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Evaluation and Management of GERD
MARIAM NAVEED, MDIPAS FALL CME 2018OCTOBER 9T H, 2018
Objectives
oDefinition of GERD
oEpidemiology of GERD
oPathophysiology of GERD
oClinical Manifestations
oDiagnostic Evaluation
oTreatment
oComplications
Definition The condition of chronic, pathologic reflux of acidic stomach contents
◦ Esophagus◦ Oropharynx◦ Larynx, even lungs
Leads to symptoms and/or mucosal damage◦ NERD (non-erosive reflux disease)= symptoms without damage◦ Symptoms may be typical or atypical
EpidemiologyoAbout 44% of the US adult population have heartburn at least once a month
o14% of Americans have symptoms weekly
o7% have symptoms daily
Typical SymptomsHeartburn
◦ Retrosternal burning sensation◦ Most commonly post-prandial, nocturnal◦ Fatty foods, spicy foods, acidic foods◦ Relived with antacids, water, milk◦ Worsened with recumbency
Acid Regurgitation◦ Perception of gastric content reflux in the mouth or hypopharynx◦ AKA water brash: bitter, acidic
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Atypical SymptomsAtypical
◦ Dysphagia, odynophagia◦ Nausea◦ Chest pain◦ Dyspepsia = non-severe upper abdominal discomfort
◦ Epigastric fullness, bloating
◦ Frequent belching◦ Heartburn
Extra-esophageal◦ Chronic cough◦ Hoarseness, laryngitis◦ Vocal Cord Dysfunction, Bronchospasm◦ Globus sensation
Complications of GERDPeptic stricture
Barrett’s Esophagus
Adenocarcinoma
Laryngitis
Pulmonary disease
Red Flags to warrant EGD Dysphagia/odynophagia
Nausea/vomiting
Melena, anemia*
Weight loss, anorexia
Extended duration of symptoms
No response to PPI
Family history of PUD
Caucasian Male, 50+ years old, sx > 10 yrs◦ Concern for Barrett esophagitis
Diagnosis
History
Trial of PPI
Upper Endoscopy
Esophageal pH monitoring (Gold Standard)
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
Diagnostic ConsiderationsEsophagitis
◦ Infectious: Fungal vs viral◦ Pill◦ Eosinophilic (Allergic)
H. pylori testing prior to PPI
CAD◦ Women◦ Elderly◦ Diabetics
Work-up
History + Empiric treatment
◦ Although a response to PPIs is not a definitive diagnosis of GERD, in clinical practice it is more appropriate to start empiric treatment than to pursue reflux pH monitoring
◦ Symptoms that do not improve warrant further evaluation to demonstrate the existence of GERD and evaluate for an alternate diagnosis
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Endoscopy with biopsyUpper endoscopy is not required for diagnosis
Indicated for suspected GERD plus◦ Red flags, or◦ Symptoms resistant to twice daily PPI therapy
Esophagitis or Barrett’s esophagus = diagnostic
Absence of endoscopic features does not exclude a GERD diagnosis
Remember NERD◦ 62% of patients with typical symptoms of GERD will have a normal EGD
Allows for detection, stratification, and management of esophageal manifestations or complications of GERD
Other diagnostic work up
Ambulatory pH monitoring◦ Persistent symptoms despite medical therapy◦ Confirmatory testing in patients with normal EGD
No Barium
Esophageal manometry for dysmotility
Initial Management of GERD
oAntacids and lifestyle changes
oH2-receptor antagonists
oStandard Proton pump inhibitor therapy
oHigh-dose Proton pump inhibitor therapy
oEndoscopy and/or pH testing followed by therapy based on results
Treatment: 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
Treatment: H2RA vs PPI 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
Proton Pump Inhibitor TestEmpiric therapy with PPI for heartburn
Functions as both diagnostic test and therapeutic trial
Sensitivity 68-80% as defined by abnormal pH test or endoscopy
May be falsely positive (does not actually make a true diagnosis or GERD)
Kahrilas PJ. Am J Gastro 2003;98: S15-23
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H2RAs block the histamine receptor, interfering with one of the stimulation pathways
PPIs block acid at its source in the proton pump
ACh=acetylcholine
PPI Mechanism of ActionAntacids neutralize secreted HCl
HCI
HistamineACh
Gastrin
K+H+
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
Reasons for PPI “Failure”Patient non-compliance
Persistent esophageal acid exposure ◦ Hypersecretory state◦ Large hiatal hernia◦ Nocturnal acid breakthrough
Acid-sensitive esophagus
Non-acid reflux
Wrong diagnosis
Functional heartburn (NOT GERD!!)
Treatment: Surgical Options 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
Anti-reflux surgery candidates◦ EGD proven esophagitis◦ ?Normal esophageal motility◦ Incomplete response to acid suppression
Treatment: Surgical Options 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
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
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Anti-reflux surgeryThe efficacy of anti-reflux surgery in controlling GERD is similar to that of chronic PPI therapy.
The outcome of anti-reflux surgery is highly dependent on the skill and experience of the surgeon.
Surgery does not always end the need for antisecretory therapy to control the symptoms of GERD.
Lundell et al 2001; Spechler et al 2001
Treatment: Endoscopic 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
Patient with heartburn
Initiate Rx with H2RA or PPI
H2RA taken
BID
Good response
Frequent relapses
On demand Rx
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
?QUESTIONS?