Gastroesophageal Reflux Disease

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Gastroesophageal Reflux Disease

• Arthur Harris, M.D.
• GI Division, Jacobi Medical Center/NCBH
• Assistant Professor of Medicine, AECOM

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Objectives

• Definition of GERD
• Epidemiology of GERD
• Pathophysiology of GERD
• Clinical Manifestations
• Diagnostic Evaluation
• Treatment
• Complications

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Definition

• American College of Gastroenterology (ACG)
• Symptoms OR mucosal damage produced by the
  abnormal reflux of gastric contents into the
  esophagus
• Often chronic and relapsing
• May see complications of GERD in patients who
  lack typical symptoms

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Physiologic vs Pathologic

• Physiologic GERD
• Post-prandial
• Short-lived
• Often asymptomatic
• TLSERs
• No nocturnal sx

• Pathologic GERD
• Symptoms
• Mucosal injury
• Nocturnal sx

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Epidemiology

• About 44 of the US adult population have
  heartburn at least once a month
• 14 of Americans have symptoms weekly
• 7 have symptoms daily

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Pathophysiology

• Primary barrier to gastroesophageal reflux is the
  lower esophageal sphincter
• LES normally works in conjunction with the
  diaphragm
• If barrier disrupted, acid goes from stomach to
  esophagus

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Clinical Manifestations

• Most common symptoms
• Heartburnretrosternal burning discomfort
• Regurgitationeffortless return of gastric
  contents into the pharynx without nausea,
  retching, or abdominal contractions

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Clinical Manifestations

• Dysphagiadifficulty swallowing
• Other symptoms include
• Chest pain, water brash, globus sensation,
  odynophagia, nausea
• Extraesophageal manifestations
• Asthma, laryngitis, chronic cough

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Diagnostic Evaluation

• If classic symptoms of heartburn and
  regurgitation exist in the absence of alarm
  symptoms the diagnosis of GERD can be made
  clinically and treatment can be initiated

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Potential Oral and Laryngopharyngeal Signs
Associated with GERD

• Edema and hyperemia of larynx
• Vocal cord erythema, polyps, granulomas, ulcers
• Hyperemia and lymphoid hyperplasia of posterior
  pharynx
• Interarytenyoid changes
• Dental erosion
• Subglottic stenosis
• Laryngeal cancer

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Alarms

• Alarm Signs/Symptoms
• Dysphagia
• Early satiety
• GI bleeding
• Odynophagia
• Vomiting
• Weight loss
• Iron deficiency anemia

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Trial of Medications

• H2RA or PPI
• Expect response in 2-4 weeks
• If no response
• Change from H2RA to PPI
• Maximize dose of PPI

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Trial of Medications

• If PPI response inadequate despite maximal dosage
  
• Confirm diagnosis
• EGD
• 24 hour pH monitoring

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Esophagogastrodudenoscopy

• Endoscopy (with biopsy if needed)
• In patients with alarm signs/symptoms
• Those who fail medication trial
• Those who require long-term Rx
• Lacks sensitivity for identifying pathologic
  reflux
• Absence of endoscopic features does not exclude a
  GERD diagnosis
• Allows for detection, stratification, and
  management of esophageal manifestations or
  complications of GERD

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Ambulatory pH Testing

• 24-hour pH monitoring
• Accepted standard for establishing or excluding
  presence of GERD for those patients who do not
  have mucosal changes
• Trans-nasal catheter or a wireless, capsule
  shaped device

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Ambulatory 24 hour pH Monitoring -1

• Physiologic study
• Quantify reflux in proximal/distal esophagus
• time pH lt 4
• DeMeester score
• Symptom correlation

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Ambulatory 24 hour pH Monitoring -2

• Normal

• GERD

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Wireless, Catheter-Free Esophageal pH Monitoring
Potential Advantages ?Improved patient comfort
and acceptance ?Continued normal work,
activities and diet during study ?Longer
reporting periods possible (up to 48 hours)
?Maintain constant probe position relative to
SCJ
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Esophageal Manometry

• Limited role in GERD
• Assess LES pressure, location and relaxation
• Assist placement of 24 hour pH catheter
• Assess peristalsis
• Prior to anti-reflux surgery

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Patient with heartburn
Initiate Rx with H2RA or PPI
H2RA taken BID
PPI taken QD
No
Good response
No
Good response
Yes
Yes
Yes
Increase to max dose QD or BID
Maintenance therapy with lowest effective dose
Frequent relapses
No
Yes
On demand Rx
Symptoms persist
Good response
No
Consider EGD if risk factors present (gt 45,
white, male and gt 5 yrs of sx)
Confirm diagnosis EGD, ph monitor
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GERD vs Dyspepsia

• Distinguish from Dyspepsia
• Ulcer-like symptoms-burning, epigastric pain
• Dysmotility like symptoms-nausea, bloating, early
  satiety, anorexia
• Distinct clinical entity
• In addition to anti-secretory meds and an EGD,
  need to consider testing for Helicobacter pylori

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Treatment

• Goals of therapy
• Symptomatic relief
• Heal esophagitis
• Avoid complications

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Better Living

• Lifestyle modifications
• Avoid large meals
• Avoid acidic foods (citrus/tomato), alcohol,
  caffeine, chocolate, onions, garlic, peppermint
• Decrease fat intake
• Avoid lying down within 3-4 hours after a meal
• Elevate head of bed 4-8 inches
• Avoid meds that may potentiate GERD (CCB, alpha
  agonists, theophylline, nitrates, sedatives,
  NSAIDs)
• Avoid clothing that is tight around the waist
• Lose weight
• Stop smoking

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Treatment

• Antacids
• O-T-C acid suppressants and antacids may be
  appropriate initial therapy
• Approx 1/3 of patients with heartburn-related
  symptoms use at least twice weekly
• More effective than placebo in relieving GERD
  symptoms

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Treatment

• Histamine H2-Receptor Antagonists
• More effective than placebo and antacids for
  relieving heartburn in patients with GERD
• Faster healing of erosive esophagitis when
  compared with placebo
• Can use regularly or on-demand

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Treatment

• AGENT EQUIVALENT DOSAGE
• DOSAGES
• Cimetadine 400mg twice daily
  400-800mg twice daily
• Tagamet
• Famotidine 20mg twice daily
  20-40mg twice daily
• Pepcid
• Nizatidine 150mg twice daily
  150mg twice daily
• Axid
• Ranitidine 150mg twice daily
  150mg twice daily
• Zantac

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Treatment

• Proton Pump Inhibitors
• Better control of symptoms with PPIs vs H2RAs
  and better remission rates
• Faster healing of erosive esophagitis with PPIs
  vs H2RAs

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Treatment

• AGENT EQUIVALENT
  DOSAGE
• DOSAGES
• Esomeprazole 40mg
  daily 20-40mg daily
• Nexium
• Omeprazole 20mg
  daily 20mg daily
• Prilosec
• Lansoprazole 30mg
  daily 15-30mg daily
• Prevacid
• Pantoprazole 40mg
  daily 40mg daily
• Protonix
• Rabeprazole 20mg
  daily 20mg daily
• Aciphex

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Treatment

• H2RAs vs PPIs
• 12 week freedom from symptoms
• 48 vs 77
• 12 week esophagitis healing rate
• 52 vs 84
• Speed of healing
• 6/wk vs 12/wk

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Treatment Modifications for Persistent Symptoms

• Improve compliance
• Optimize pharmacokinetics
• Adjust timing of medication to 15 30 minutes
  before meals (as opposed to bedtime)
• Allows for high blood level to interact with
  parietal cell proton pump activated by the meal
• Consider switching to a different PPI

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Treatment

• Anti-reflux surgery - Indications
• Failed medical management
• Patient preference
• GERD complications
• Medical complications attributable to a large
  hiatal hernia
• Atypical symptoms with pathologic reflux
  documented on 24-hour pH monitoring

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Treatment

• Anti-reflux surgery candidates
• EGD proven esophagitis
• ?Normal esophageal motility
• Incomplete response to acid suppression

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Treatment

• Anti-reflux surgery (laparoscopic)
• Tenets of surgery
• Reduce hiatal hernia
• Repair diaphragm
• Strengthen GE junction
• Strengthen anti-reflux barrier via gastric wrap
• 75-90 effective at alleviating symptoms of
  heartburn and regurgitation

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Treatment

• Post-surgery
• 10 have solid food dysphagia
• 2-3 have permanent symptoms
• 7-10 have gas, bloating, diarrhea, nausea, early
  satiety
• Within 3-5 years, up to 52 of patients back on
  anti-reflux medications

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Treatment

• Endoscopic treatment
• Relatively new
• No clearly established indications
• Well-informed patients with well-documented GERD
  responsive to PPI therapy may benefit
• Three categories
• Radiofrequency application to increase LES reflux
  barrier
• Endoscopic sewing devices
• Injection of a non-resorbable polymer into LES
  region

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Complications

• Erosive esophagitis
• Stricture
• Barretts esophagus

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Complications

• Erosive esophagitis
• Responsible for 40-60 of GERD symptoms
• Severity of symptoms often fail to match severity
  of erosive esophagitis

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Complications

• Esophageal stricture
• Occurs as a result of healing of erosive
  esophagitis
• May need dilation

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Peptic Stricture
Barium swallow
Endoscopy
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Complications

• Barretts Esophagus
• Columnar metaplasia of the esophagus
• Associated with the development of adenocarcinoma

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Complications

• Barretts Esophagus
• Acid damages lining of esophagus and causes
  chronic esophagitis
• Damaged area heals in a metaplastic process with
  abnormal columnar cells replacing squamous cells
• This specialized intestinal metaplasia can
  progress to dysplasia and adenocarcinoma

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Complications

• Patients who need EGD
• Alarm symptoms
• Poor therapeutic response
• Long symptom duration
• Once in a lifetime EGD for patients with
  chronic GERD becoming accepted practice
• Many patients with Barretts are asymptomatic

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Complications

• Barretts Esophagus
• Manage in same manner as GERD
• EGD every 3 years in patients without dysplasia
• In patients with dysplasia, annual to even
  shorter interval surveillance is recommended

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Summary

• Definition of GERD
• Epidemiology of GERD
• Pathophysiology of GERD
• Clinical Manifestations
• Diagnostic Evaluation
• Treatment
• Complications

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• ?QUESTIONS?