GERD | Clinical Medicine

Summary

This video educates viewers on Gastroesophageal Reflux Disease (GERD), detailing its causes, symptoms like heartburn and dyspepsia, and complications such as esophagitis and cancer. It explores diagnostic methods, including PPI trials and EGD, and treatment options from lifestyle changes to medications like PPIs and H2 blockers. The video also stresses the importance of monitoring GERD patients for potential cancer risk.

Takeaways

• 🔥 Gastroesophageal reflux disease (GERD) is a condition where stomach acid flows back into the esophagus, causing discomfort.
• 🔑 Common symptoms of GERD include heartburn and dyspepsia, which can manifest as burning chest pain and upper abdominal pain.
• 🚨 Complications of GERD can range from esophagitis and strictures to aspiration, which can lead to laryngitis, worsening asthma, and even cancer.
• 🌡 The process of metaplasia is when squamous cells in the esophagus transform into columnar cells due to prolonged exposure to stomach acid.
• 🔬 Dysplasia is the term for the transformation of columnar cells into neoplastic cells, which can be a precursor to esophageal cancer.
• 🛑 Causes of GERD include a low lower esophageal sphincter tone, hiatal hernias, increased hydrochloric acid production, and high intragastric pressure.
• 🚭 Lifestyle factors like smoking, alcohol, and caffeine can decrease lower esophageal sphincter tone and exacerbate GERD.
• 🏥 GERD is often diagnosed clinically, but an ECG may be needed to rule out heart issues if chest pain is present.
• 💊 Treatment for GERD typically involves medications like proton pump inhibitors (PPIs) or H2 blockers to reduce stomach acid production.
• ✂️ In severe cases, a Nissen fundoplication surgery may be necessary to reinforce the lower esophageal sphincter and prevent acid reflux.
• 🔄 Regular endoscopic surveillance is crucial for GERD patients, especially if dysplasia is detected, to monitor for potential cancer development.

Q & A

What is Gastroesophageal Reflux Disease (GERD)?

GERD, also known as GORD, is a condition where stomach acid frequently flows back into the esophagus, causing heartburn and other potential complications.

What are the common symptoms of GERD?

Common symptoms of GERD include heartburn, dyspepsia (epigastric pain), and a burning sensation in the chest that often occurs after eating.

What is the main cause of GERD?

The main cause of GERD is the reflux of hydrochloric acid from the stomach into the esophagus, which can be due to a low lower esophageal sphincter tone, a hiatal hernia, increased hydrochloric acid production, or high intragastric pressure.

What is the relationship between GERD and esophagitis?

GERD can lead to esophagitis, which is the inflammation of the esophagus caused by the irritation from stomach acid.

How can a hiatal hernia contribute to GERD?

A hiatal hernia occurs when the upper part of the stomach pushes into the diaphragm, causing the lower esophageal sphincter to be above its normal position, which can lead to acid reflux.

What are some complications associated with GERD?

Complications of GERD can include esophagitis, stricture formation, aspiration, laryngitis, worsening asthma, GI bleeding, and an increased risk of esophageal cancer.

What is the process of cells changing from squamous to columnar called?

The process of cells changing from squamous to columnar is called metaplasia.

How can lifestyle factors affect GERD?

Lifestyle factors such as smoking, drinking alcohol, and consuming caffeine can lower the lower esophageal sphincter tone, increase hydrochloric acid production, or raise intragastric pressure, contributing to GERD.

What is the diagnostic approach for GERD?

The diagnostic approach for GERD often begins with an empiric trial of a proton pump inhibitor (PPI) to see if symptoms improve. If there are alarm symptoms, an EGD with biopsy may be performed. Esophageal manometry and pH monitoring may also be used to confirm the diagnosis.

How is GERD typically treated?

Treatment for GERD typically involves suppressing hydrochloric acid production with medications like proton pump inhibitors (PPIs) or H2 receptor antagonists. Lifestyle modifications and sometimes surgical intervention, such as a Nissen fundoplication, may also be necessary.

Outlines

00:00

🔍 Introduction to Gastroesophageal Reflux Disease (GERD)

The speaker begins the lecture by introducing the topic of Gastroesophageal Reflux Disease (GERD), also known as GIRD. They encourage viewers to check the description for additional resources like notes and illustrations to aid in understanding the lecture. The speaker then delves into the basic concept of GERD, explaining how stomach acid can reflux into the esophagus, causing discomfort and potentially serious health issues. Symptoms such as heartburn and dyspepsia are discussed, along with the more severe complications that can arise from chronic GERD, including esophagitis, stricture formation, and the increased risk of esophageal cancer due to the metaplastic changes in esophageal cells caused by constant exposure to stomach acid.

05:03

📚 Understanding the Progression and Causes of GERD

This section further explores the progression of GERD from normal esophageal cells to columnar cells through a process called metaplasia, and then potentially to neoplastic cells through dysplasia. The speaker emphasizes the importance of recognizing the stages of disease progression, which can lead to conditions like Barrett's esophagus and adenocarcinoma. The lecture then moves on to discuss the various causes of GERD, including a low lower esophageal sphincter tone, hiatal hernias, increased hydrochloric acid production, and high intra-gastric pressure. The speaker also explains how certain medications can help manage GERD by inhibiting acid production or blocking the histamine 2 receptors, which can stimulate acid secretion.

10:03

🚭 Lifestyle Factors and Conditions That Exacerbate GERD

The speaker identifies and explains the factors that can decrease lower esophageal sphincter tone, such as smoking, alcohol consumption, and caffeine intake. They also discuss the role of hiatal hernias in GERD, particularly sliding hernias, and how conditions like pregnancy, obesity, large meals, and gastroparesis can increase intra-gastric pressure, contributing to the disease. The lecture highlights the importance of understanding these factors to manage GERD effectively, including the role of certain medical conditions like Zollinger-Ellison syndrome, which can increase hydrochloric acid production.

15:05

🩺 Diagnostic Approach and Treatment Options for GERD

This part of the lecture covers the diagnostic approach to GERD, emphasizing the importance of differentiating GERD from other conditions like acute coronary syndrome, especially when patients present with chest pain. The speaker suggests an empiric proton pump inhibitor (PPI) trial as a diagnostic tool and outlines the steps to take if symptoms do not improve, including looking for alarm symptoms that might indicate more severe complications. The lecture also touches on additional diagnostic tools like esophageal manometry and pH monitoring. The speaker discusses the treatment of GERD, focusing on the suppression of hydrochloric acid production through the use of PPIs or H2 receptor antagonists, and the importance of addressing underlying causes like weight loss in obese patients.

20:06

🛑 Surgical Intervention and Cancer Surveillance in GERD

The final section of the lecture discusses surgical options for patients with refractory GERD, such as Nissen fundoplication, which aims to reinforce the lower esophageal sphincter and prevent acid reflux. The speaker also stresses the importance of cancer surveillance in GERD patients, especially those with chronic disease or alarm symptoms, advocating for regular endoscopies to check for dysplasia and take prompt action if needed. The lecture concludes with a summary of the key points and a reminder of the importance of understanding and managing GERD to prevent serious complications.

Keywords

💡Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease, or GERD, is a chronic condition where stomach acid frequently flows back into the esophagus, causing irritation and damage. In the video, GERD is described as a 'basic concept' where 'nasty stuff' like hydrochloric acid moves from the stomach into the esophagus, leading to discomfort and potential complications. It's the central theme of the video, with various discussions revolving around its causes, symptoms, and treatments.

💡Hydrochloric Acid

Hydrochloric acid is a key component of the stomach's digestive juices. In the context of the video, it is highlighted as the 'nasty stuff' that, when refluxed into the esophagus, can cause significant discomfort and damage. The video mentions that an increase in hydrochloric acid production can exacerbate GERD symptoms.

💡Heartburn

Heartburn is a common symptom of GERD characterized by a burning sensation in the chest, often after eating. The video uses heartburn as a primary example of how GERD can affect individuals, describing it as a 'common sensation' that can occur post meals and be particularly bothersome when lying down.

💡Dyspepsia

Dyspepsia, also known as indigestion, is another symptom of GERD that the video discusses. It is described as a 'burning pain' in the epigastric region. The script mentions dyspepsia as a 'very common manifestation' of GERD, indicating its prevalence in those suffering from acid reflux.

💡Esophagitis

Esophagitis refers to the inflammation of the esophagus, which can be a complication of GERD. The video describes how the constant reflux of hydrochloric acid can 'really inflame the esophagus and start ulcerating it,' leading to esophagitis. It is an example of how untreated GERD can progress to more serious conditions.

💡Stricture

A stricture is a narrowing of the esophagus that can occur due to chronic inflammation from GERD. The video explains that repeated inflammation can cause a 'fibrotic reaction' leading to stricture formation. This term is used to illustrate a potential long-term complication of GERD if left untreated.

💡Aspiration

Aspiration in the context of GERD refers to the accidental inhalation of stomach contents, including acid, into the airways. The video describes this as a 'very interesting' complication where the refluxed contents can 'move its way into the airway,' potentially leading to conditions like laryngitis and worsening asthma.

💡Metaplasia

Metaplasia is a process where cells change from one type to another in response to chronic irritation, such as from GERD. The video script explains that normal squamous cells of the esophagus can transform into columnar cells due to constant exposure to hydrochloric acid, a process termed 'metaplasia.' This is a critical step towards the development of Barrett's esophagus.

💡Dysplasia

Dysplasia is a term used to describe abnormal cell changes that can be a precursor to cancer. In the video, dysplasia is mentioned as a progression from metaplasia where columnar cells can transform into neoplastic cells. This is a significant point in the discussion about the potential for GERD to escalate to esophageal cancer.

💡Proton Pump Inhibitors (PPIs)

Proton Pump Inhibitors are a class of medications used to reduce the production of stomach acid. The video discusses PPIs as a first-line treatment for GERD, mentioning how they 'suppress the hydrochloric acid production' and are used to manage symptoms and prevent complications. Examples given include omeprazole and lansoprazole.

💡Empiric PPI Trial

An empiric PPI trial is a diagnostic approach where a patient suspected of having GERD is given a PPI to see if their symptoms improve. The video describes this as a method to 'initiate' a treatment and observe if the reduction in acid production alleviates heartburn, which would suggest GERD as the cause.

Highlights

Gastroesophageal reflux disease (GERD) involves stomach acid refluxing into the esophagus, causing issues like heartburn and dyspepsia.

The downside of acid reflux is the potential for damage to the esophagus, leading to conditions like esophagitis and strictures.

Acid reflux can also cause aspiration, leading to issues like laryngitis and worsening asthma.

Chronic GERD can increase the risk of esophageal cancer due to the constant inflammation.

The process of cells adapting from squamous to columnar cells is called metaplasia.

Dysplasia is the term for the transformation of columnar cells into neoplastic cells in the esophagus.

The progression from metaplasia to dysplasia can lead to conditions like Barrett's esophagus and adenocarcinoma.

Four main reasons for GERD include low lower esophageal sphincter tone, hiatal hernia, increased hydrochloric acid production, and high intragastric pressure.

Smoking, alcohol, and caffeine can decrease lower esophageal sphincter tone, contributing to GERD.

A sliding hernia is a common type of hiatal hernia associated with GERD.

Increased intragastric pressure can be caused by pregnancy, obesity, large meals, and gastroparesis.

Certain conditions like Zollinger-Ellison syndrome can increase hydrochloric acid production, exacerbating GERD.

GERD is generally diagnosed clinically, often starting with an empiric proton pump inhibitor (PPI) trial.

Alarm symptoms like dysphagia, vomiting, anemia, and weight loss may indicate severe complications and require further investigation.

Esophageal manometry and pH monitoring can help diagnose GERD when other tests are inconclusive.

Treatment for GERD involves suppressing hydrochloric acid production, often with PPIs for severe cases and H2 blockers for milder cases.

Fundoplication surgery may be necessary for refractory GERD that does not respond to medical therapy.

Regular endoscopic surveillance is important for GERD patients, especially if there is any dysplasia present.

Transcripts

what's up Ninja nerds in this video

today we're going to be talking about

gastrosoph agile reflux disease also

known as gird what I want you guys to do

before we get started on this video I

want you guys to take a second go down

the description box below we got links

to our website where it'll be a lot of

awesome notes and illustrations that I

think will be super critical for you

guys to follow along with me during this

lecture also if you guys benefit from

this lecture please support us by

hitting that like button commenting down

in the comment section and please

subscribe all right let's start talking

about gastral reflux disease so gird is

this basic concept it's super super

basic in which things like nasty stuff

like hydrochloric acid contents from the

stomach unfortunately will just decide

to move its way upwards into the

esophagus now when that happens what's

the downside of that what's the actual

problematic issue with this actual

hydrochloric acid getting into the

esophagus well if we zoom in here what

you'll notice is that this acid

substance within the actual esophagus

can cause a lot of problems one of these

things is it can lead to just common

sensation such as heartburn and this may

manifest if you will with this Burning

retro sternal chest pain that usually

occurs after meals and it's really bad

when you lay

supine sometimes because the esophagus

is not just here within the chest but it

can actually come down here just to the

epigastric level you may even have epep

gastric pain we call this dyspepsia it's

that burning pain that you may have

right here in the epigastrium so two

very common manifestations is going to

be heartburn and

dyspepsia this is super critical and the

reason why is because this hydrochloric

acid is going to be coming up into the

esophagus causing a lot of burning and

inflammation now the question I have for

you guys is what are some of the

complications that are associated with

gastr Solage or reflux disease so the

basic concept is hydrochloric acid is

coming up into the esophagus it's

ripping it up causing heartburn

dyspepsia but it can also do a lot of

other things like what it can really

inflame the esophagus and start

ulcerating it and this can lead to

esophagitis additionally with the

esophagitis sometimes patients can come

in presenting with like things like

oasia like a lot of pain with swallowing

that's one common thing the other

problem here is that as you kind of

cause this constant inflammation over

time if this esophagus is being inflamed

and inflamed and inflamed it'll then

undergo a fibrotic reaction to heal but

it'll narrow the actual Lumin of the

esophagus and this can lead to stricture

formation another potential complication

associated with this gastro Solage or

reflux disease is that sometimes this is

very very interesting with this

hydrochloric acid not only can It

inflame the Esopus lead to strictures

but sometimes the actual contents can

move its way into the airway

and this could lead to features of a lot

of what's called kind of a reflux or an

aspiration type of event so you want to

watch out for

aspiration now the problems with this

very quickly is if you aspirate some of

this Hydrochloric contents into the

larynx it can cause laryngitis what's a

common manifestation of that voice

changes if it goes into the bronchos it

can inflame the bronchos and lead to

inflammation of the bronchos what could

that worsen asthma so the other ways

that I want you to think about gird

presenting is not just with esophagitis

or strictures but aspiration that can

lead to heness larynx and worsening

Asthma bronchial inflammation boom

roasted what's another potential

complication you know if you erode and

ulcerate the esophagus there's blood

vessels that are lining that you can

erode into the actual blood vessel and

lead to bleeding so you want to watch

out for GI

bleeding ways that GI beds can present

is this can have a patient who presents

with like a lot of maybe anemia right so

maybe it's an actual uh a lab finding or

they can present with a lot of fatigue

that's another particular thing the last

and scariest complication of gastrosoph

reflux disease over chronic and chronic

and chronic inflammation is you increase

the risk of what's called esophageal

cancer with that being said one of the

very interesting Concepts here that we

have to dig into just quickly for the

pathophysiology is whenever you look at

normal cells of the esophagus it's

actually stratified squamous so it's

stratified squamous so here we'll

actually write on the side here this

should be squamous

cells but whenever you expose the actual

Squam cells over a long period of time

to a lot of hydrochloric

acid this will cause the cells to have

to adapt when the cells have to adapt

they undergo something called

metaplasia so whenever they adapt they

change into a different type of cell and

this is going to be called columnar

cells

this process where they go from squamous

to columnar you know what that's called

This is called metaplasia let's actually

write that here this process here is

called

metaplasia all right beautiful so going

from the Squam cells to the columnar

cells is called metaplasia but then if

you continue and continue to cause more

erosive damage more inflammation you can

turn these columnar cells into

neoplastic cells so you can turn these

into to neoplastic cells let's stick

with our color here which we did was

blue so again this is our neoplastic

cells so this here going from columnar

cells to neoplastic cells is called

dysplasia so one of the biggest things

to understand here is with this

metaplasia aspect that's really a very

specific type of intermediate so I want

you guys to understand kind of the

progression here is that the progression

of this disease is you have something

called

barrettes and then over time this baret

will then progress to what's called

adino

carcinoma so this is the metaplasia this

is the dysplasia so this is the concept

that I want you guys to understand okay

now let's go and let's talk about the

different causes of Girt all right my

friends so gastrosoph reflux disease

heartburn dyspepsia from the reflux of

the hydrochloric acid we know the

complications associated with it

esophagitis strictures aspiration we

also know that you can have gi bleeds

and we know that you can have a Soph

cancer the question that you have to ask

yourself is why is the hydrochloric acid

going up into the esophagus as much it

is as it is causing these

complications there's four particular

reasons one of the reasons is that this

part here this is a problematic area for

us this area here is called the lower

esophagal sphincter it's supposed to be

nice and tight and prevent things like

Hydrochloric hydrochloric acid from

going up into the esophagus what if the

tone is really low that's one particular

mechanism so a low lower esophageal

sphincter

tone another particular mechanism that

can cause this is that there is a defect

somewhere here so you know the esophagus

is supposed to go up through this little

area here called the esophageal Hiatus

but in certain patients they have a

defect within that Junction and it

slides upwards and if it slides upwards

above the actual esophageal Hiatus this

is a very significant problem for gird

you know what that's called where parts

of the esophagus slides up above the

esophagal hatus this is called a hiatal

hernia remember that hiatal

hernia Okay the third particular problem

here is that the hydrochloric acid that

you're producing by the stomach is much

more so if you have hydrochloric acid

going up into the Esopus it's going to

burn it but what if you had a lot more

hydrochloric acid you're likely going to

cause more symptoms the more

hydrochloric acid the more severe the

actual gird can be so another particular

problem here is that we have cells of

the stomach that is just banging out

hydrochloric acid that's another

particular mechanism is increased

hydrochloric acid

production all right let me take you

through a quick mechanism here of why

this is a problem and how we can

actually treat this so here we have a

couple parietal cells you know parietal

cells are cells that make hydrochloric

acid there's a couple ways that they do

this one way that they do this is they

use these kind of like proton potassium

ATP Aces to push out things like

potassium and pro I'm sorry push out

things like protons and these protons

are what make the hydrochloric acid

contents super super acidic so there's

one thing that's the proton pumps but

you also have little receptors here on

these cells that tell them to actually

stimulate and increase the production of

hydrochloric acid you know what these

are these are histamine 2 receptors so

what are these particular receptors here

these guys here are

called histamine 2

receptors

when these receptors are stimulated they

increase they increase the hydrochloric

acid production and this is super

important because you know when we talk

about pharmacology if we give drugs that

block this proton pump like proton pump

inhibitors you would decrease the

hydrochloric acid production if we give

drugs that block the histamine from

binding to the H2 receptors you would

block hydrochloric acid production

that'll come into play when we talk

about the actual pharmacology okay the

last particular mechanism here is that

you have a very high inter gastric

pressure imagine the pressure in your

stomach is higher than the pressure

within your esophagus where are things

going to want to go from high pressure

to low pressure things will decompress

into the esophagus so that's the last

particular problem here is you're going

to have a patient who has very high

intragastric

pressure all right so out of all of this

these are the four reasons why the

patient would develop a very nasty G

gastrosoph reflux disease what I want to

do is I want to quickly talk about what

are the things that decrease the lower

Sagel sphincter tone what are the actual

basic type of hiatal hernia that is

really really highly associated with

gird what increases hydrochloric acid

production and what increases inter

gastric pressure so let's come down here

and let's go through these and let's

write them all down because again I

think this will help you with the

repetition first one decrease the lower

esophagal sphincter

tone next one is you have AAL

Heria

third one is you have high in gastric

pressure and the fourth mechanism is you

have increased hydrochloric acid

production okay we have to now say what

is the reasons why you have a low

esophagal sphincter tone one of these is

because the patient is smoking drinking

alcohol or they're just consuming tons

and tons of caffeine these are very very

common triggers so I want you to

remember these particular

causes all right so again smoking

alcohol caffeine are triggers that lower

the esophagal fter tone all right H

hernias what is the most common type

associated with gird I want you to

remember sliding hernas sliding

hernas the next thing I want you to

remember is what are the things that can

increase the intragastric pressure

causing it to decompress the contents

into the esophagus pregnancy

obesity as well as very large meals and

one other disease called

gastroparesis so again pregnancy obesity

very large meals gastroparesis which is

a disease associated with diabetes it's

where the nerves of the actual stomach

aren't actually working properly so the

stomach can't contract if you can't

contract can you empty things into the

actual duodenum no so all the stomach

does is distend distend distend pressure

Rises can decompress into the actual

esophagus the last one here is you

increase hydrochloric acid production

the big things are things like ineds

alcohol smoking and a rare rare disease

called Zinger Ellison

syndrome okay again ineds alcohol

smoking zeling or Ellison syndrome which

is a rare disorder where you're actually

have a tumor like a pancreatic tumor

that pumps out gastrin you know what

gastrin does a hydrochloric acid

production cranks it up all right so

these are the mechanisms behind

gastrosoph reflux disease now let's dig

into the diagnostic approach all right

so gird heartburn we know the particular

three pathophysiological processes

intragastric pressure GE AB uh gastral

Junction abnormality or reduced lower

solal sphincter tone we know the three

complications that they can present with

how do we diagnose this well gir's

generally a clinical diagnosis but I

think it's important to remember that

often times they'll present with

heartburn and so heartburn kind of

present sometimes presents like chest

pain and here's the other thing

sometimes patients who present with

heartburn or maybe even a little bit of

like epigastric abdominal pain dyspepsia

we don't want to miss an inferior mind

and so you should always in any

complaint of chest pain obtain an ECG

and depending upon the ECG results get

your opponents if you see any evidence

of St elevation reciprocal change es and

positive tronin this is not gird this is

potentially an acute coronary syndrome

and you should completely change your

diagnostic approach here but if it comes

back normal and there is no evidence of

any true changes such as troponin

elevation no ST depression t-wave

inversions or elevations then I'm

starting to think it could be more gird

related so how do I do this it's more of

just you try a treatment and see if it

improves it what I do is I would

initiate an empiric PPI trial I'll give

them a proton pump inhibitor that'll

suppress the hydrochloric acid

production in the stomach and if that

happens I'll reduce the hydrochloric

acid moving into the esophagus and

causing the heartburn sensation and

complications do they get better if they

do it's probably gir if they don't then

you can't completely exclude that it's

not gir so then what else could we do if

maybe their symptoms are not

significantly better with the PPI then I

really want to start asking myself the

question is there any severe

complications am I missing something so

I look for alarm symptoms is there

dysphasia because that could identify a

strcture is there vomiting that could

identify a stricture is there anemia

this could be indicative of a GI bleed

or sometimes even cancer and is there

weight loss this could be indicative of

a stricture or cancer if I have any of

these alarm symptoms I have to get an

EGD with a

biopsy the reason why is gird can lead

to potential complications and I want to

see is this just esophagitis from from

the reflux or does this look really bad

and I got some really bad like reflux

like related structures

here and then worst case scenario is is

there cancer and so sometimes this may

lead you to kind of find potential

complications related to the gird I

think one of the big things though is if

a patient has a normal EGD they have not

improved with the empiric PPI trial then

I think the next thing that you could

potentially do is say let me just rule

out any other type of esophageal dis

order so I'm going to get esophagal

manometry and if I do that I can rule

out an esophagal motility disorder

because if all they have is their lower

Sagal sphincter tone is reduced but all

the other mid distal kind of tone is

normal it's likely gir and if that's the

case I've ruled out any other Sage Gil

motility

disorder the other thing that I can do

is I can get pH monitoring this is where

I take kind of a little U it's kind of

like a pH sensor goes through the nose

down into the esophagus and it has

different pH sensors at each different

point here of the esophagus what happens

is in a patient who has very bad gird

hydrochloric acid will move up into the

esophagus and it'll trigger this pH

sensor so the amount of times that this

pH sensor picks up that the pH is lower

than it's supposed to be it'll trigger a

triggering of the score activation and

what happens is this will lead to the

act the calculation of something called

a demer score and the demer score

greater than 14.7 how they came up with

that I'm not sure really helps me to

identify that this sensor was picking up

drops and pH pretty frequently and it

really adds to the diagnosis of gird so

that's how I would go about it empiric

PPI trial they improve it's gir if they

have alarm symptoms get an EG with

biopsy if that's normal but they're

still not better with the PPI trial rule

out that it's not an esophagal motility

disorder and then from there try and do

the actual pH monitoring to definitely

see if they have the evidence of

gird now we've identified gird how do we

treat it it's really pretty

straightforward we got to suppress

hydrochloric acid production because

that's the Crux of it all obviously it's

about treating the underlying causes so

in obesity what should you do lose

weight in patients who have some type of

uh maybe trigger such as caffeine reduce

your caffeine if you're smoking stop

smoking if you drink alcohol reduce your

alcohol intake these are things that

potentially can be

reversed but otherwise it should always

start with trying to suppress the

hydrochloric acid production in patients

with severe gird so really bad heartburn

maybe on top of that they have atypical

findings like cough laryngitis worsening

of their asthma and maybe they even have

a gird complication maybe they have

reflux of esophagitis maybe they have

strictures maybe on top of that they've

had GI bleeds or maybe they have some

type of barit esophagus you need to get

them on a PPI right away and keep that

going going for at least 8 weeks and

then reevaluate if I can actually step

down on that PPI ppis work by kind of

suppressing hydrochloric acid production

right so they block these hydrogen

proton ATP channels reduce hydrochloric

acid secretion that reduces a lot of the

gird and complications associated with

gird now if the patient has mild gird

they just have some mild heartburn they

have no evidence of any complications no

esophagitis no strictures no barretts

nothing to that effect I think h 2as are

a little bit more appropriate the reason

why is ppis they can interfere with

other drugs and reduce the actual

bioavailability of those drugs because

they can interact with the cytochrome

p450 complex and on top of that it

actually has been associated with like

electrolyte abnormalities such as

hypomagnesemia and CI so it's important

to remember that and so sometimes h2ras

are just a little bit more safe and not

as having as many complications so this

would be things like foden that's a very

common one renadine whereas pprs are

things like ome prol pentool Lano prasol

so how does an H2 work it's the same

concept it's going to suppress the

actual histamine response at the

receptor site histamine actually helps

to stimulate hydrochloric acid

production so if I give them this it'll

block the actual histamine at that

receptor reduce the hydrochloric acid

secretion and reduce gird and the any

for formation of any complications of

that sense often times when patients

come in if they have severe gird and

gird complic put them on a PPI for 8

weeks review to see if they're getting

any better and see if you can step down

to an

H2 if they can't then maybe you have to

go back to the lowest dose of the PPI

that they were on where they were

completely controlled if they're on an

H2 and they develop any worsening gird

or G complications then you have to upti

trate them to a

PPI let's say that you've had them on

Max PPI and they're still not getting

any better they're still having very bad

gird they're having gird related

complications then you need to go to

What's called a Nance fundoplication so

what that is is you're going to

basically take a part of the fundus and

you're going to you're basically going

to help to reinforce the lower sofel

sphincter so you're going to take the

fundus and literally wrap this sucker

around the lower sofro sphincter and

tighten that area up and so look at this

thing I took the fundus wrapped it

around it and then I sued it tight and

now I have a very very tight lower Sagel

sphincter which will reduce into the

hydrochloric acid leaking back up into

the esophagus reducing the gird related

complications so that'd be a niss

application if they have refractory gird

that's not responsive to Medical therapy

and then also Improvement or at least

treating of their underlying

cause last thing is gird has a very high

risk of cancer especially if it's

chronic so you need to survey these

patients if they have any alarm symptoms

such as vomiting they have dysphasia

they have anemia they have weight loss

you really should be doing an EGD if

they have no dysplasia on an EGD then

you should at least check it every 3 to

5 years but if they do have any evidence

of dysplasia you want to catch it right

then and there and ablate that area of

cancer or resect that area of cancer and

that's something that we'll talk about a

little bit more when we talk about

esophageal cancer in the actual oncology

section all right my friends that covers

gird I hope that made sense I hope that

you guys enjoyed it and as always until

next

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time

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