![Page 1: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/1.jpg)
A gastroenterologist’s view of GERD and its pre-
operative workup
George Triadafilopoulos, MDClinical Professor of MedicineStanford University School of
MedicineM.I.S.S. 2.22.2011 Disclosures: None
![Page 2: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/2.jpg)
Outline
• What can happen
• How do we find out
• What can we do about it
![Page 3: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/3.jpg)
![Page 4: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/4.jpg)
- Erosive reflux disease (ERD): Erosions in the distal esophagus- Non-erosive reflux disease (NERD): Normal esophagus and abnormal pH- Barrett’s esophagus: Endoscopic and histologic evidence of intestinal metaplasia/dysplasia
= Heartburn/regurgitation
![Page 5: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/5.jpg)
Not all GERD is the same…
• NERD (most common)• Erosive esophagitis (LA B, C and
D)– +/- Hiatal hernia
• Refractory GERD• Consequences of repair – Peptic stricture – Barrett's metaplasia
• Extra-esophageal manifestations – Asthma – Laryngitis– CoughHiatal hernia
Peptic stricture
![Page 6: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/6.jpg)
PPI therapy in GERD• The most effective medical therapy available– 90%+ healing rates– 70%+ symptom control rates
• Symptoms may continue despite therapy
• Relapses may still occur despite maintenance therapy
• Subject to drug-drug interactions, long-term side effects and poor adherence
![Page 7: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/7.jpg)
Understand
Understand PreventPrevent ManageManage
![Page 8: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/8.jpg)
PPI drawbacks
![Page 9: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/9.jpg)
PPI may lose efficacy over time! Total percentage acid exposure time at baseline, at the time of normalization, and
at 2-year follow-up.
Frazzoni M, Dig Liv Dis 2007
![Page 10: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/10.jpg)
Long term PPI safety
• Pneumonia• C.difficile infection• Other enteric infections• Hypergastrinemia• Atrophic gastritis• Vitamin B12 malabsorption• Hip fractures• Drug interactions
![Page 11: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/11.jpg)
GERD in primary care
• Patients with heartburn, regurgitation, or chest pain, are typically treated initially with proton pump inhibitors (PPI).
• 3 possible outcomes:– Complete response (no symptoms)– Partial response (breakthrough
symptoms)–No response (no change in
symptoms)
![Page 12: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/12.jpg)
Refractory GERD
Clinically significant impairment of health-related well-being (GERD-HRQoL) due to
episodes of gastro-esophageal reflux while on PPI therapy
“GERD” symptoms may not always reflect the acidity of the refluxate but may be due to: refluxate volume, esophageal distensibility and sensitivity to acid
![Page 13: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/13.jpg)
Differential Diagnosis
![Page 14: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/14.jpg)
-Achalasia & dysmotility: Defined manometrically- EoE: > 25 eosinophils / hpf- RD (Reflux-like dyspepsia): Normal endoscopy, biopsies and pH monitoring - Gastroparesis: Normal endoscopy, abnormal GES
![Page 15: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/15.jpg)
Clinical evaluation
![Page 16: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/16.jpg)
Endoscopy
![Page 17: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/17.jpg)
Esophageal biopsy
Eosinophilic esophagitis Barrett’s esophagus
![Page 18: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/18.jpg)
Esophageal Motility
• Non-invasive & quasi-physiologic
• Measures effectiveness of peristalsis and LES pressure/relaxation
• Essential in defining esophageal dysmotility (achalasia, spasm, etc)
![Page 19: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/19.jpg)
Fox, M R et al. Gut 2008;57:405-4
HRM depicts esophageal pressure activity from the pharynx to the stomach
![Page 20: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/20.jpg)
• Non-invasive & physiologic
• Quantifies acid reflux (off/on Rx)
• Correlates symptoms to acid reflux
• Sensitivity and specificity > 90%
• Indispensable for atypical & refractory cases
24-hr ambulatory pH monitoring
![Page 21: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/21.jpg)
“Abnormal” intra-esophageal pH profile on PPI
56 yo man with persistent heartburn while on PPI
24-hr pH study on lansoprazole (30 mg bid)
DeMeester score (on therapy): 17.3
% time intra-gastric pH < 4.0: 57.4
On high-dose PPI, this patient has achieved an inadequate intra-gastric pH control, resulting in persistent symptomatic GERD
ie pH
ig pH
![Page 22: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/22.jpg)
62 yo man with belching/regurgitation but no heartburn while on
PPI
24-hr pH study on rabeprazole 40mg bid.
DeMeester score (on therapy): 12.9
% time ig pH<4.0: 27.4
“Normalized” intra-esophageal & intra-gastric pH profile
![Page 23: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/23.jpg)
Disease prevalence in PPI-refractory GERD
270 patients (143 men and 127 women), aged 16-89 years
%
Triadafilopoulos G et al. Gastroenterology 2010
![Page 24: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/24.jpg)
Acid reflux frequently overlaps
%
Triadafilopoulos G et al. Gastroenterology 2010
![Page 25: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/25.jpg)
![Page 26: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/26.jpg)
Reasons to consider endoscopic therapies
for GERD
Refractory GERD
Persistent heartburn despite escalating PPIs
Residual regurgitation without heartburn on PPIs
PPI intolerance (2% of users)
Desire to stop drug therapy (concerns about long-term effects)
Concerns about LARS side effects (i.e. dysphagia, gas bloat)
Symptomatic GERD after fundoplicationTriadafilopoulos, G. Am. J. Med. 115(3A): 192S-200S, 2003.
Fundic polyps
![Page 27: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/27.jpg)
StrettaCatheter
Module
Radiofrequency Rx
Enhances LESP
Reduces tLESRs
![Page 28: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/28.jpg)
Transoral incisionless fundoplication (TIF)
Serosa-to-serosa Serosa-to-serosa fixationfixation
FastenersFasteners
Full thickness tissue plications are used to reconstruct & augment the ARB
Pre Pre TIFTIF
Post Post TIFTIF
Serosa-to-serosa fixation Serosa-to-serosa fixation at 2wksat 2wks
![Page 29: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/29.jpg)
Who are not good candidates for EndoRx?
• Patients with refractory GERD who have a large, fixed, hiatal hernia (> 3 cm long) and foreshortened esophagus
Laparoscopic Nissen fundoplication
![Page 30: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/30.jpg)
• Patients with “functional” heartburn
– Patients with 0 % response to PPIs
– “Les malades du petit papier”
–Negative pH studies + no symptom correlation with acid events
Who are not good candidates for either
endoscopic or surgical therapy?
Bravo pH monitoring
![Page 31: A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School](https://reader036.vdocuments.net/reader036/viewer/2022062422/56649ece5503460f94bdaea7/html5/thumbnails/31.jpg)
Conclusions
• Reflux symptoms may or may not reflect GERD
• PPI therapy is widely used and quite effective in ~80% of cases
• Structural and functional evaluation of the esophagus are essential in refractory cases
• Emerging role of endoscopic and newer surgical therapies
• Multidisciplinary approach is essential to successful outcomes