GERD and its supraesophageal or extraesophageal manafestations

1
GERD and itssupraesophageal or extraesophageal
manafestations

• Yousif A. Qari
• Ass.prof,Consultant Gastroenterologist KAUH

2
What is GERD

• A condition that occurs when the lower esophageal
  sphincter (LES) does not close properly and
  stomach contents leak back, or reflux, into the
  esophagus.
• The LES is a ring of muscle at the bottom of the
  esophagus that acts like a valve between the
  esophagus and stomach.

3
Prevalence of GERD

• Approximately 20 of adults have frequent
  "classic" symptoms of gastroesophageal reflux
  (GER)
• Heartburn
• Regurgitation.

4
What causes GERD?

• No one knows why people get GERD.
• A hiatal hernia may contribute.

5
Other factors that may contribute to GERD

• Alcohol use
• Overweight
• Pregnancy
• Smoking

6
Certain foods can be associated with reflux
events

• Citrus fruits
• Chocolate
• Drinks with caffeine
• Fatty and fried foods
• Garlic and onions
• Mint flavorings
• Spicy foods
• Tomato-based foods, like spaghetti sauce, chili,
  and pizza

7
What are the symptoms of GERD

• Persistent heartburn and acid regurgitation.
• Belching
• Waterbrash (sudden excess of saliva)
• Sour taste in the mouth
• Food stuck in throat
• Difficulty or pain when swallowing
• Chest pain
• Hoarseness
• Choking or throat tightness.
• Chronic sore throat
• Dry cough
• Bad breath
• Inflammation of the gums
• Erosion of tooth enamel (the surface of the teeth)

8
How is GERD diagnosed?

• Review of symptoms and a complete physical
  examination, with Special attention to alarming
  symptoms.
• Duration severity of symptoms
• Anemia
• Dysphagia (Difficulty in swollowing)
• Weight loss

9
Diagnosis of supraesophageal Reflux

• Heartburn and regurgitation
• many of these patients fail to demonstrate
  the typical symptoms of heartburn and
  regurgitation
• The response of symptoms to an empirical trial of
  antireflux therapy
• Ambulatory, esophageal pH monitoring
• Upper gastrointestinal endoscopy
• Most do not have esophagitis when looked at
  endoscopically.

10
A normal upper esophagoscopy
11
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis

• GRADE A
• One or more mucosal breaks no longer than 5
  mm, non of which extends between the tops of the
  mucosal folds

12
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis

• GRADE B
• One or more mucosal breaks more than 5 mm
  long, none of which extends between the tops of
  two mucosal folds

13
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis

• GRADE C
• Mucosal breaks that extend between the tops of
  two or more mucosal folds, but which involve less
  than 75 of the oesophageal circumference

14
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis

• GRADE D
• Mucosal breaks which involve at least 75 of
  the oesophageal circumference

15
Endoscopic view of GERD complications
16
(No Transcript)
17
Limitations of esophsgeal pH monitoring

• Not accepted by patients easily
• Optimal site of probe placement (ie, pharyngeal
  vs upper esophageal)
• What is a normal vs abnormal amount of acid
  reflux.
• False-negatives may occur
• A positive test does not prove a causative
  relationship to the symptoms
• Normal pH testing in the upper and lower
  esophagus is strong evidence against acid-related
  symptoms
• Nonacidic reflux may also play a pathophysiologic
  role in the symptoms of some patients (which may
  only resolve with fundoplication

18
Catheter-Free pH-Monitoring System

• BRAVO Catheter-Free ph Testing
• Bravo can be placed during endoscopy
• Allows 24-hour or 48-hour pH monitoring to record
  more clinical data
• Patients maintain normal diet and routine
  activities
• Minimizes throat and nasal discomfort associated
  with transnasal catheters
• Transmits data to pager-sized reciever
• Uploads easily to pH analysis software

1. C, DeMeester T, Peters J, et al. Clinical
   evaluation of the BRAVOTM probe - a catheter-free
   ambulatory esophageal pH monitoring system.
   Gastroenterology. 2001120A-35. Abstract 177

19
Catheter-Free pH-Monitoring System

• In a controlled study of only 7 asymptomatic
  subjects
• the small amounts of measured acid reflux
  appeared comparable to that obtained with the
  conventional pH probe.
• Additional head-to-head trials of the micro-probe
  and conventional catheter systems are needed in
  symptomatic patients to determine the accuracy,
  reliability, and patient acceptance of this
  technique.

20
How is GERD treated?

• Lifestyle Changes
• Medications
• Surgery
• Endoscopic options

21
Lifestyle Changes

• If you smoke, stop.
• Do not drink alcohol.
• Lose weight if needed.
• Eat small meals.
• Wear loose-fitting clothes.
• Avoid lying down for 3 hours after a meal.
• Raise the head of your bed 6 to 8 inches by
  putting blocks of wood under the bedposts--just
  using extra pillows will not help.

22
Medications

• Antacids
• Maalox,
• Mylanta
• Pepto-Bismol
• Rolaids
• Foaming agents
• Gaviscon
• H2 blockers
• Cimetidine (Tagamet )
• Famotidine (Pepcid)
• Nizatidine (Axid)
• Ranitidine (Zantac 75)

Magnesium salt can lead to diarrhea, and aluminum
salts can cause constipation
23
Medications

• Proton pump inhibitors
• omeprazole (Prilosec)
• lansoprazole (Prevacid)
• pantoprazole (Protonix)
• rabeprazole (Aciphex)
• esomeprazole (Nexium)
• Prokinetics
• Bethanechol (Urecholine)
• Metoclopramide (Primpran)
• Domperidone (Motilium)

24
Surgery
Nissen Fundoplication
25
Nissen Fundoplication
26
Endoscopic view of Nissen Fundoplication
27
Long-term complications of GERD?

• Inflammation of the esophagus
• Bleeding or ulcers
• strictures
• Barrett's esophagus and adenoarcinoma
• Supraesphageal manafestations
• Asthma
• chronic cough
• pulmonary fibrosis
• ENT manafestations

28
Endoscopic pictures of GERD
29
Extraesophageal disorders in GERD

• Extraesophageal manifestations of
  gastroesophageal reflux disorder (GERD) are
  frequent, and consist broadly of
• Noncardiac chest pain
• pulmonary diseases
• Asthma
• chronic cough
• recurrent bronchitis
• sleep apnea
• pulmonary fibrosis
• laryngeal diseases
• Laryngitis
• subglottic stenosis
• laryngeal cancer
• other ENT (ear, nose, throat) disorders
• Sinusitis
• Otitis media
• Pharyngitis
• dental erosion

30
Noncardiac chest pain is associated with GERD

• Among patients with angina-like chest pain
• 30 will have normal coronary arteries of these,
  40 to 50 have objective evidence of GERD by
  endoscopy or ambulatory pH monitoring
• Prevalence of GERD symptoms is 23 to 100
• Esophagitis is seen in 0 to 47
• Abnormal ambulatory pH recordings noted in 20 to
  63
• Empiric trial of PPI
• 78 sensitivity and 86 specificity , for
  diagnosing GERD association with noncardiac chest
  pain.

31
GERD and Chronic Cough

• Direct mucosal injury and/or
• Triggering vagally mediated mechanisms
• Increased airway secretions
• Bronchospasm

32
Nonacid Gastroesophageal Reflux

• Reflux of gastric contents
• Food
• Nonacidic material.
• Symptoms that fail to respond to aggressive
  therapy with proton-pump inhibitors may still
  improve after antireflux surgery
• Traditional pH testing (which detects reductions
  in intraesophageal pH from a baseline of pH 6-7)
  cannot detect nonacidic reflux.

33
Nonacid Gastroesophageal Reflux

• Nonacidic reflux was seen in both normal (healthy
  controls) subjects and GERD patients
• Measured by multichannel intraluminal impedance
  (MII) monitoring
• Accounted for one third of all reflux events
• Occurred more commonly after meals and in
  recumbency
• Only 4 of nonacidic reflux events were due to
  bile reflux
• Three fourths of bile reflux episodes occurred in
  conjunction with acid reflux
• Compared with acid reflux events, nonacidic
  reflux typically did not extend as far proximally
  and was cleared more quickly from the esophagus.

34
importance of nonacidic reflux

• The true importance of nonacidic reflux in the
  pathogenesis of both esophageal and
  extraesophageal symptoms remains to be
  established.
• may be a factor in
• Functional heartburn (ie, heartburn with normal
  esophageal pH measurements)
• Nonerosive reflux disorders
• Extraesophageal disorders, whose symptoms persist
  despite aggressive proton-pump inhibitor therapy.
• MII may be used to test for nonacidic reflux

35
GERD and Chronic Cough

• The mechanisms remain controversial.
• Microaspiration
• Stimulation of a vagally mediated
  esophageal-bronchial reflex. That may also
  involve brainstem centers.

36
GERD and Chronic Cough

• Establishing a definite cause-and-effect
  relationship between GER and chronic cough is
  difficult.
• A normal esophageal pH study argues against acid
  GER as a cause of chronic cough
• An abnormal pH study does not prove that acid
  reflux is the cause of chronic cough.
• Only a minority of patients with proven GER have
  improvement of cough after proton-pump inhibitor
  therapy.

37
GERD and Chronic Cough

• Empirical trial of high-dose therapy with PPI
• Uncontrolled trials
• 70 to 100 improvement
• The only published placebo-controlled trial
  reported
• 35 response rate.

38
GERD and Chronic Cough

• 75 patients with chronic cough prospectively
  evaluated
• GER symptoms in 72
• abnormal pH testing in 56 (42 of 75)
• 20/42 had minimal or no reflux symptoms.
• Omeprazole was given to a subset of patients (n
  55) with either GER symptoms and/or abnormal pH
  testing.
• After 3-6 months, significant improvement was
  noted 45
• No symptom or pH parameter was predictive of
  improvement.

Garrigues V, Bastida G, Bau I, et al.
Gastroenterology. 2001120A-430. Abstract
2195
39
GERD and Chronic Cough

• Conclusions
• ambulatory esophageal pH testing still is of
  limited utility in the evaluation of patients
  with chronic cough.
• A normal pH study with a low SI (symptom index) ,
  probably excludes acid-related cough, but a
  positive pH study does not prove a causal
  relationship.
• Many clinicians may choose to treat all patients
  with chronic cough with an empirical trial of
  high-dose proton-pump inhibitors (eg, omeprazole
  40 mg twice daily), even if symptoms of reflux
  are absent.
• Cough usually responds within 2 weeks of therapy.
• An empirical trial is more cost-effective than
  formal evaluation with manometry and pH testing.

40
Laryngopharyngeal reflux

• 81 will have a normal-appearing esophagus
• 40 may have symptoms of heartburn
• Symptoms consistent with this diagnosis
• Dysphonia
• Globus sensation
• Throat clearing
• Halitosis
• Sore throat
• Cough.
• Hoarseness is a majer coplaint in 92 of patients
  with GERD-related laryngitis
• gt 50 of patients presenting to ENT specialists
  with hoarsness will have a component of GERD
  contributing to their symptoms

41
Reflux Laryngitis

• Posterior laryngitis at laryngoscopy is a typical
  finding of reflux laryngitis
• Niether laryngoscopic findings nor positive pH
  studies have been found to be of predictive value
  in identifying patients likely to respond to
  proton-pump inhibitors.
• No agreement as to the optimal site of pharyngeal
  probe placement or normal values of
  esophagopharyngeal reflux (EPR).
• EPR is also is detected in up to 20 of normal
  controls.

42
Reflux Laryngitis

• Study involved 62 cadidates
• 19 healthy controls
• 43 patients with suspected reflux laryngitis
• 17 with symptoms but a normal ENT exam
• 26 with posterior laryngitis.
• Videolaryngoscopy was performed in all subjects
• Dual-probe pH testing was performed, with the
  proximal probe located 1 cm above the upper
  esophageal sphincter in the pharynx.
• Pharyngeal acid reflux occurred in
• 26 of controls
• 53 patients with ENT symptoms alone
• 69 in patients with ENT symptoms and findings of
  posterior laryngitis
• However, there was no difference in symptoms
  between patients with abnormal and normal pH
  values, or between patients with an abnormal or
  normal-appearing larynx.

Ylitalo R et al , Gastroenterology.
2001120A-426. Abstract 2175
43
Reflux Laryngitis

• 49 patients with chronic ENT symptoms and
  abnormal laryngoscopic examination underwent a
  questionnaire and dual-probe esophageal (not
  pharyngeal) pH testing.
• After initial evaluation, patients were treated
  in an uncontrolled fashion with either
• high-dose proton-pump inhibitors
• high-dose proton-pump-inhibitor therapy and
  bedtime ranitidine.
• At 4 months, improvement was noted in 32 of 49
  (65) of patients treated with proton-pump
  inhibitors (with or without ranitidine).
• Symptoms, ENT findings, and pH parameters were
  not predictive of response to proton-pump
  inhibitor therapy.

1. Vaezi M et al. Gastroenterology. 2001120A-118.
   Abstract 636

44
(No Transcript)
45
Management of suspected reflux-laryngitis
The laryngoscopic finding of "posterior
laryngitis"
Refer patient for 24h pH-metry on PPI therapy
Increase dose / consider surgery
Richter Gasroenterol clin north Am 1996 25 75
46
Reflux Laryngitis

• Conclusions
• lack of predictive value for
• Symptoms
• ENT findings
• pH testing
• In uncontrolled trials, improvement is seen in
  60 to 90 of selected patients.
• The efficacy, optimal dose, and duration of
  proton-pump inhibitors for reflux laryngitis have
  not been established in controlled trials.

47
Other GERD-Associated ENT conditions

• Subglottic stenosis
• laryngeal carcinoma
• Globus
• Otitis media
• Sleep apnea
• Proving a cause-and-effect relationship
  between GER and these conditions is difficult.

48
GER in Otitis Media

• GER may cause chronic otitis media
• Reflux of gastric contents into the nasopharynx
  and middle ear might precipitate infections
  and/or chronic effusions.
• Assessed 50 middle-ear effusions for pepsin and
  pepsinogen levels using an enzyme-linked
  immunosorbent assay (ELISA).
• Pepsin and pepsinogen were detected in 41 of 50
  effusions (82)
• provocative observation, but proof of causation
  is lacking.

1. Tasker A, et al. Gastroenterology.
   2001120A-119. Abstract 638

49
GER and Sleep Apnea

• Obstructive sleep apnea (OSA)
• A condition that occurs as a result of the loss
  of normal pharyngeal muscle tone while sleeping,
  which allows the pharynx to collapse during
  inspiration.
• It is most common in
• Obese
• anatomically narrowed upper airways due to
  macroglossia, micrognathia
• redundant pharyngeal or tonsillar soft tissue.
• Strong association between OSA and GER was
  suggested

50
GER and Sleep Apnea

• 101 patients undergoing sleep studies for
  suspected OSA were evaluated for symptoms of GER
• Sleep apnea was diagnosed in 71 of 101 patients
• GER symptoms
• 50 in patients with OSA
• 33 in patients without OSA.
• GER symptoms were not related to the severity of
  OSA.

Guda N, et al .Gastroenterology. 2001120A-429.
Abstract 2190
51
GER and Sleep Apnea

• Coclusions
• Observations so far do not prove symptom
  causality.
• Patients with OSA may be predisposed to GER
• Obesity
• sedentary lifestyle
• alcohol use
• smoking.
• Obstructed breathing patterns (with negative
  intrathoracic pressure) also may predispose to
  GER
• A controlled trial of GER therapy in patients
  with OSA is needed.
• Patients with OSA should be assessed for GER
  symptoms pre- and post-OSA treatment.

52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
Coclusions

• Gastroesophageal reflux is extremely common and
  may manifest with typical and atypical symptoms.
• At present it is extremely difficult to establish
  a definite diagnosis of extraesophageal GERD.
• Typical esophageal symptoms (heartburn,
  regurgitation) may be absent in a large number of
  patients.
• Neither the type of ENT symptoms nor the ENT
  findings are of predictive value in determining
  underlying GER.

56
Coclusions

• Although interesting new modalities for reflux
  testing are available (capsule pH monitoring,
  impedance testing) it remains to be seen whether
  these modalities improve diagnostic accuracy
• Currently, the most cost-effective approach for
  most patients with suspected reflux-related
  symptoms is a trial of a high-dose proton-pump
  inhibitor for 3 monthes.
• pH testing reserved to confirm adequate acid
  suppression in those with refractory symptoms.
• Although improvement in cough symptoms may be
  evident within 2 weeks of treatment, improvement
  in other ENT disorders may require 3 or more
  months of therapy.
• The place of Fundoplication is yet to be defined

57
Thank you
58
Diagnosis

• The majority of patients with extraesophageal
  manifestations of GER do not have the classic
  symptoms of heartburn or regurgitation
• less than 30 have endoscopic evidence of reflux
  esophagitis
• Twenty-four-hour pH monitoring has been commonly
  used to look for evidence of acid reflux into the
  lower esophagus, upper esophagus, and pharynx.
  However, this test is not comfortable for most
  patients

59
GER and Sleep Apnea

• 41 consecutive patients with suspected OSA
  undergoing sleep exams were prospectively
  evaluated with a GERD symptom questionnaire.
• 22/41 enrolled patients, reported heartburn or
  acid regurgitation.
• 17/22 patients with heartburn reported that this
  symptom awakened them at night.
• Regression analysis suggested that GER severity
  was correlated to the apnea-hypoventilation
  index.