Gastroesophageal Gastroesophageal Reflux DiseaseReflux Disease

Arthur Harris, M.D.Arthur Harris, M.D.GI Division, Jacobi Medical Center/NCBHGI Division, Jacobi Medical Center/NCBHAssistant Professor of Medicine, AECOMAssistant Professor of Medicine, AECOM

ObjectivesObjectives Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManifestationsClinical Manifestations 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

• Post-prandialPost-prandial• Short-livedShort-lived• Often asymptomaticOften asymptomatic• TLSER’sTLSER’s• 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 Manifestations Clinical Manifestations

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 ManifestationsClinical Manifestations

• 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

Potential Oral and Laryngopharyngeal Signs Potential Oral and Laryngopharyngeal Signs Associated with GERDAssociated with GERD

Edema and hyperemia Edema and hyperemia of larynxof larynx• Vocal cord erythema, Vocal cord erythema,

polyps, granulomas, polyps, granulomas, ulcersulcers

Hyperemia and Hyperemia and lymphoid hyperplasia lymphoid hyperplasia of posterior pharynx of posterior pharynx

Interarytenyoid Interarytenyoid changeschanges

Dental erosionDental erosion Subglottic stenosisSubglottic stenosis Laryngeal cancerLaryngeal cancer

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 monitoring24 hour pH monitoring

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 medication trialThose who fail medication trial• Those who require long-term RxThose who require long-term Rx

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 manifestations or manifestations or complications of GERDcomplications of GERD

Ambulatory pH TestingAmbulatory pH Testing 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

Ambulatory 24 hour pH Monitoring -1 Ambulatory 24 hour pH Monitoring -1

Physiologic studyPhysiologic study Quantify reflux in Quantify reflux in

proximal/distal proximal/distal esophagusesophagus• % time pH < 4% time pH < 4• DeMeester scoreDeMeester score

Symptom Symptom correlationcorrelation

Ambulatory 24 hour pH Monitoring -2Ambulatory 24 hour pH Monitoring -2

NormalNormal

GERDGERD

Wireless, Catheter-Free Esophageal pH Monitoring

Potential AdvantagesPotential Advantages

●●Improved patient Improved patient comfort and acceptancecomfort and acceptance ● ●Continued normal Continued normal work, activities and diet work, activities and diet during studyduring study ● ●Longer reporting Longer reporting periods possible (up to periods possible (up to 48 hours)48 hours) ● ●Maintain constant Maintain constant probe position relative to probe position relative to SCJSCJ

Esophageal ManometryEsophageal Manometry

Limited role in GERDLimited role in GERD

Assess LES pressure, Assess LES pressure, location and location and relaxationrelaxation• Assist placement of Assist placement of

24 hour pH catheter24 hour pH catheter Assess peristalsisAssess peristalsis

• Prior to anti-reflux Prior to anti-reflux surgery surgery

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 Yes No

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 anti-secretory meds In addition to anti-secretory meds

and an EGD, need to consider testing and an EGD, need to consider testing for Helicobacter pylorifor 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, caffeine, Avoid acidic foods (citrus/tomato), alcohol, caffeine,

chocolate, onions, garlic, peppermintchocolate, onions, 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 Avoid meds that may potentiate GERD (CCB, alpha

agonists, theophylline, nitrates, sedatives, NSAID’s)agonists, theophylline, nitrates, sedatives, NSAID’s)• Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist• Lose weightLose weight• Stop smokingStop smoking

TreatmentTreatment AntacidsAntacids

• O-T-C acid O-T-C acid suppressants and suppressants and antacids may be antacids may be appropriate initial appropriate initial therapytherapy

• 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

TreatmentTreatmentAGENT 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 PPI’s vs Better control of symptoms with PPI’s 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

TreatmentTreatmentAGENT 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 15-30mg dailyLansoprazole 30mg daily 15-30mg dailyPrevacidPrevacid

Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg dailyProtonixProtonix

Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg dailyAciphexAciphex

TreatmentTreatment H2RAs vs PPI’sH2RAs vs PPI’s

• 12 week freedom from symptoms12 week freedom from symptoms 48% vs 77%48% vs 77%

• 12 week esophagitis healing rate12 week esophagitis healing rate 52% vs 84%52% vs 84%

• Speed of healingSpeed of healing 6%/wk vs 12%/wk6%/wk vs 12%/wk

Treatment Modifications for Persistent SymptomsTreatment Modifications for Persistent Symptoms

Improve complianceImprove compliance Optimize pharmacokineticsOptimize pharmacokinetics

• Adjust timing of medication to 15 – 30 minutes Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime)before meals (as opposed to bedtime)

• Allows for high blood level to interact with Allows for high blood level to interact with parietal cell proton pump activated by the mealparietal cell proton pump activated by the meal

Consider switching to a different PPI Consider switching to a different PPI

TreatmentTreatment Anti-reflux surgery - IndicationsAnti-reflux surgery - Indications

• 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 pathologic reflux Atypical symptoms with pathologic reflux

documented on 24-hour pH monitoringdocumented on 24-hour pH monitoring

TreatmentTreatment Anti-reflux surgery candidatesAnti-reflux surgery candidates

• EGD proven esophagitisEGD proven esophagitis• ?Normal esophageal motility?Normal esophageal motility• Incomplete response to acid suppressionIncomplete response to acid suppression

TreatmentTreatment Anti-reflux surgery (laparoscopic)Anti-reflux surgery (laparoscopic)

• Tenets of surgeryTenets of surgery Reduce hiatal herniaReduce hiatal hernia Repair diaphragmRepair diaphragm Strengthen GE junctionStrengthen GE junction Strengthen anti-reflux barrier via gastric wrapStrengthen anti-reflux barrier via gastric wrap 75-90% effective at alleviating symptoms of 75-90% effective at alleviating symptoms of

heartburn and regurgitationheartburn and regurgitation

TreatmentTreatment Post-surgeryPost-surgery

• 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, up to 52% of patients Within 3-5 years, up to 52% of patients

back on anti-reflux medicationsback on anti-reflux medications

TreatmentTreatment Endoscopic treatmentEndoscopic treatment

• Relatively newRelatively new• No clearly established indicationsNo clearly established indications• Well-informed patients with well-documented Well-informed patients with well-documented

GERD responsive to PPI therapy may benefitGERD responsive to PPI therapy may benefit Three categoriesThree categories

• Radiofrequency application to increase LES reflux Radiofrequency application to increase LES reflux barrierbarrier

• Endoscopic sewing devicesEndoscopic sewing devices• Injection of a non-resorbable polymer into LES Injection of a non-resorbable polymer into LES

regionregion

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• Occurs as a Occurs as a

result of healing result of healing of erosive of erosive esophagitisesophagitis

• May need May need dilationdilation

Peptic StricturePeptic Stricture

Barium swallow Endoscopy

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 with abnormal columnar with abnormal columnar cells replacing cells replacing squamous cellssquamous cells

• 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

even shorter interval surveillance is even shorter interval surveillance is recommendedrecommended

SummarySummary Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManifestationsClinical Manifestations Diagnostic EvaluationDiagnostic Evaluation TreatmentTreatment ComplicationsComplications

?QUESTIONS??QUESTIONS?