Hard Core CME GERD

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Hard Core CMEGERD

• Robert A.Solomon M.D.
• LTC, USAR
• Montgomery Family Practice Residency Program
• Norristown, PA

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GERD Objectives

• Cost effective treatment
• Complications of GERD
• Beyond medications

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GERD

• Symptoms or mucosal damage produced by the
  abnormal reflux of gastric contents into the
  esophagus
• American College of Gastroenterology

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GERD
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GERD
Only 2-3 of acid reflux events reach the level
of perception by the patient
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GERD statistics

• Monthly GERD symptoms- 44 or 61 million
  Americans
• Weekly GERD symptoms- 14
• Daily GERD symptoms- 7

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GERD etiology
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GERD Diagnosis

• Symptoms
• Heartburn (pyrosis)
• Regurgitation-especially after large meal
• Aggravated by recumbency/bending over
• Relieved with antacids
• Difficult cases
• 24 hr pH monitoring

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Atypical GERD Presentations

• Asthma
• Chest pain
• Chronic cough
• Recurrent laryngitis
• Recurrent sore throat
• Globus sensation

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GERD Alarm Symptoms

• Dysphagia
• Early satiety
• GI bleeding
• Iron deficiency anemia
• Odynophagia
• Vomiting
• Weight loss

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GERD-Etiology of Complications
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GERD Complications
Esophagitis
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GERD-Etiology of Complications
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GERD-Barretts Esophagus
Barretts esophagus
Normal endoscopy
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Barretts Esophagus

• Progression to adenocarcinoma of esophagus
• 0.2-2 annual incidence of CA in Barretts
• Aggressive acid suppression (high dose PPI) may
  not lead to regression in transformation to
  malignancy
• Surveillance endoscopy- looking for
  dysplasia-intervals are controversial

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Esophageal Stricture
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Esophageal Stricture
Stricture Balloon
Post dilation
Balloon dilator
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Complications of GERD

• Reflux induced asthma
• Laryngeal and tracheal stenosis
• Laryngeal cancer

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Treatment of GERD

• Lifestyle modifications
• Antacids
• Histamine-2 receptor antagonists
• Proton pump inhibitors
• Anti-reflux surgery
• Endoscopic treatment

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GERD-Lifestyle Modifications

• Elevate head of bed
• Decrease fat intake
• Stop smoking
• Avoid lying down 3 hrs post prandially
• Avoid chocolate, alcohol, peppermint, coffee,
  ?onions/garlic all lower LES pressure

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GERD-Antacids

• Good for milder forms of GERD
• Gaviscon-antacid/alginic acid may be superior to
  antacid alone

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GERD H2 Blockers

• Multiple trials showed faster healing vs. placebo
  of erosive esophagitis
• Four available-cimetidine (Tagamet),famotidine
  (Pepcid), nizatidine (Axid), ranitidine
  (Zantac)-all equally effective
• Side effects-drug interactions with cimetidine,
  confusion in elderly,rare cytopenias, elevated
  LFTs, gynecomastia

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GERD- PPIs

• Proton pump inhibitors provide the most rapid
  symptomatic relief
• Five available-esomeprazole (Nexium),
  lansoprazole (Prevacid), omeprazole (Prilosec),
  pantoprazole (Protonix), rabeprazole (Aciphex)
• All are generally equal

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GERD- PPIs

• Administer prior to meals
• Side effects-headache, diarrhea, abdominal pain
• Long term safety
• ?gastric atrophy
• ?impaired B12 absorption
• ?increase in community acquired pneumonia
• ?decreased absorption of calcium-
• osteoporosis

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Suggested algorithm for treatment of GERD
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GERD-Beyond Meds

• Antireflux surgery
• Endoscopic treatment

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Refractory GERD

• Failed medical management
• Patient preference for surgery despite successful
  medical management
• Complications of GERD

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GERD-Antireflux Surgery

• Nissen fundoplication
• complete (360 degree) wrap of stomach
• around esophagus
• Toupet fundoplication
• partial (270 degree) wrap of stomach
• around esophagus

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GERD-Endoscopic Therapy

• Stretta-radiofrequency
• Endocinch-endoscopic sewing
• Full thickness plication
• Enteryx-Injection of a nonresorbable polymer

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Endocinch
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Enteryx-Polymer injection
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GERD
Only 2-3 of acid reflux events reach the level
of perception by the patient
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GERD-Summary

• Cost effective treatment
• Complications of GERD
• Newer treatments beyond meds

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References

• 1.Devault KR, Castell DO. Updated Guidelines for
  the Diagnosis and Treatment of Gastroesophageal
  Reflux Disease. Am J Gastroenterology
  2005100190-200
• 2.Heidelbaugh JJ,Nostrant TT et al. Management of
  Gastroesophageal Reflux Disease. Am Fam Physician
  2003681311-16
• 3.Richter JE, Bradley LC.Psychophysiological
  interactions in esophageal diseases. Semin
  Gatrointest Dis 19957169-84
• 4.DaCosta LR. Value of a therapeutic trial to
  diagnose gastroesophageal reflux diseasestep up
  versus step down therapy. Can J Gastroenter
  199711(suppl B)788-818
• 5.Van Pinxteren B, Numans ME et al. Short term
  treatment with proton pump inhibitors,H2-receptor
  antagonists and prokinetics for gastroesophageal
  reflux disease-like symptoms and endoscopy
  negative reflux disease. Cochrane Database Syst
  Rev 2001(4)CDO02095
• 6.Inadomi JM, Jamal R et al. Step-down management
  of gastroesophageal reflux disease.
  Gastroenterology 20011211095-100
• 7.Up to Date On Line
• 8.Society of American Gastrointestinal Endoscopic
  Surgeons website- SAGES.org