Gastroesophageal Reflux Disease GERD

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Gastroesophageal Reflux Disease (GERD)

• Any symptoms or esophageal mucosal damage that
  results from reflux of gastric acid into the
  esophagus
• Classic GERD symptoms
• Heartburn (pyrosis) substernal burning
  discomfort
• Regurgitation bitter, acidic fluid in the mouth
  when lying down or bending over

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High Prevalence of Gastroesophageal Reflux
Symptoms
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Important Reasons to Diagnose and Treat GERD

• Negative impact on health-related quality of
  life1
• Risk factor for esophageal adenocarcinoma2

• Revicki et al. Am J Med 1998104252.
• Lagergren et al. N Engl J Med 1999340825.

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Clinical Presentations of GERD

• Classic GERD
• Extraesophageal/Atypical GERD
• Complicated GERD

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Extraesophageal Manifestations of GERD

• Pulmonary
• Asthma
• Aspiration pneumonia
• Chronic bronchitis
• Pulmonary fibrosis
• Other
• Chest pain
• Dental erosion

• ENT
• Hoarseness
• Laryngitis
• Pharyngitis
• Chronic cough
• Globus sensation
• Dysphonia
• Sinusitis
• Subglottic stenosis
• Laryngeal cancer

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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

Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin
Gastro Hep 20031333-344.
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Pathophysiology of Extraesophageal GERD
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Symptoms of Complicated GERD

• Dysphagia
• Difficulty swallowing food sticks or hangs up
• Odynophagia
• Retrosternal pain with swallowing
• Bleeding

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When to Perform Diagnostic Tests

• Uncertain diagnosis
• Atypical symptoms
• Symptoms associated with complications
• Inadequate response to therapy
• Recurrent symptoms
• Prior to anti-reflux surgery

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Diagnostic Tests for GERD

• Barium swallow
• Endoscopy
• Ambulatory pH monitoring
• Esophageal manometry

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Barium Swallow

• Useful first diagnostic test for patients with
  dysphagia
• Stricture (location, length)
• Mass (location, length)
• Birds beak
• Hiatal hernia (size, type)
• Limitations
• Detailed mucosal exam for erosive esophagitis,
  Barretts esophagus

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Endoscopy

• Indications for endoscopy
• Alarm symptoms
• Empiric therapy failure
• Preoperative evaluation
• Detection of Barretts esophagus

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Ambulatory 24 hr. pH Monitoring

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

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Ambulatory 24 hr. pH Monitoring
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 study
• Longer reporting periods possible (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 hr. pH catheter
• Assess peristalsis
• Prior to antireflux surgery

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Treatment Goals for GERD

• Eliminate symptoms
• Heal esophagitis
• Manage or prevent complications
• Maintain remission

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Lifestyle Modifications are Cornerstone of GERD
Therapy

• Elevate head of bed 4-6 inches
• Avoid eating within 2-3 hours of bedtime
• Lose weight if overweight
• Stop smoking
• Modify diet
• Eat more frequent but smaller meals
• Avoid fatty/fried food, peppermint, chocolate,
  alcohol, carbonated beverages, coffee and tea
• OTC medications prn

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Acid Suppression Therapy for GERD

• H2-Receptor Antagonists
• (H2RAs)
• Cimetidine (Tagamet)
• Ranitidine (Zantac)
• Famotidine (Pepcid)
• Nizatidine (Axid)

• Proton Pump Inhibitors
• (PPIs)
• Omeprazole (Prilosec)
• Lansoprazole (Prevacid)
• Rabeprazole (Aciphex)
• Pantoprazole (Protonix)
• Esomeprazole (Nexium )

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Effectiveness of Medical Therapies for GERD
Treatment Response Lifestyle
modifications/antacids 20 H2-receptor
antagonists 50 Single-dose PPI 80
Increased-dose PPI up to 100
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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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GERD is a Chronic Relapsing Condition

• Esophagitis relapses quickly after cessation of
  therapy
• gt 50 relapse within 2 months
• gt 80 relapse within 6 months
• Effective maintenance therapy is imperative

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Complications of GERD

• Erosive/ulcerative esophagitis
• Esophageal (peptic) stricture
• Barretts esophagus
• Adenocarcinoma

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Erosive Esophagitis
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Peptic Stricture
Barium Swallow
Endoscopy
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Esophageal Stricture Dilating Devices
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TTS Balloon Dilation of a Peptic Stricture
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Barretts Esophagus
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Esophageal Cancer
Barium Swallow
Endoscopy
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When to Discuss Anti-Reflux Surgery with Patients

• Intractable GERD rare
• Difficult to manage strictures
• Severe bleeding from esophagitis
• Non-healing ulcers
• GERD requiring long-term PPI-BID in a healthy
  young patient
• Persistent regurgitation/aspiration symptoms
• Not Barretts esophagus alone

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Endoscopic GERD Therapy

• Endoscopic antireflux therapies
• Radiofrequency energy delivered to the LES
• Stretta procedure
• Suture ligation of the cardia
• Endoscopic plication
• Submucosal implantation of inert material in the
  region of the lower esophageal sphincter
• Enteryx