GASTROESOPHAGEAL REFLUX

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Gordon Alexander
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1 DR. PHILIP K. BLUSTEIN M.D. F.R.C.P.(C) TH ST. NW. CALGARY AB T2N2A1 PHONE (403) FAX (404) GASTROESOPHAGEAL REFLUX DEFINITION: *MONTREAL CONSENSUS DEFINED GERD AS A CONDITION WHICH DEVELOPS WHEN THE REFLUX OF STOMACH CONTENTS CAUSES TROUBLESOME SYMPTOMS AND/OR COMPLICATIONS *GERD IS DIAGNOSED BY ITS SYMPTOMS. IT IS IMPORTANT THAT WHEN A PATIENT SAYS THEY HAVE HEARTBURN HAVE THEM SPECIFY WHAT THEY MEAN * RETROSTERNAL BURNING SENSATION THAT MAY RISE TO THE BACK OF THE THROAT AND ACID REGURGITATION DEFINES REFLUX HISTORY OF SYMPTOMS: *RETROSTERNAL BURNING PAIN *WHAT TIME OF DAY IS THE HEARTBURN WORSE (AM, NOCTURNALLY) *IS IT MEAL RELATED *REGURGITATION OF FLUID *ANY ASSOCIATED ANOREXIA, WEIGHT LOSS, NAUSEA, VOMITING, DYSPHAGIA THAT CAN BE AN ALARM SYMPTOM *CHEST PAIN *GAS, BLOATING, IRREGULAR BOWEL PATTERN THAT WOULD SUGGEST AN ASSOCIATED IRRITABLE BOWEL SYNDROME *ATOPIC HISTORY (FOOD ALLERGIES, SEASONAL ALLERGIES, ALLERGIES TO ANIMALS, ASTHMA, ATOPIC DERMATITIS) THAT COULD SUPPORT THE DIAGNOSIS OF EOSINOPHILIC ESOPHAGITIS *RAYNAUD S PHENOMENA THAT SUGGEST SCLERODERMA *VOICE CHANGE, GLOBUS SENSATION, COUGH, ASTHMA THAT COULD SUGGEST EXTRAESOPHAGEAL SYMPTOMS HISTORY OF PRECIPITATING FACTORS: *RECENT WEIGHT GAIN OFTEN AFTER STOPPING SMOKING *NEW ONSET STRESS *NEW MEDS INVESTIGATIONS: INVESTIGATION IS NOT INDICATED FOR UNCOMPLICATED REFLUX

2 1) RADIOLOGIC INVESTIGATONS CINE ESOPHAGRAM: *CINE ESOPHAGRAM MAY BE OF VALUE AS THE INITIAL TEST IN THE EVALUATION OF CRICOPHARYNGAL DYSPHAGIA TO RULE OUT A ZENKER S DIVERTICULUM, CRICOPHARYNGEAL ACHALASIA OR A CRICOPHARYNGEAL WEB *MAY BE OF VALUE IN GASTROSCOPY NEGATIVE DYSPHAGIA TO LOOK FOR ACHALASIA UGI SERIES: *MAY INDICATE ACHALASIA, PARAESOPHAGEAL HERNIA, GASTRIC VOLVULUS *MAY BE OF VALUE IN GASTROSCOPY NEGATIVE DYSPHAGIA, EARLY SATIETY AND VOMITING MODIFIED BARIUM SWALLOW: *INDICATED FOR CRICOPHARYNGEAL DYSPHAGIA ESPECIALLY IF ONE IS CONCERNED ABOUT A TRANSFER DISORDER *DONE WITH A SPEECH PATHOLOGIST PRESENT *PERFORMED AT A HOSPITAL XRAY SETTING 2) GASTROSCOPY INDICATIONS: *GASTROSCOPY IS PREFERRED TO XRAY FOR EVALUATION OF LOWER RETROSTERNAL DYSPHAGIA AND SYMPTOMS INSPITE OF MEDICAL THERAPY *DYSPHAGIA THAT DOES NOT RESOLVE WITH 2-4 WEEKS OF PPI THERAPY *HEARTBURN ASSOCIATED WITH ALARM SYMPTOMS (WEIGHT LOSS, ANOREXIA, VOMITING, BLEEDING, ANEMIA) *PERSISTENT RETROSTERNAL BURNING INSPITE OF A 4 WEEK TRIAL WITH A BID PPI *SEVERE ENDOSCOPIC EROSIVE ESOPHAGITIS AFTER A 2 MONTH COURSE OF PPI THERAPY TO ASSESS HEALING AND RULE OUT A BARRETT S ESOPHAGUS *SCREENING FOR BARRETT S IN WHITE MALES OVER AGE 50 WITH CHRONIC REFLUX (HEARTBURN LONGER THAN 5 YEARS), FREQUENT REFLUX (SEVERAL TIMES A WEEK) AND ADDITIONAL RISK FACTORS (NOCTURNAL REFLUX SYMPTOMS, SMOKING, HIATUS HERNIA, ELEVATED BODY MASS INDEX AND ABDOMINAL ADIPOSITY *SURVEILLANCE IN PATIENTS WITH A DOCUMENTED BARRETT S ESOPHAGUS *PRESURGICAL EVALUATION GASTROSCOPY IS NOT INDICATED FOR: *RETROSTERNAL BURNING THAT RESPONDS TO A PPI AND THERE ARE NO ALARM SYMPTOMS 3) BREATH TEST FOR HELICOBACTER PYLORI: *A BREATH TEST IS NOT INDICATED IN THE EVALUATION OF REFLUX *THEORETICALLY HP MAY BE PROTECTIVE FOR REFLUX AS IN THE MAJORITY OF CASES IT CAUSES PANGASTRITIS WITH GASTRIC ATROPHY AND DECREASED ACID PRODUCTION

3 4) INDICATIONS FOR ESOPHAGEAL MOTILITY, 24 HR ph AND IMPEDANCE TESTING: *GASTROSCOPY NEGATIVE DYSPHAGIA *RETROSTERNAL BURNING INSPITE OF BID PPI THERAPY TO LOOK FOR NON ACID REFLUX *CHEST PAIN WHERE CARDIAC CAUSE HAS BEEN RULED OUT *IF EXTRAESOPHAGEAL SYMPTOMS (COUGH, VOICE CHANGE, GLOBUS) ARE SECONDARY TO REFLUX *BEFORE NISSEN FUNDOPLICATION TO ENSURE ACHALASIA IS NOT PRESENT TREATMENT: EMPERICAL MEDICAL TREATMENT IS INDICATED FOR UNCOMPLICATED REFLUX LIFESTYLE MODIFICATIONS: *WEIGHT LOSS FOR OVERWEIGHT OR OBESE PATIENTS *AVOID FOODS THAT MAY PRECIPITATE HEARTBURN SUCH AS COFFEE, ALCOHOL, CHOCOLATE, FATTY FOODS, ACIDIC FOODS (CITRUS, CARBONATED DRINKS, SPICY FOODS) *STOP SMOKING *IF NOCTURNAL RELUX ELEVATE THE HEAD OF THE BED *DO NOT LIE DOWN AFTER MEALS *NO FOOD FOR SEVERAL HOURS BEFORE BEDTIME *EMPERICALLY GLUTEN FREE DIET CAN BE OF VALUE IN SOME PATIENTS PHARMACOLOGIC TREATMENT: *ANTACIDS AND GAVISCON GAVISCON MAY BE EFFECTIVE IN POSTPRANDIAL REFLUX *H2 RECEPTOR ANTAGONISTS 50% EFFECTIVE IN THE TREATMENT OF REFLUX LONG TERM USE CAN LEAD TO TACHYPHYLAXIS *PPI S 80% EFFECTIVE IN THE TREATMENT OF REFLUX PPI SIDE EFFECTS: *INCREASED RISK OF VITAMIN B12 DEFICIENCY IN ELDERLY INSTITUTIONALIZED PATEINTS *INCREASED RISK OF CLOSTRIDIUM DIFFICILE AND ENTERIC INFECTIONS *NOT A PROVEN FACTOR IN CAUSING HIP FRACTURES OR OSTEOPOROSIS *CAN BE TAKEN WITH PLAVIX TREATMENT STRATEGIES: *TREAT MILD AND INFREQEUNT HEARTBURN (FEWER THAN 3 TIMES A WEEK) WITH PRN ANTACIDS, GAVISCON AND OTC H- 2 RECEPTOR ANTAGONISTS *FOR MORE SIGNIFICANT HEARTBURN PPI S ARE MORE EFFECTIVE THAN H- 2 RECEPTOR ANTAGONISTS

4 *IF THE HEARTBURN IS PREDOMINANTLY SYMPTOMATIC IN THE MORNING AND AFTERNOON TREAT WITH A PPI IN THE MORNING BEFORE BREAKFAST *IF THE HEARTBURN IS PREDOMINANTLY SYMPTOMATIC AFTER DINNER AND NOCTURNALLY TREAT WITH A PPI BEFORE DINNER *PPI S ARE MOST EFFECTIVE PRIOR TO A MEAL *DO NOT USE A PPI AT BEDTIME *IF THE PATIENT DOES NOT IMPROVE AFTER 4 WEEKS OF A PPI ONCE A DAY SWITCH TO AN ALTERNATE PPI *IT IS INTERESTING THAT SOME PATIENTS WILL RESPOND TO ONE PPI AND NOT ANOTHER *IF THE PATIENT DOES NOT IMPROVE AFTER 4 WEEKS OF THE ALTERNATE PPI THEN TRY A BID DOSE OF THE PPI FOR 4 WEEKS *WITH LONG TERM THERAPY USE THE LOWEST DOSE OF A PPI POSSIBLE BASED ON SYMPTOM CONTROL *PATIENTS CAN TAKE A PPI ON AN ON DEMAND BASIS FOR UNCOMPLICATED REFLUX *IF THERE IS PREDOMINANT NOCTURNAL HEARTBURN INSPITE OF A PPI, A 4 WEEK TRIAL OF AN H2R ANTAGONIST (RANITIDINE 300 MG) AT BEDTIME IN ADDITION TO THE PPI MAY BE EFFECTIVE ALTHOUGH THERE IS NOT GOOD EVIDENCE TO SUPPORT THIS AND CONTINUAL USE OF AN H2R LEADS TO TACHYPHYLAXIS *IF THERE IS SYMPTOMS OF EARLY SATIETY AND BLOATING TO SUGGEST AN ASSOCIATED GASTRIC MOTILITY DISORDER A 4 WEEK TRIAL WITH MOTILIUM 10 MG PO AC (NOT TO EXCEDE TID) MAY HELP ALTHOUGH THERE IS NOT GOOD EVIDENCE TO SUPPORT THIS *A BASLINE ECG MUST BE OBTAINED PRIOR TO THE USE OF MAXERAN OR MOTILIUM TO ENSURE THERE IS NO UNDERLYING QT ISSUE *PROKINETIC DRUGS (MOTILIUM, MAXERAN) ARE ONLY OF VALUE IN GERD IF THERE IS ASSOCIATED GASTROPARESIS *IF THERE IS ASSOCIATED CONSTIPATION OF THE IRRITABLE BOWEL SYNDROME TREATMENT OF THE CONSTIPATION MAY HELP THE UPPER GI SYMPTOMS. ALWAYS ENQUIRE IF THERE IS ASSOCIATED COLONIC SYMPTOMS (GAS, BLOATING, CONSTIPATION) DAILY MAINTENANCE WITH AT LEAST A ONCE A DAY PPI THERAPY IS INDICATED FOR: *ENDOSCOPIC EROSIVE OR ULCERATIVE ESOPHAGITIS *BARRETT S ESOPHAGUS *PEPTIC STRICTURE

5 RESISTANT HEARTBURN: *BEWARE OF THE PATIENT WHO DOES NOT RESPOND TO BID PPI THERAPY. THIS IS UNLIKLEY REFLUX! *IF A PATIENT FAILS TO RESPOND TO A BID PPI THEN WE MAY BE DEALING WITH INEFFECTIVE ACID SUPPRESSION, NONACID REFLUX, MOTILITY DISORDER AND FUNCTIONAL HEARTBURN *INITIALLY EVALUATE IF THE PATIENT IS COMPLIANT AND IF THEY ARE TAKING THEIR PPI S BEFORE MEALS *THESE PATIENTS MAY REQUIRE AN ESOPHAGEAL MOTILITY, 24 HR ph AND IMPEDANCE TEST ON A BID PPI *THE COMMONEST REASON FOR RESISTANT HEARTBURN IS FUNCTIONAL HEARTBURN FUNCTIONAL HEARTBURN: *THAT REFLECTS ESOPHAGEAL HYPERSENSITIVITY TO MECHANICAL AND CHEMICAL STIMULI WITH HEIGHTENED CENTRAL SENSITIZATION *THIS IS ESOPHAGEAL EQUIVALENT OF THE IRRITABLE BOWEL SYNDROME *ESOPHAGEAL SYMPTOMS INSPITE OF BID PPI THERAPY *STRESS MAY BE A SIGNIFICANT FACTOR IN FUNCTIONAL HEARTBURN. ALWAYS ENQUIRE WHETHER STRES IS PLAYING A ROLE IN THEIR SYMPTOMS TREATMENT OF FUNCTIONAL HEARTBURN: LOW DOSE TRICYCLICS (DESIPRAMINE 25 MG PO QHS INCREASING BY 25 MG WEEKLY UNTIL ONE REACHES 150 MG PO QHS FOR A 4 WEEK TRIAL AT THE MAXIMAL DOSE) SNRI (DULOXETINE MG PO OD) FOR EFFECTIVE STRESS MANAGEMENT STRATEGIES HAVE YOUR PATIENT VISIT THE WEBSITE: SURGERY INDICATIONS: *PATIENT RESPONDS TO PPI THERAPY BUT DOES NOT WANT TO TAKE MEDS DUE TO PREFERENCES, COST OR SIDE EFFECTS *IDEALLY IF THE PATIENT RESPONDS TO PPI THERAPY THIS IS THE PREFERRED TREATMENT *PATIENT DOES NOT RESPOND TO PPI THERAPY AND REFLUX HAS BEEN OBJECTIVELY CONFIRMED *LARGE VOLUME REGURGITATION (NON ACID REFLUX)

6 NECESSARY INVESTIGATIONS PRIOR TO SURGERY: *GASTROSCOPY TO ENSURE NO OTHER ORGANIC CAUSE FOR THE PATIENTS SYMPTOMS *PATIENTS MUST HAVE REFLUX OBJECTIVELY CONFIRMED BY EITHER: GASTROSCOPY DEMONSTRATING EROSIVE AND ULCERATIVE ESOPHAGITIS Or A 24 HR ph TEST DEMONSTRATING INCREASED REFLUX IF THE GASTROSCOPY IS NORMAL *ESOPHAGEAL MOTILITY STUDY TO RULE OUT ACHALASIA DYSPHAGIA: CRICOPHARYNGAL DYSPHAGIA DIFFERENTIAL DIAGNOSIS: *ZENKER S DIVERTICULUM *CRICOPHARYNGEAL ACHALASIA (CRICOPHARYNGEAL MUSCLE FAILS TO RELAX) *CRICOPHARYNGEAL BAR *TRANSFER MOTILITY DISORDER *GERD INVESTIGATIONS: *CINE ESOPHGRAM OR MODIFIED BARIUM SWALLOW AS FIRST LINE INVESTIGATION PRIOR TO A GASTROSCOPY *IF THE XRAY IS NORMAL THEN PROCEDE TO A GASTROSCOPY LOWER RETROSTERNAL DYSPHAGIA DIFFERENTIAL DIAGNOSIS *PEPTIC STRICTURE *CANCER *SCHATZKI S RING *EOSINOPHILIC ESOPHAGITIS *ACHALASIA *PARAESOPHAGEAL HERNIA *ESOPHAGEAL DIVERTICULUM *EXTRINSIC COMPRESSION INVESTIGATIONS: *GASTROSCOPY AS THE FIRST LINE INVESTIGATION *IF THE GASTROSCOPY IS NORMAL THEN CINE ESOPHAGRAM AND ESOPHAGEAL MOTILITY STUDY

7 BARRETT S ESOPHAGUS: *THIS REFLECTS A METAPLASTIC CHANGE IN THE ESOPHAGEAL MUCOSA FROM A NORMAL SQUAMOUS LINING TO A SPECIALIZED COLUMNAR LINING WITH INTESTINAL METAPLASIA *5-8% OF PATIENTS WITH REFLUX MAY DEVELOP A BARRETT S ESOPHAGUS *PATIENTS WITH A BARRETT S ESOPHAGUS WITHOUT DYSPLASIA HAVE A 0.25% PER PATIENT- YEAR RISK OF DEVELOPING AN ESOPHAGEAL ADENOCARCINOMA *SYMPTOMS ARE NOT HELPFUL IN MAKING THIS DIAGNOSIS *GERD TENDS TO PRESENT AS PHENOTYPIALLY DISTINCT CATEGORIES (NONEROSIVE, EROSIVE ESOPHAGITIS AND BARRETT S ESOPHAGUS) RATHER THAN AS A PROGRESSIVE DISEASE FROM NONEROSIVE ESOPHAGITIS TO EROSIVE ESOPHAGITIS TO A BARRETT S ESOPHAGUS *THEREFORE ENDOSCOPICALLY MONITORING PATIENTS WITH GERD IS NOT INDICATED *A ONCE IN A LIFETIME SCREENING GASTROSCOPY MAY BE INDICATED FOR WHITE MALES OVER AGE 50 WITH A HISTORY OF REFLUX FOR LONGER THAN 5 YEARS AND ADDITIONAL RISK FACTORS (HIATUS HERNIA, SMOKING, NOCTURNAL REFLUX, ABDOMINAL ADIPOSITY AND ELEVATED BODY MASS INDEX) *NO NEED TO REPEAT THE GASTROSCOPY IF THE INITIAL SCOPE WAS NORMAL AND THERE HAS BEEN NO WORRISOME CHANGES IN THE PATIENT S SYMPTOMS SURVEILLANCE OF A BARRETT S ESOPHAGUS: IF NO DYSPLASIA: *FOLLOWUP GASTROSCOPY EVERY 3-5 YEARS IF LOW GRADE DYSPLASIA: *FOLLOWUP GASTROSCOPY IN 6 MONTHS *IF NO DYSPLASIA AT THAT POINT FOLLOWUP GASTROSCOPY IN 1 YEAR IF HIGH GRADE DYSPLASIA: *REVIEW OF THE PATHOLOGY *CONSIDER ENDOSCOPIC MUCOSAL RESECTION TO REMOVE ANY FOCAL HIGH GRADE LESIONS AND RADIOFREQUENCY ABLATION OF THE UNDERLYING BARRETT S

8 EOSINOPHILIC ESOPHAGITIS: *THIS IS A CONDITION WHERE ESPECIALLY YOUNG MALES PRESENT WITH DYSPHAGIA AND FOOD IMPACTION *AT GASTROSCOPY THERE MAY BE CHARACTERISTIC FINDINGS OF ESOPHAGEAL RINGS AND VERTICAL FURROWS *ONE NEEDS BIOPSY CONFIRMATION WITH THE PRESENCE OF AT LEAST 15 EOSINOPHILS PER HIGH POWER FIELD *IT REFLECTS AN AUTOIMMUNE PROCESS CHARACTERIZED PATHOLOGICALLY BY AN INCREASED ESOPHAGEAL EOSINOPHIL COUNT *THIS MAY BE SECONDARY TO REFLUX OR AN ALLERGIC REACTION TO FOODS AND AEROALLERGENS *ENQUIRE INTO AN ATOPIC HISTORY SUCH AS ALLERGIES TO FOODS AND ANIMALS, SEASONAL ALLERGIES, ASTHMA, ATOPIC DERMATITIS, ALLERGIC RHINITIS *TREATMENT CONSISTS OF ESOPHAGEAL DILATATION, PPI, FLOVENT SWALLOWED, ORAL VISCOUS BUDESONIDE AND FOOD ELIMINATION DIETS EXTRAESOPHAGEAL SYMPTOMS: *PATIENTS CAN PRESENT WITH OTOLARYNGOLIC AND PULMONARY SYMPTOMS FROM REFLUX SUCH AS COUGH, LARYNGITIS (VOICE CHANGE, HOARSE VOICE), GLOBUS (LUMP LIKE SENSATION) AND ASTHMA *IN THE ABSENCE OF RETROSTERNAL BURNING IT IS UNLIKELY THAT REFLUX IS THE CAUSE OF OTOLARYNGOLIC OR PULMONARY SYMPTOMS *IF THE PATIENT HAS CONCOMITANT ESOPHAGEAL REFLUX SYMPTOMS (RETROSTERNAL BURNING) ONE CAN EMPERICALLY TREAT WITH AN 8 WEEK TRIAL OF A BID PPI *IT THEY RESPOND DECREASE THE PPI TO THE LOWEST DOSE THAT IS EFFECTIVE FOR SYMPTOM CONTROL *IF THEY FAIL THE PPI TRIAL LOOK FOR A NONESOPHAGEAL CAUSE *THERE ARE NO CHARACTERISITC VOCAL CORD FINDINGS OF REFLUX

9 NONCARDIAC CHEST PAIN: *CARDIAC CAUSES MUST BE RULED OUT INITIALLY *EMPERICAL TRIAL WITH A PPI BID FOR 4 WEEKS TO RULE OUT AN ESOPHAGEAL CAUSE *IF THEY RESPOND TO THE PPI TRIAL DECREASE THE PPI TO THE LOWEST DOSE THAT IS EFFECTIVE *IF THE PATIENT FAILS TO RESPOND TO THE PPI TRIAL REFER FOR AN ESOPHAGEAL MOTILITY, 24 HR ph AND IMPEDANCE TEST ON A BID PPI TO RULE OUT AN UNDERLYING MOTILITY DISORDER OR REFRACTORY REFLUX

Speaker disclosure. Objectives. GERD: Who and When to Treat 7/21/2015

Speaker disclosure. Objectives. GERD: Who and When to Treat 7/21/2015 GERD: Who and When to Treat Eugenio J Hernandez, MD Gastrohealth, PL Assistant Professor of Clinical Medicine, FIU Herbert Wertheim School of Medicine Speaker disclosure I do not have any relevant commercial