Post on 13-Nov-2014
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Gastroesophageal Gastroesophageal Reflux DiseaseReflux Disease
Howard J. McGowan, Maj, USAF, MCHoward J. McGowan, Maj, USAF, MC
ObjectivesObjectives
Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManisfestationsClinical Manisfestations Diagnostic EvaluationDiagnostic Evaluation TreatmentTreatment ComplicationsComplications
DefinitionDefinition American College of American College of
Gastroenterology (ACG)Gastroenterology (ACG)• Symptoms OR mucosal Symptoms OR mucosal
damage produced by the damage produced by the abnormal reflux of gastric abnormal reflux of gastric contents into the esophaguscontents into the esophagus
• Often chronic and relapsingOften chronic and relapsing• May see complications of May see complications of
GERD in patients who lack GERD in patients who lack typical symptomstypical symptoms
Physiologic vs PathologicPhysiologic vs Pathologic
Physiologic GERDPhysiologic GERD• PostprandialPostprandial• Short livedShort lived• AsymptomaticAsymptomatic• No nocturnal sxNo nocturnal sx
Pathologic GERDPathologic GERD• SymptomsSymptoms• Mucosal injuryMucosal injury• Nocturnal sxNocturnal sx
EpidemiologyEpidemiology
About 44% of the US adult population About 44% of the US adult population have heartburn at least once a have heartburn at least once a monthmonth
14% of Americans have symptoms 14% of Americans have symptoms weeklyweekly
7% have symptoms daily7% have symptoms daily
PathophysiologyPathophysiology Primary barrier to Primary barrier to
gastroesophageal gastroesophageal reflux is the lower reflux is the lower esophageal sphincteresophageal sphincter
LES normally works in LES normally works in conjunction with the conjunction with the diaphragmdiaphragm
If barrier disrupted, If barrier disrupted, acid goes from acid goes from stomach to esophagusstomach to esophagus
Clinical Manisfestations Clinical Manisfestations
Most common symptomsMost common symptoms• Heartburn—retrosternal burning Heartburn—retrosternal burning
discomfortdiscomfort• Regurgitation—effortless return of Regurgitation—effortless return of
gastric contents into the pharynx gastric contents into the pharynx without nausea, retching, or without nausea, retching, or abdominal contractionsabdominal contractions
Clinical ManisfestationsClinical Manisfestations
• Dysphagia—difficulty swallowingDysphagia—difficulty swallowing• Other symptoms include:Other symptoms include:
Chest pain, water brash, globus sensation, Chest pain, water brash, globus sensation, odynophagia, nauseaodynophagia, nausea
• Extraesophageal manifestationsExtraesophageal manifestations Asthma, laryngitis, chronic coughAsthma, laryngitis, chronic cough
Diagnostic EvaluationDiagnostic Evaluation
• If classic symptoms of heartburn and If classic symptoms of heartburn and regurgitation exist in the absence of regurgitation exist in the absence of “alarm symptoms” the diagnosis of “alarm symptoms” the diagnosis of GERD can be made clinically and GERD can be made clinically and treatment can be initiatedtreatment can be initiated
AlarmsAlarms
• Alarm Signs/SymptomsAlarm Signs/Symptoms DysphagiaDysphagia Early satietyEarly satiety GI bleedingGI bleeding OdynophagiaOdynophagia VomitingVomiting Weight lossWeight loss Iron deficiency anemiaIron deficiency anemia
Trial of MedicationsTrial of Medications
H2RA or PPIH2RA or PPI• Expect response in 2-4 weeksExpect response in 2-4 weeks• If no responseIf no response
Change from H2RA to PPIChange from H2RA to PPI Maximize dose of PPIMaximize dose of PPI
Trial of MedicationsTrial of Medications
If PPI response inadequate despite If PPI response inadequate despite maximal dosage maximal dosage • Confirm diagnosisConfirm diagnosis
EGDEGD 24 hour pH monitor24 hour pH monitor
EsophagogastrodudenoscopyEsophagogastrodudenoscopy Endoscopy (with biopsy if Endoscopy (with biopsy if
needed)needed)• In patients with alarm In patients with alarm
signs/symptomssigns/symptoms• Those who fail a medication Those who fail a medication
trialtrial• Those who require long-term txThose who require long-term tx
Lacks sensitivity for Lacks sensitivity for identifying pathologic refluxidentifying pathologic reflux
Absence of endoscopic Absence of endoscopic features does not exclude a features does not exclude a GERD diagnosisGERD diagnosis
Allows for detection, Allows for detection, stratification, and stratification, and management of esophageal management of esophageal manisfestations or manisfestations or complications of GERDcomplications of GERD
pHpH
24-hour pH monitoring24-hour pH monitoring• Accepted standard for establishing or Accepted standard for establishing or
excluding presence of GERD for those excluding presence of GERD for those patients who do not have mucosal patients who do not have mucosal changeschanges
• Trans-nasal catheter or a wireless, Trans-nasal catheter or a wireless, capsule shaped devicecapsule shaped device
Patient with heartburn
Iniate tx with H2RA or PPI
H2RA taken BID
Good response
Frequent relapses
On demand tx
PPI taken QD
Good response
Maintenance therapywith lowest effective dose
Symptoms persist
Consider EGD if risk factors present(> 45, white, maleand > 5 yrs of sx)
Increase tomax dose QD or BID
Good response
Confirm diagnosisEGD, ph monitor
No
Yes YesNo
Yes
Yes
No
No
GERD vs DyspepsiaGERD vs Dyspepsia
Distinguish from DyspepsiaDistinguish from Dyspepsia• Ulcer-like symptoms-burning, epigastric Ulcer-like symptoms-burning, epigastric
painpain• Dysmotility like symptoms-nausea, Dysmotility like symptoms-nausea,
bloating, early satiety, anorexiabloating, early satiety, anorexia Distinct clinical entityDistinct clinical entity In addition to antisecretory meds and In addition to antisecretory meds and
an EGD need to consider an an EGD need to consider an evaluation for Helicobacter pylorievaluation for Helicobacter pylori
TreatmentTreatment
Goals of therapyGoals of therapy• Symptomatic reliefSymptomatic relief• Heal esophagitisHeal esophagitis• Avoid complicationsAvoid complications
Better LivingBetter Living Lifestyle modificationsLifestyle modifications
• Avoid large mealsAvoid large meals• Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate,
onions, garlic, peppermintonions, garlic, peppermint• Decrease fat intakeDecrease fat intake• Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal• Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches• Avoid meds that may potentiate GERD (CCB, alpha agonists, Avoid meds that may potentiate GERD (CCB, alpha agonists,
theophylline, nitrates, sedatives, NSAIDS)theophylline, nitrates, sedatives, NSAIDS)• Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist• Lose weightLose weight• Stop smokingStop smoking
TreatmentTreatment AntacidsAntacids
• Over the counter acid Over the counter acid suppressants and suppressants and antacids appropriate antacids appropriate initial therapyinitial therapy
• Approx 1/3 of patients Approx 1/3 of patients with heartburn-related with heartburn-related symptoms use at least symptoms use at least twice weeklytwice weekly
• More effective than More effective than placebo in relieving placebo in relieving GERD symptomsGERD symptoms
TreatmentTreatment
Histamine H2-Receptor AntagonistsHistamine H2-Receptor Antagonists• More effective than placebo and More effective than placebo and
antacids for relieving heartburn in antacids for relieving heartburn in patients with GERDpatients with GERD
• Faster healing of erosive esophagitis Faster healing of erosive esophagitis when compared with placebowhen compared with placebo
• Can use regularly or on-demandCan use regularly or on-demand
TreatmentTreatment
AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESCimetadine 400mg twice daily 400-800mg twice dailyCimetadine 400mg twice daily 400-800mg twice dailyTagametTagamet
Famotidine 20mg twice daily 20-40mg twice dailyFamotidine 20mg twice daily 20-40mg twice dailyPepcidPepcid
Nizatidine 150mg twice daily 150mg twice dailyNizatidine 150mg twice daily 150mg twice dailyAxidAxid
Ranitidine 150mg twice daily 150mg twice dailyRanitidine 150mg twice daily 150mg twice dailyzantaczantac
TreatmentTreatment
Proton Pump InhibitorsProton Pump Inhibitors• Better control of symptoms with PPIs vs Better control of symptoms with PPIs vs
H2RAs and better remission ratesH2RAs and better remission rates• Faster healing of erosive esophagitis Faster healing of erosive esophagitis
with PPIs vs H2RAswith PPIs vs H2RAs
TreatmentTreatment
AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESEsomeprazole 40mg daily 20-40mg dailyEsomeprazole 40mg daily 20-40mg dailyNexiumNexium
Omeprazole 20mg daily 20mg dailyOmeprazole 20mg daily 20mg dailyPrilosecPrilosec
Lansoprazole 30mg daily 15-10md dailyLansoprazole 30mg daily 15-10md dailyPrevacidPrevacid
Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg dailyProtonixProtonix
Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg dailyAciphexAciphex
TreatmentTreatment
H2RAs vs PPIsH2RAs vs PPIs• 12 week freedom from symptoms12 week freedom from symptoms
48% vs 77%48% vs 77%
• 12 week healing rate12 week healing rate 52% vs 84%52% vs 84%
• Speed of healingSpeed of healing 6%/wk vs 12%/wk6%/wk vs 12%/wk
TreatmentTreatment
Antireflux surgeryAntireflux surgery• Failed medical managementFailed medical management• Patient preferencePatient preference• GERD complicationsGERD complications• Medical complications attributable to a Medical complications attributable to a
large hiatal hernialarge hiatal hernia• Atypical symptoms with reflux Atypical symptoms with reflux
documented on 24-hour pH monitoringdocumented on 24-hour pH monitoring
TreatmentTreatment
Antireflux surgery candidatesAntireflux surgery candidates• EGD proven esophagitisEGD proven esophagitis• Normal esophageal motilityNormal esophageal motility• Partial response to acid suppressionPartial response to acid suppression
TreatmentTreatment
Antireflux surgeryAntireflux surgery• Tenets of surgeryTenets of surgery
Reduce hiatal herniaReduce hiatal hernia Repair diaphragmRepair diaphragm Strengthen GE junctionStrengthen GE junction Strengthen antireflux barrier via gastric Strengthen antireflux barrier via gastric
wrapwrap 75-90% effective at alleviating symptoms of 75-90% effective at alleviating symptoms of
heartburn and regurgitationheartburn and regurgitation
TreatmentTreatment
PostsurgeryPostsurgery• 10% have solid food dysphagia10% have solid food dysphagia• 2-3% have permanent symptoms2-3% have permanent symptoms• 7-10% have gas, bloating, diarrhea, 7-10% have gas, bloating, diarrhea,
nausea, early satietynausea, early satiety• Within 3-5 years 52% of patients back Within 3-5 years 52% of patients back
on antireflux medicationson antireflux medications
TreatmentTreatment
Endoscopic treatmentEndoscopic treatment• Relatively newRelatively new• No definite indicationsNo definite indications• Select well-informed patients with well-Select well-informed patients with well-
documented GERD responsive to PPI therapy may documented GERD responsive to PPI therapy may benefitbenefit
Three categoriesThree categories• Radiofrequency application to increase LES reflux Radiofrequency application to increase LES reflux
barrierbarrier• Endoscopic sewing devicesEndoscopic sewing devices• Injection of a nonresorbable polymer into LES areaInjection of a nonresorbable polymer into LES area
ComplicationsComplications
Erosive esophagitisErosive esophagitis StrictureStricture Barrett’s esophagusBarrett’s esophagus
ComplicationsComplications
Erosive esophagitisErosive esophagitis• Responsible for 40-60% of GERD Responsible for 40-60% of GERD
symptomssymptoms• Severity of symptoms often fail to match Severity of symptoms often fail to match
severity of erosive esophagitisseverity of erosive esophagitis
ComplicationsComplications
Esophageal Esophageal stricturestricture• Result of healing Result of healing
of erosive of erosive esophagitisesophagitis
• May need May need dilationdilation
ComplicationsComplications
Barrett’s EsophagusBarrett’s Esophagus• Columnar metaplasia Columnar metaplasia
of the esophagusof the esophagus• Associated with the Associated with the
development of development of adenocarcinomaadenocarcinoma
ComplicationsComplications Barrett’s EsophagusBarrett’s Esophagus
• Acid damages lining of Acid damages lining of esophagus and causes esophagus and causes chronic esophagitischronic esophagitis
• Damaged area heals in Damaged area heals in a metaplastic process a metaplastic process and abnormal columnar and abnormal columnar cells replace squamous cells replace squamous cellscells
• This specialized This specialized intestinal metaplasia intestinal metaplasia can progress to can progress to dysplasia and dysplasia and adenocarcinomaadenocarcinoma
ComplicationsComplications
• Patient’s who need EGDPatient’s who need EGD Alarm symptomsAlarm symptoms Poor therapeutic responsePoor therapeutic response Long symptom durationLong symptom duration
• ““Once in a lifetime” EGD for patient’s Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted with chronic GERD becoming accepted practicepractice
• Many patients with Barrett’s are Many patients with Barrett’s are asymptomaticasymptomatic
ComplicationsComplications
Barrett’s EsophagusBarrett’s Esophagus• Manage in same manner as GERDManage in same manner as GERD• EGD every 3 years in patient’s without EGD every 3 years in patient’s without
dysplasiadysplasia• In patients with dysplasia annual to In patients with dysplasia annual to
shorter interval surveillanceshorter interval surveillance
SummarySummary
Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManisfestationsClinical Manisfestations Diagnostic EvaluationDiagnostic Evaluation TreatmentTreatment ComplicationsComplications
?QUESTIONS??QUESTIONS?