Evaluating the GERD Patient – Minimum to Maximum

1. Evaluating the GERD Patient – Minimum to Maximum Blair A. Jobe, MD Professor of Surgery Department of Surgery University of Pittsburgh Pittsburgh, Pennsylvania

2. Failure of Antireflux Surgery “It is well recognized that inadequate or inaccurate preoperative evaluation can be a major contributor to a poor outcome following antireflux surgery” Gastrointest Endoscopy Clin N Am 2005;15:347

3. Symptoms are not a Reliable Indicator of Reflux Status Prior to ARS Abnormal pH Test 27% Normal pH Test 73% Typical GERD Symptoms (N=179) DeMeester et al. J Thorac Cardiovasc Surg. 1980;79:656 Patti MG et al. Dig Dis Sci. 2001;46:597

4. Symptoms are not a Reliable Indicator of Reflux StatusAfter Antireflux Surgery Abnormal DeMeester 11.9% 29.3% PPV=29% NPV=88% 70.6% 88.1% Normal DeMeester Asymptomatic (N=151) Symptoms (N=58) Khajanchee et al. Arch Surg. 2002;137:1008

5. The majority of patients taking acid suppression medications after ARS do not have GERD 24% 76% PPI (N=37) Lord et al. J Gastrointest Surg. 2002;6:3

6. Antireflux Surgery Eliminates Symptoms of GERD

7. Antireflux Surgery is Effective and Durable Surg Endosc 2006;20:159

8. Antireflux Surgery Improves Quality of Life

9. Success in Antireflux Surgery:What is Essential? • Patient Selection • Patient Selection • Patient Selection • Surgeon Training • Procedure Tailoring • Wrap type, length, tightness

10. Technique for Nissen Fundoplication • Hernia reduction • Esophageal mobilization • Hiatal Closure • Short gastric division • Short and Floppy Fundoplication

11. Goals in Workup • Query GERD-related symptoms • Assess co-morbid conditions as they relate to surgery • Objectify GERD • Identify anatomic abnormalities • Identify functional abnormalities • Set expectations with patient • Pick procedure (complete fundoplication) Gastrointest Endoscopy Clin N Am 2005;15:347

12. The History and Expectation Setting • Typical vs. atypical symptoms • R/O non-GERD causes of atypical symptoms • Primary and secondary symptoms • Response to medical therapy • Associated symptoms • Bloating, emesis, nausea • Eating disorder • Counsel patient as to the probability of success

13. The Quiver • Esophagram • Upper Endoscopy • Manometry • High resolution • pH testing • Catheter-based • “Wireless” • Impedance • pH or Manometry • Gastric Emptying • Esophageal Emptying

14. Video Esophagram (Required) • Dynamic imaging of entire organ • Contour • Obstructive lesions • Some functional information

15. Upper Endoscopy (Required) • Mucosal Inspection • Complications of reflux • Barrett’s esophagus and cancer • Structural Inspection • Therapy prior to surgery

16. Native Flap-Valve Anatomy Lesser curvature Posterior Valve Anterior Valve Body Lip Tightness around scope Relationship to diaphragm Fundus

17. Fundoplication as an Anatomic Remedy Pre-fundoplication Post-fundoplication

18. EUS: Normal Nissen Gopal et al. J Gastrointest Endosc 2005

19. Manometry (Required) • Identify etiology and severity of GERD (LES) • Assess ability to tolerate fundoplication • Exclude primary motility disorder (Body) • Guide pH probe placement

20. 24-Hour pH Testing (Required) • Detects esophageal acid exposure • Correlate symptoms with reflux episodes • ? Tailor fundoplication • Considered the “gold standard” for making diagnosis

21. Potential Pitfalls with pH Testing • Wrong position • “Good day” • Acidic foods • Atrophic gastritis • Sensitive esophagus • Achalasia • Poor sensitivity in LPR

22. Refluxate pH Changes During Migration Weusten, Bas L. et al, American. Journal GI. 266:G357-G362, 1994

23. How Do You Select the Correct Patient with GERD?The Three Most Important Factors which Predict the Likelihood of Success • Abnormal 24-hour pH score • Typical primary symptom • Clinical response to PPI J Gastrointest Surg 1999;3:292

24. Situations in which ARS may be Applied • Typical GERD • NERD • PEH • Achalasia • Primary, Secondary, Tertiary Failure • Asthma and other Extraesophageal Sxs • Atypical

25. Pitfall #1Missed Achalasia Perform manometry on everyone Think of this with re-dos Read your own tracings Be suspicious Positive pH Esophagitis

26. Pitfall #2Eating Disorder History Physical Finger nails Dentition Body habitus may be normal Esophagitis with normal manometry or pH Index of suspicion

27. Pitfall #3Functional Dyspepsia History and physical Don’t mistake for GERD Listen to your objective evidence Order more tests If uncertain, refer for second opinion

28. Pitfall #4Structural Gastric Outlet Obstruction Be suspicious with normal LES physiology and abnormal pH Bloating, nausea NSAID use or prior treatment for H. pylori EGD

29. Pitfall #5: Occult GERD-Proving Association with Extraesophageal Symptoms 1) Gastric juice, of either acid or alkaline pH, can cause damage to the laryngeal or airway mucosa 2) Airway desquamation is followed by mucosal regeneration over 3-7 days 3) Microaspiration can be asymptomatic and occur with a normal 24 hour pH score 4) Symptoms can occur with only distal esophageal acid exposure

30. Gastroesophageal Reflux of Fluid Over an Impedance Electrode Pair No bolus=few ions= high impedance Bolus present=many ions= low impedance Refluxate Proximal Air liquid

31. Proximal pH Distal

32. 3.25 cm 1.75 cm 2.5 cm 0.25 cm 1.0 cm UES Hypopharyngeal Sensor Positions

33. Mr. E 75 year old male non-smoker 17 months of non-productive cough and dysphonia Worse when supine and after meals Mild HB symptoms and no regurgitation History of post-nasal drip Two episodes of pneumonia in last year No history of Asthma Does not take ACE inhibitors

34. Mr. E Physical Exam Fit appearing VSS normal

35. CXR

36. “PPI Test” Omeprazole 40mg bid for 4mos • Mild subjective improvement in hoarseness but cough is same • Chronic throat clearing • GERD symptoms resolved

37. ENT: Granulation tissue on vocal cords with gastric matter in pyriform recess; no other identifiable ENT-related etiology for symptoms

38. Esophagram NL Manometry -Esophageal Body-NL -LES-NL DeMeester Score=22 -off meds -all upright reflux -no symptom correlation with cough -some symptom correlation with GERD -cough more pronounced off meds -3 proximal reflux events

39. Upper Endoscopy No esophagitis No hiatal hernia Slightly varigated squamocolumnar junction -less than 2 cm Biopsy obtainedBarrett’s esophagus without dysplasia

40. LPR Impedance

42. “Wisdom and understanding can only become the possession of individual men (and women) by traveling the old road of observation, attention, perseverance, and industry” -Samuel Smiles

44. LETS VOTE • Nissen Fundoplication after lengthy informed consent? • Increase PPI therapy? • Promotility Agent? • Antihistamines, beta-2 agonists, corticosteroids • Other Tests

45. Why is Making the Diagnosis so Difficult? GERD sxs SE sxs Very Prevalent (PND, Asthma, Allergies, TOB) Very Prevalent