gerd: an old problem with new approaches jason phillips, md
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GERD:GERD:An Old Problem with New An Old Problem with New
ApproachesApproaches
Jason Phillips, MDJason Phillips, MD
CaseCase
HPI: 44 y/o M with heartburnHPI: 44 y/o M with heartburn• Heartburn symptoms off/on for many years but Heartburn symptoms off/on for many years but
increasing in severity and frequency in last 6-increasing in severity and frequency in last 6-12 months12 months
• Symptoms are described as:Symptoms are described as: Sternal ‘burning’ with acid taste in mouthSternal ‘burning’ with acid taste in mouth Occurs most frequently at night most days of the Occurs most frequently at night most days of the
weekweek Last hoursLast hours Partially relieved with MylantaPartially relieved with Mylanta
CaseCase
Exacerbated by: Exacerbated by: • Supine positions after mealSupine positions after meal• Large mealsLarge meals• Food triggers: pasta, greasy food, Food triggers: pasta, greasy food,
coffee, alcohol coffee, alcohol
Denies weight loss, dysphagia, Denies weight loss, dysphagia, melena, hematemesismelena, hematemesis
CaseCase
PMH: Obesity PMH: Obesity
Meds: MylantaMeds: Mylanta
NKDANKDA
SH: smokes 1ppd x 10+years, drinks SH: smokes 1ppd x 10+years, drinks 2-4 glasses of wine per night2-4 glasses of wine per night
FH: No h/o esophageal CaFH: No h/o esophageal Ca
CaseCase
PE: BP 140/86 P 96 Afeb PE: BP 140/86 P 96 Afeb
Wt 275 lbs (BMI 36) Wt 275 lbs (BMI 36)
Gen: obese, NADGen: obese, NAD
Exam essentially normal Exam essentially normal
CaseCase
Pt was seen by his PCP and Pt was seen by his PCP and diagnosed with GERD.diagnosed with GERD.• Prescribed a PPI to take once a day. Prescribed a PPI to take once a day. • Advised pt to lose weight and quit Advised pt to lose weight and quit
smokingsmoking• Follow-up in 4-6 weeksFollow-up in 4-6 weeks
CaseCase
At 5 weeks, he called his PCP and At 5 weeks, he called his PCP and complained he was still having daily complained he was still having daily episodes of heartburn though ‘the episodes of heartburn though ‘the medicine helped a little’medicine helped a little’• PCP’s 3 options:PCP’s 3 options:
Increase PPI to BIDIncrease PPI to BID Change PPIChange PPI Referral to GIReferral to GI
CaseCase
PPI was increased to BID and the PPI was increased to BID and the patient continued to have reflux patient continued to have reflux symptomssymptoms
Therefore, the pt was referred to GI for Therefore, the pt was referred to GI for further evaluationfurther evaluation
CaseCase
GI visit: Additional historyGI visit: Additional history• Pts symptoms sounded like typical Pts symptoms sounded like typical
reflux-like symptomsreflux-like symptoms• Symptoms mostly occurred from 8-10 Symptoms mostly occurred from 8-10
PM after his dinner at 7 PMPM after his dinner at 7 PM• Large evening meals most daysLarge evening meals most days• Had not tried avoiding typical food Had not tried avoiding typical food
triggerstriggers• Had not lost weight or stopped smokingHad not lost weight or stopped smoking
CaseCase
GI visit: Additional historyGI visit: Additional history• He was taking his PPI 30 minutes after He was taking his PPI 30 minutes after
meals (during dessert) twice per day as meals (during dessert) twice per day as recommendedrecommended
• His symptoms overall improved by His symptoms overall improved by ~50% but as mentioned, he continued ~50% but as mentioned, he continued to have daily symptoms to have daily symptoms
CaseCase
GI visit: Additional historyGI visit: Additional history
Reflux events also increased during Reflux events also increased during the day during stressful moments at the day during stressful moments at workwork
CaseCase
Possible diagnosesPossible diagnoses• Inadequately treated GERD vs functional Inadequately treated GERD vs functional
heartburnheartburn• MalignancyMalignancy• Esophageal spasmEsophageal spasm• Peptic ulcer diseasePeptic ulcer disease• AnginaAngina
CaseCase
EGD while still taking medications: EGD while still taking medications: • normal esophagus with no evidence of normal esophagus with no evidence of
esophagitis or Barrett’s esophagusesophagitis or Barrett’s esophagus• Normal stomach and duodenumNormal stomach and duodenum
CaseCase
Does he have non-erosive acid reflux Does he have non-erosive acid reflux that is inadequately treated with his that is inadequately treated with his current PPI or is this functional current PPI or is this functional heartburn?heartburn?
CaseCase
To distinguish, I arranged for the To distinguish, I arranged for the patient to have a 24 pH probe while patient to have a 24 pH probe while still taking his BID PPIstill taking his BID PPI
Bravo wireless 24 hour pH probeBravo wireless 24 hour pH probe
CaseCase
Diagnosed with acid refluxDiagnosed with acid reflux RecommendationsRecommendations
• BID PPI – taken 30 minutes BEFORE mealsBID PPI – taken 30 minutes BEFORE meals• Additional nocturnal H2 blockerAdditional nocturnal H2 blocker• Behavioral modificationsBehavioral modifications
Earlier dinner, smaller portionsEarlier dinner, smaller portions Avoidance of trigger foodsAvoidance of trigger foods Quit smokingQuit smoking Lose weightLose weight
GERD IncidenceGERD Incidence
Complaints of heartburnComplaints of heartburn• 40% of Americans complain of monthly 40% of Americans complain of monthly
heartburnheartburn• 20% complain of weekly heartburn20% complain of weekly heartburn• 7% complain of daily heartburn7% complain of daily heartburn
Prevalence of GERD is increasing over the Prevalence of GERD is increasing over the 30 years30 years
Problem of GERDProblem of GERD
Difficult to defineDifficult to define
Physiologic vs pathologic acid refluxPhysiologic vs pathologic acid reflux• Physiologic Physiologic postprandial, short lived, postprandial, short lived,
asymptomatic, rarely during sleepasymptomatic, rarely during sleep• Pathologic Pathologic symptoms, often include symptoms, often include
nocturnal episodesnocturnal episodes
SymptomsSymptoms
HeartburnHeartburn Epigastric painEpigastric pain RegurgitationRegurgitation DysphagiaDysphagia Chest painChest pain NauseaNausea OdynophagiaOdynophagia Globus sensationGlobus sensation Supraesophageal symptomsSupraesophageal symptoms
SymptomsSymptoms
Patient’s descriptions can be difficult Patient’s descriptions can be difficult to interpret: “Its not heartburn its…to interpret: “Its not heartburn its…• “…“…bile coming up into my throat.”bile coming up into my throat.”• “…“…intense pain in my stomach.”intense pain in my stomach.”• “…“…its not pain, its heaviness in my its not pain, its heaviness in my
chest.”chest.”• “…“…pain in the back of my throat when I pain in the back of my throat when I
awake.”awake.”
PathophysiologyPathophysiology
80% of reflux symptoms occur as a 80% of reflux symptoms occur as a result of transient LES relaxationresult of transient LES relaxation
Other motility defectsOther motility defects• LES incompetenceLES incompetence• GastroparesisGastroparesis• Esophageal body dymotilityEsophageal body dymotility
Anatomic defects: Hiatal herniaAnatomic defects: Hiatal hernia
DiagnosisDiagnosis
Symptoms Symptoms empiric PPI empiric PPI• Uncomplicated symptoms (no alarm Uncomplicated symptoms (no alarm
signs – weight loss, GI bleeding, signs – weight loss, GI bleeding, dysphagia)dysphagia)
• Age < 65 yearsAge < 65 years• No esophagotoxic medications (e.g, No esophagotoxic medications (e.g,
bisphophonates)bisphophonates)• 6 weeks trial6 weeks trial
Diagnosis: Empiric treatmentDiagnosis: Empiric treatment
Sensitivity ~75%Sensitivity ~75% Specificity ~80%Specificity ~80% Using 50% improvement as the Using 50% improvement as the
therapeutic endpointtherapeutic endpoint
• Schindlbeck et al…Arch Int Med 155:1808-12, Schindlbeck et al…Arch Int Med 155:1808-12, 19951995
• Fass et al…Arch Int Med 159:2161-8, 1999Fass et al…Arch Int Med 159:2161-8, 1999
Evaluation of GERDEvaluation of GERD
In patients who have ‘red flags’ or In patients who have ‘red flags’ or fail 6 weeks of a PPI fail 6 weeks of a PPI EGD EGD
EGD: EGD: • signs of esophagitissigns of esophagitis• Barrett’s esophagusBarrett’s esophagus• Hiatal herniasHiatal hernias• Exclusion of cancer and other diagnoses Exclusion of cancer and other diagnoses
(PUD)(PUD)
Evaluation of GERDEvaluation of GERD
Evaluation of GERDEvaluation of GERD
PillCam may offer a non-invasive PillCam may offer a non-invasive method to look for evidence of method to look for evidence of esophagitis or Barrett’s esophagusesophagitis or Barrett’s esophagus
PillCamPillCam
Identified 97% (32/33) of the cases of Identified 97% (32/33) of the cases of Barrett’s esophagus when confirmed by Barrett’s esophagus when confirmed by traditional endoscopytraditional endoscopy
Agreed 99% (72/73) of the time in Agreed 99% (72/73) of the time in excluding Barrett’s esophagus confirmed excluding Barrett’s esophagus confirmed by traditional EGDby traditional EGD
Identified 89% (33/37) of the cases of Identified 89% (33/37) of the cases of esophagitisesophagitis
Agreed 99% (68/69) of the cases of ‘no Agreed 99% (68/69) of the cases of ‘no evidence of esophagitis’evidence of esophagitis’
Eliakim et al… Preliminary results. ACG 2004.Eliakim et al… Preliminary results. ACG 2004.
EvaluationEvaluation
75% of community based EGD for 75% of community based EGD for evaluation of GERD have NO evaluation of GERD have NO evidence of mucosal injuryevidence of mucosal injury
50% of patients with endoscopy 50% of patients with endoscopy negative reflux disease have negative reflux disease have abnormal esophageal acid exposure abnormal esophageal acid exposure
In these cases, other tests are In these cases, other tests are neededneeded
Ambulatory pH monitorAmbulatory pH monitor
Considered to be the most sensitive Considered to be the most sensitive test for diagnosing refluxtest for diagnosing reflux
Traditional Traditional transnasal catheter transnasal catheter with probe situated 5 cm above LESwith probe situated 5 cm above LES
Bravo pH system Bravo pH system wireless wireless technologytechnology
TreatmentTreatment
PPI are standard medical therapyPPI are standard medical therapy• Daily PPI generally has a 80% healing Daily PPI generally has a 80% healing
rate for moderate to severe esophagitis rate for moderate to severe esophagitis and relief of symptoms in up to 90% of and relief of symptoms in up to 90% of patientspatients
Overall, all PPI are equally effective Overall, all PPI are equally effective in treating symptoms. However, in treating symptoms. However, there is some variability in response there is some variability in response from patient to patient from patient to patient
TreatmentTreatment
Proper timing of PPI administration is Proper timing of PPI administration is critical for efficacycritical for efficacy
30 minutes before breakfast or other 30 minutes before breakfast or other large meallarge meal
In select patients, a second dose can In select patients, a second dose can be added before the evening mealbe added before the evening meal
Surgical TreatmentSurgical Treatment
IndicationsIndications• EsophagitisEsophagitis• StrictureStricture• Barrett’s metaplasiaBarrett’s metaplasia• Medication failureMedication failure
Purpose of surgery Purpose of surgery restoration the restoration the LESLES
Surgical TreatmentSurgical Treatment
Most studies indicate that the majority of Most studies indicate that the majority of patients are symptom-free (70-95%)patients are symptom-free (70-95%)
Recent studies suggest that after 5 years, Recent studies suggest that after 5 years, up to 1/3 of patients required PPI to up to 1/3 of patients required PPI to control symptoms. At 10 years, up to 50% control symptoms. At 10 years, up to 50% require PPIsrequire PPIs
Side-effects: gas-bloat symptoms, Side-effects: gas-bloat symptoms, diarrhea, dysphagiadiarrhea, dysphagia
Endoscopic TreatmentsEndoscopic Treatments
In development with ongoing studiesIn development with ongoing studies
Most try to improve LES function in Most try to improve LES function in some mannersome manner
Not quite ready for prime time in Not quite ready for prime time in community practice community practice
Stretta procedureStretta procedure
Stretta procedureStretta procedure
Decrease in Decrease in symptom scoresymptom score
Decreased PPIDecreased PPI No effect on LESPNo effect on LESP No effect on acid No effect on acid
exposureexposure
Some serious Some serious thermal injury thermal injury complicationscomplications
Enteryx injectionEnteryx injection
Enteryx injectionEnteryx injection
Decreased in heartburn symptoms Decreased in heartburn symptoms Decreased 24 hour acid exposureDecreased 24 hour acid exposure Decreased need for PPIDecreased need for PPI
No improvement in severity of No improvement in severity of esophagitis at EGDesophagitis at EGD
Long term safety issues not knownLong term safety issues not known
Endoscopic suturingEndoscopic suturing
Endoscopic suturingEndoscopic suturing
Decreased heartburn symptomsDecreased heartburn symptoms PPI eliminated in 74% of patients at 6 PPI eliminated in 74% of patients at 6
monthsmonths Decreased esophageal acid Decreased esophageal acid
exposure; however, only 30% exposure; however, only 30% completely normalizedcompletely normalized
Long term follow-up neededLong term follow-up needed
Questions?Questions?
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