GERD DIAGNOSIS & TREATMENT Subhash Chandra MBBS Assistant Professor CHI Health Clinic Gastroenterology Creighton University, School of Medicine April 28, 2018 DISCLOSURES None 1
OBJECTIVES Review update in pathophysiology of have changed diagnostic strategy in GERD Review update in pathophysiology of have changed treatment strategy in GERD Review a management strategy Gut. 2014 Jun;63(6):871-80 2
PATHOPHYSIOLOGY Multifactorial process Dysfunction of mechanisms that Prevent GER, Clear noxious material rapidly from the esophagus Recent work suggests that the injury to GER is cytokine mediated instead of traditional thinking of chemical injury of surface epithelium JAMA 2016;315:2104 Makes a case for biopsies even if erosive esophagitis is not seen. JAMA 2016;315:2104 3
Acid Pocket Gastroenterology. 2001 Oct;121(4):775-83 4
Neurogastroenterol Motil 2009 ; 21:725 e42 Acid Pocket The median time for onset of the acid pocket is 14 min. Presence of a large hiatus hernia is an independent risk factor for acidic reflux to occur during a TLESR. Am J Gastroenterol 2009 ; 104 : 2714 20 Gut. 2010 Apr;59(4):441-51 5
Acid Pocket as a Target of Treatment Prokinetic agents suppress acid pocket. PPIs smaller and less acidic Alginate preparations formation of a raft at the air meal interface Am J Gastroenterol 2009 ; 104 : 2714 20 Gut. 2010 Apr;59(4):441-51 Aliment Pharmacol Ther. 2013 Jun;37(11):1093-102 6
J Gastroenterol (2012) 47:760 769 DIAGNOSIS A condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications Montreal definition Am J Gastroenterol. 2006 Aug;101(8):1900-20 7
Establishing the Diagnosis 1. A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation. 2. Empiric medical therapy with a PPI is recommended in this setting. Limited sensitivity and and specificity, both improve with combination. Am J Gastroenterol 2013; 108:308 328 8
Establishing the Diagnosis Further testing: Ambulatory reflux monitoring, ph or impedance-ph Upper endoscopy Barium radiographs is NOT Am J Gastroenterol 2013; 108:308 328 Ambulatory Reflux Monitoring Only test that can assess reflux symptom association 9
Ambulatory Reflux Monitoring Patients refractory to PPI therapy Diagnosis of GERD is in question Before consideration of endoscopic or surgical therapy in patients with NERD In these cases, PPIs should be held for 7 days prior to the procedure Upper Endoscopy Can answer the three clinical questions Is there reflux esophagitis? Establishes a diagnosis, PPIs likely needed indefinitely Is there an esophageal stricture? Is there Barrett s esophagus? PPIs are needed, esophageal dilation may be needed Surveillance should be advised 10
Troubles Normal endoscopic examination does not eliminate GERD as a cause of symptoms. Heartburn severity is not a reliable index of the presence or severity of esophagitis. Esophagus typically appears normal endoscopically in patients who have only extra-esophageal symptoms. Elderly patients with GERD experience a more severe mucosal disease that is associated with overall milder and more atypical symptoms Guidelines Endoscopy with biopsies is recommended for patients with an esophageal GER syndrome and.. Troublesome dysphagia Not responded to an empirical trial of twice-daily PPI therapy For screening of patients at high risk for complications 11
Risk Factors for Complications Men with chronic (>5 years) and/or frequent (weekly or more) symptoms of GERD (heartburn or acid regurgitation) and two or more risk factors Age 50 years, White race, Central obesity History of smoking, A confirmed family history of Barrett s esophagus or esophageal adenocarcinoma (in a first-degree relative) Women with multiple risk factors. Non-Erosive Reflux Disease (NERD) Presence of troublesome, reflux-related symptoms in the absence of endoscopically-visible mucosal breaks Harder to treat 12
TREATMENT Gut Liver. 2018 Jan 15;12(1):7-16 13
Medical Management PPIs are: The most cost effective Better symptom response in NERD Better mucosal healing on erosive esophagitis Newer PPIs are not better than omeprazole Esomeprazole has very small relative increase in the probability of GERD symptom relief. Medical Management Dexlansoprazole Is effective as a sole PPI in patients who require standard dose PPI twice daily to control their symptoms. The convenience of being able to dose the drug any time of the day regardless of food intake. Omeprazole-sodium bicarbonate Can control nighttime ph when given at bedtime Can be chosen specific patients 14
Medical Management 70 80 % of patients with ERD would demonstrate complete relief on PPI therapy and 60 % of patients with NERD >85% healing of esophagitis with once daily PPIs Clinical Primer Heartburn & regurgitation Chest pain GERD+ dysphagia or high risks for complication Wt loss HEB elevation, Avoidance of meals 2-3 h before bedtime Omeprazole 20 mg before breakfast Confirms diagnosis Discuss exit strategy 8-week FU R/o cardiac cause Therapy optimization Lifestyle modification Improve compliance Ensure proper dosing time Split the PPI dose Switch to another PPI Referral for diagnostic evaluation 8-week FU EGD Male Age 50 years White race Central obesity History of smoking 1 0 family hx EAC/BE Abnormal with symptom correlation GERD Treat the mucosal abnormalities Impedance + ph off PPIs Normal with symptom correlation Esophageal hypersensitivity Normal with no symptom correlation Functional heartburn 15
Refractory Heartburn Esophageal GERD that do not respond to a double dose of a PPI given for at least 8 weeks Psychological comorbidity Compliance Improper dosing time Functional hearburn Esophageal hypersensitivity Delayed gastric emptying Eosinophilic esophagitis Bile reflux Nonacid reflux Rapid PPI metabolism, PPI resistance Refractory Heartburn H2RA - night time but tachyphylaxis is real Gaviscon helps to target acid pocket Baclofen helps to target TLESRs 16
Surgical Therapy Candidates Symptomatic with a large hiatal hernia Abnormal ph test on maximum PPI dose Symptoms correlate with nonacid reflux while on maximum PPI dose Concern about or wish to discontinue chronic medical therapy Poor compliance with medical therapy Not interested in medical therapy Endoluminal Therapies Transoral incisionless fundoplication 17
Stretta Anti-Reflux Mucosectomy 18
Potential risks associated with PPIs Osteoporosis Clostridium difficile infection Community-acquired pneumonia short term Concomitant clopidogrel users does not appear to be an increased risk for adverse cardiovascular events B12 def, small intestinal bacterial overgrowth Hypomagnesemia 19
Extraesophageal Syndromes of GER Asthma, chronic cough, laryngitis and dental erosion Careful evaluation for non-gerd causes should be done Diagnosis of reflux laryngitis should not be made based solely upon laryngoscopy findings PPI trial is recommended but EGD is not for diagnosis Ambulatory ph-impedance monitoring is an option for 20
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