In the Name of God. Refractory GERD

In the Name of God Refractory GERD S Nasseri-Moghaddam MD, MPH, AGAF Associate Professor of Medicine Digestive Disease Research Institute Shariati Hospital, TUMS sianasseri@yahoo.com IAGH meeting, Ordibehesht 1394 (May 21, 2015), Tehran Difestive Health Day 2015: Heartburn

GERD: Definition, The Montreal Consensus Vakil N, et al. AJG 2006;101:1900 1920 A condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications characteristic symptoms: Retrosternal burning (often labeled heartburn) and regurgitation, and the most common manifestation of esophageal injury is reflux esophagitis

The overall definition of GERD Vakil N, et al. AJG 2006;101:1900 1920

The LA Classification system for the endoscopic assessment of reflux esophagitis Grade A Grade B One (or more) mucosal break, no longer than 5 mm, that does not extend between the tops of two mucosal folds One (or more) mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds Grade C Grade D One (or more) mucosal break that is continuous between the tops of two or more mucosal folds, but which involves less than 75% of the circumference One (or more) mucosal break athat involves at least 75% of the esophageal circumference Lundell et al 1999

Mainstays of treatment Lifestyle modification Acid-suppressive therapy, mainly PPIs PPIs introduced in 1989 They changed our understanding of GERD Prior to that: H2Bs Refractory GERD: usually severe erosive ones with strictures and ulcers Thereafter, most pts responsive, definition changed (refractory symptoms rather than refractory mucosal disease)

Refractory GERD: Definition No or partial response to PPIs once or twice daily for 4-8 weeks 10-40% of cases Most NERD

Mechanisms

Most common causes of non-response to PPIs

Potential Reasons Why GERD Symptoms: Might Persist During PPI Therapy Abnormal acid reflux causes symptoms Normal acid reflux causes symptoms (Hypersensitive esophagus) Non-acidic reflux causes symptoms Esophageal ph/impedance monitoring Non-GERD esophageal disorders cause symptoms Endoscopy/Esophageal manometry/ba swallow Extra-esophageal disorders cause symptoms Test for heart/biliary/other disorders Symptoms are functional

Approach to the patient with refractory GERD Revisit patient s symptoms

PPI efficacy for potential manifestations of GERD

Case-1 A 32 Y/O lady, physician refers for evaluation of heartburn and acid regurgitation of several years duration She takes PPIs erratically with partial improvement She also takes Xanax and Citalopram for her anxiety and depression symptoms She had an EGD done 6 years before which was reported to be WNL On P/E she looked somewhat obsessive and had tenderness in the subxiphoid area, otherwise WNL, wt: 63kg

How will you get along with her?

Appropriate dietary/lifestyle advice were given and the patient started on Omeprazole 20mg bid (before breakfast and dinner) On follow-up 8 weeks later, she stated that has improved but still has some HB/AR a couple of times a week, especially in the morning P/E is essentially unchanged What will you recommend

After checking for compliance w Rx and appropriate timing of the medication, Ranitidine 300mg was added at bedtime After 8 weeks she stated that her symptoms are still there and awakens her at night She stated that she feels the acid odor coming out from her mouth and her husband admitted to that How will you continue with her?

EGD: GEJ nodularity, otherwise WNL, HP-ve Upper and lower esophageal 4 quarant bx: Upper esophagus: WNL Lower esophagus: moderate reflux esophagitis No evidence for eosinophilic esophagitis GEJ: Severe chronic follicular gastritis, focal atypical changes, HP-ve Ba swallow: WNL Abdominal sonography: WNL LFT, ESR, CBC, dif, OBPx3, FBS, Creatinine, Ca: WNL

How will you progress with her? Does increasing the dose of Omeprazole, or increasing its dosing frequency help? Does switching to another PPI help? If yes, what will you recommend? How about adding Baclofen? May any other lab tests help? Does probing for other treatments she takes help?

She stated that she takes Depakin, Librium, Triametrene-H, Dimenhydrinate, betasurge, and Cinarzinal She was switched to Rabezole (Pariet) 40mg bid, and Baclofen 10mg tid (before each meal) was added In 4 weeks she stated that has improved much but still experiences HB 2x/week

What will you recommend? Continue as such and intervene if symptoms get worse Send the patient for endoscopic Rx Send the patient to surgery Request a formal psychiatric consultation Ask for a ph-mii (Multi-channel Intraluminal Impedance) measurement

Multi-channel Intraluminal Impedance Measurement (MII)

MII

What is your recommendation? The patient underwent laparascopic Nissen fundoplication Six months post-op she s off medication and feels well

Case-2 A 45 Y/O lady presented for evaluation of HB occuring 2-3x/week of 2 years duration She did not complain of any other problems P/E was within normal limits except for a BMI of 29kg/m 2 What will you recommend for her?

EGD: WNL Appropriate life style modification advice was given, she was advised to reduce weight and PPI bid was started She was followed in 8 weeks and reported partial improvement She stated that she took the medication correctly She had not reduced any weight Meanwhile she reported anxiety and stressful life conditions and complained of bloating and IBS symptoms as well How will you continue?

She was advised to engage in a wt reduction program and a psychiatric consultation was made Omeprazole was changed to Rabeprazole (Pariet) 20mg bid and she was scheduled to follow in 2 months

At her next follow-up, she stated that although she had improved, but she still suffered from the HB almost on a weekly basis How will you follow her?

EGD was repeated with upper and lower esophageal biopsies which was normal A Ba swallow was also requested

How will you manage her? Esophageal manometry

High resolution manometry

Incomplete bolus transit Absent peristalsis (Required) Low esophageal amplitude High LES-P +/- Incomplete LES relaxation +/-

The patient underwent pneumatic dilatation She s doing well 2 years after treatment

Thank you for your attention