Gastroesophageal Reflux Disease

1. Gastroesophageal Reflux Disease Howard J. McGowan, Maj, USAF, MC

2. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manisfestations • Diagnostic Evaluation • Treatment • Complications

3. 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

4. Physiologic vs Pathologic • Physiologic GERD • Postprandial • Short lived • Asymptomatic • No nocturnal sx • Pathologic GERD • Symptoms • Mucosal injury • Nocturnal sx

5. 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

6. 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

7. Clinical Manisfestations • Most common symptoms • Heartburn—retrosternal burning discomfort • Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions

8. Clinical Manisfestations • Dysphagia—difficulty swallowing • Other symptoms include: • Chest pain, water brash, globus sensation, odynophagia, nausea • Extraesophageal manifestations • Asthma, laryngitis, chronic cough

9. 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

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

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

12. Trial of Medications • If PPI response inadequate despite maximal dosage • Confirm diagnosis • EGD • 24 hour pH monitor

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

14. pH • 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

15. Patient with heartburn Iniate tx 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 tx Symptoms persist Good response No Consider EGD if risk factors present (> 45, white, male and > 5 yrs of sx) Confirm diagnosis EGD, ph monitor

16. 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 antisecretory meds and an EGD need to consider an evaluation for Helicobacter pylori

17. Treatment • Goals of therapy • Symptomatic relief • Heal esophagitis • Avoid complications

18. Better Living • Lifestyle modifications • Avoid large meals • Avoid acidic foods (citrus/tomato), alcohol, caffiene, 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

19. Treatment • Antacids • Over the counter acid suppressants and antacids 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

20. 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

21. 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

22. 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

23. Treatment AGENT EQUIVALENT DOSAGE DOSAGES Esomeprazole 40mg daily 20-40mg daily Nexium Omeprazole 20mg daily 20mg daily Prilosec Lansoprazole 30mg daily 15-10md daily Prevacid Pantoprazole 40mg daily 40mg daily Protonix Rabeprazole 20mg daily 20mg daily Aciphex

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

25. Treatment • Antireflux surgery • Failed medical management • Patient preference • GERD complications • Medical complications attributable to a large hiatal hernia • Atypical symptoms with reflux documented on 24-hour pH monitoring

26. Treatment • Antireflux surgery candidates • EGD proven esophagitis • Normal esophageal motility • Partial response to acid suppression

27. Treatment • Antireflux surgery • Tenets of surgery • Reduce hiatal hernia • Repair diaphragm • Strengthen GE junction • Strengthen antireflux barrier via gastric wrap • 75-90% effective at alleviating symptoms of heartburn and regurgitation

28. Treatment • Postsurgery • 10% have solid food dysphagia • 2-3% have permanent symptoms • 7-10% have gas, bloating, diarrhea, nausea, early satiety • Within 3-5 years 52% of patients back on antireflux medications

29. Treatment • Endoscopic treatment • Relatively new • No definite indications • Select 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 nonresorbable polymer into LES area

30. Complications • Erosive esophagitis • Stricture • Barrett’s esophagus

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

32. Complications • Esophageal stricture • Result of healing of erosive esophagitis • May need dilation

33. Complications • Barrett’s Esophagus • Columnar metaplasia of the esophagus • Associated with the development of adenocarcinoma

34. Complications • Barrett’s Esophagus • Acid damages lining of esophagus and causes chronic esophagitis • Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells • This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma

35. Complications • Patient’s who need EGD • Alarm symptoms • Poor therapeutic response • Long symptom duration • “Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice • Many patients with Barrett’s are asymptomatic

36. Complications • Barrett’s Esophagus • Manage in same manner as GERD • EGD every 3 years in patient’s without dysplasia • In patients with dysplasia annual to shorter interval surveillance

37. Summary • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manisfestations • Diagnostic Evaluation • Treatment • Complications

38. ?QUESTIONS?