarely if ever
heals without the use of PPIs). Upper GI endoscopy, the most common used diagnostic
modality in GERD, is negative (NERD or non-erosive reflux disease) for erosive esophagitis in more than 50% of patients exhibiting
GERD related chest pain, heartburn, regurgitation, as well as ENT and pulmonary
Attention to the posterior larynx for evidence of erythema and edema (Reflux
Laryngitis slides), as well as careful observation of lower esophagus for
presence of patulous lower esophageal sphincter (LESC) and HH can enhance diagnostic
capabilities of EGD and saves considerable costs (Increase
the Diagnostic Yield of Upper G.I. endoscopy).
In patients with Barrett’s esophagus
the frequency of surveillance endoscopies remain mostly specialist individual
choice.(Link to Barrett's Surveillance)
In our experience, proper esophageal mucosal biopsy and proper histological
study of endoscopic biopsies has confirmed the diagnosis of up to 82% of
our GERD patients. However, due to its expense and considerable degree of
false positive and false negative reporting if morphometric studies (Pathology
Slide) are not done, biopsy should be done only when diagnosis is in doubt.
the most common presenting symptom, is present no further diagnostic testing
is necessary before initiating empirical therapy for symptomatic relief. Recent
studies suggest that proton pump inhibitors are the preferred form of medical
therapy. In addition to symptomatic relief of heartburn, they heal esophageal
mucosal injury and reduce the need for frequent dilatation in patients with
peptic stricture. Grades III and IV according to the Savary-Miller classification
of mucosal injury (C and D according to the Los Angeles criteria of erosive
esophagitis) usually do not heal without the use of PPIs. Furthermore, at least
for heartburn relief, not all the PPIs have the same therapeutic benefits on
a mg-to-mg basis, hence knowing your PPIs becomes very important especially
in this managed care era.
Occasionally, as in chest pain,
chronic cough, asthma or dyspepsia due to GERD, therapeutic trials of PPIs
may be our only diagnostic as well as therapeutic tool.
Unfortunately, if treatment is stopped symptoms will return. As for mucosal injury there
is an 80% recurrence within six months of stopping PPI therapy. Since the
basic mechanism of injury is reflux of acid gastric contents in to the esophagus
via an incompetent lower esophageal sphincter (LES), continuous long-term
medical treatment or surgical repair of the sphincter mechanism is recommended
in severe cases.
Laparoscopic Nissen's Fundoplication must be reserved for patients that are surgical candidates
and have responded favorably to the therapeutic dose of PPIs for their given
information about GERD, refer to "Improving
Diagnostic Accuracy of Upper GI Endoscopy in Patients with GERD". This
body of clinical research was carried out in Caritas Norwood Hospital during
1993, parts of which were presented during the Digestive Disease Week (DDW)
conference (San Diego, 1995) before the American Society of Gastrointestinal
Endoscopy (ASGE). You can also view selected slides pertaining to this research: Selected
you Need to Know about PPIs (i.e. Prilosec)
for Endoscopy in GERD
Reflux Laryngitis (Posterior)
Reflux Esophagitis (Modified Savary-Miller)
Angeles Classification of Esophagitis
Esophagitis (Chronic Acid and/or Alkaline Esophagitis)
of TT, BZT, PH
of Barrett's Esophagitis
Dysplasia & Invasive Adenocarcinoma in Barrett's
Surveillance in Patients with Barrett's Esophagus
Epidemiology: Adenocarcinoma of the Esophagus
link between H.
pylori eradication & GERD
GERD Treatment in Infants & Children