Gastroesophageal Reflux Disease

1. Gastroesophageal Reflux Disease Arthur Harris, M.D. GI Division, Jacobi Medical Center/NCBH Assistant Professor of Medicine, AECOM

2. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • 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 • Post-prandial • Short-lived • Often asymptomatic • TLSER’s • No nocturnal sx • Pathologic GERD • Symptoms • Mucosal injury • Nocturnal sx

6. 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

7. 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

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

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

10. 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

11. 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 Potential Oral and Laryngopharyngeal Signs Associated with GERD

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

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

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

15. 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

16. 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

17. Physiologic study Quantify reflux in proximal/distal esophagus % time pH < 4 DeMeester score Symptom correlation Ambulatory 24 hour pH Monitoring -1

18. Ambulatory 24 hour pH Monitoring -2 Normal GERD

19. 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

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

21. 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 (> 45, white, male and > 5 yrs of sx) Confirm diagnosis EGD, ph monitor

22. 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

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

24. 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, NSAID’s) • Avoid clothing that is tight around the waist • Lose weight • Stop smoking

25. 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

26. 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

27. 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

28. Treatment • Proton Pump Inhibitors • Better control of symptoms with PPI’s vs H2RAs and better remission rates • Faster healing of erosive esophagitis with PPIs vs H2RAs

29. 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

30. Treatment • H2RAs vs PPI’s • 12 week freedom from symptoms • 48% vs 77% • 12 week esophagitis healing rate • 52% vs 84% • Speed of healing • 6%/wk vs 12%/wk

31. 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

32. 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

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

34. 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

36. 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

37. 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

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

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

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

41. Peptic Stricture Barium swallow Endoscopy

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

43. Complications • Barrett’s 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

44. 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

45. 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 even shorter interval surveillance is recommended

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

47. ?QUESTIONS?