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?