Sally Bowa, RN, MSN, FNP-C Dr. Hass Jassim, GERD Seminar Sally Bowa, RN, MSN, FNP-C Dr. Hass Jassim,

Objectives: Examine general GERD overview, pathophysiology and disease progression GERD symptoms-typical versus atypical Comprehensive Diagnosis of GERD Our current medical options for treatment Current surgical options for treatment Surgical interventions-what to expect

What is GastroEsophogeal Reflux Disease? (GERD)

GERD It is a chronic, often progressive disease Caused by a weak Lower Esophageal Sphincter (LES) LES is the body’s natural barrier to reflux Esophagus Lower Esophageal Sphincter Duodenum Stomach

Weak Sphincter (LES)? Unknown Weakens over time Family history Association with hiatal hernias

Hiatal hernia -Upper part of stomach can herniate into the chest cavity -Can contribute to GERD symptoms -If the LES is functioning normally (barrier), a hiatal hernia alone does not necessarily cause GERD Picture obtained from Medicine Net, Inc.

GERD SYMPTOMS

Common (typical) Symptoms Heartburn Regurgitation Mild dysphagia Chest pain

Atypical Symptoms Chronic cough Hoarseness Chronic sore throat Dental problems Recurrent (aspiration) pneumonia Worsening asthma Sleep disturbances Globus sensation Bad breath

Complications of GERD Esophagitis Stricture

Complications of GERD (cont’d) Pulmonary ENT -Poor asthma control -Cough -Aspiration pneumonia -pulmonary fibrosis -Hoarseness -Voice changes -Chronic ear infections -Chronic sinusitis -Sore throat -Globus sensation

Complications of GERD (cont’d) Barrett’s esophagus Cartoon depicting the appearance when the squamocolumnar and gastroesophageal junctions coincide. In this situation, there is no apparent columnar-lined esophagus (ie, the entire esophagus is lined by squamous epithelium).

Barrett’s Esophagus cont’d

Esophageal Cancer Incidence of adenocarcinoma arising out of Barrett’s esophagus is rising dramatically (Uptodate, 2015). Risk factors: Long standing GERD (>20 years) Severe symptoms Smoking Obesity Daily sx increased odds of adenocarcinoma 7fold Among patients who have Barrett’s esophagus, the risk of developing esophageal cancer is increased at least 30-fold above that of the general population Endoscopic screening to detect dysplasia is recommended for patients with Barrett’s esophagus

Comprehensive evaluation of GERD Patient visit Arrange for endoscopic evaluation Additional testing if needed Esophageal manometry Barium esophogram

Upper endoscopy -VISUAL Evalution -Rule out significant lesion -Obtain biopsies (microscopic evaluation) -Rule out Barrett’s esophagus, EoE, candida, adenocarcinoma -Placement of pH monitor

Breakthrough symptoms on PPIs Long-standing GERD (>5 years) Indications for EGD Breakthrough symptoms on PPIs Long-standing GERD (>5 years) Rule out other pathology Dysphagia Barrett’s surveillance Screening Male, smoker, obese, >50 yrs 80% of pts will have normal EGD

Ambulatory pH testing -PHYSIOLOGIC evaluation -Most accurate test to establish diagnosis of GERD - Study can be programmed for 24-96 hours Wireless receiver

Case Study #1 Patient #1

Case Study #2 Patient #2

Esophageal Manometry Functional evaluation of esophagus and LES

Case study #1 cont’d

Case study #2 cont’d

Barium Esophogram Visualizes the swallowing mechanism, esophagus Contrast study using barium Radiopaque Appears white on the film

Symptom Management & Treatment Options

Dietary Modification Avoid trigger foods Fatty, spicy or fried foods Tomato based products Caffeine Chocolate Alcohol Carbonated beverages Specific trigger foods vary from person to person Omit the foods that cause problems

Lifestyle Modifications Bed blocks Avoid overeating Lose excess weight Avoid postprandial recumbency

Medical Therapy Antacids H2 Blockers Proton Pump Inhibitors Mylanta Pepto-Bismol Rolaids Tums H2 Blockers Pepcid Tagamet Zantac Proton Pump Inhibitors Aciphex Nexium Prevacid Prilosec

Medical therapy BENEFITS Reduces the amount of acid in the stomach May reduce inflammation of esophageal lining Provides symptom relief for many patients, but relief can be temporary LIMITATIONS DOES NOT affect the cause of reflux (LES) DOES NOT prevent reflux May require life-long use and dose escalation

Decreased calcium absorption Increased pneumonia risk PPI side effects Common side effects: Diarrhea or constipation Nausea Headache Decreased calcium absorption Increased pneumonia risk Decreased Plavix efficacy Decreased magnesium absorption

Potential Risks of Long term PPI use FDA alerts FDA: Possible Fracture Risk with High Dose, Long-term Use of Proton Pump Inhibitors May 25, 2010 Labeling changes will include new safety information The U.S. Food and Drug Administration today warned consumers and health care professionals about a possible increased risk of fractures of the hip, wrist, and spine with high doses or long-term use of a class of medications called proton pump inhibitors. The product labeling will be changed to describe this possible increased risk. FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs) March 2, 2011 Safety Announcement The U.S. Food and Drug Administration (FDA) is informing the public that prescription proton pump inhibitor (PPI) drugs may cause low serum magnesium levels (hypomagnesemia) if taken for prolonged periods of time (in most cases, longer than one year). In approximately one-quarter of the cases reviewed, magnesium supplementation alone did not improve low serum magnesium levels and the PPI had to be discontinued. FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs) February 8, 2012 Safety Announcement The U.S. Food and Drug Administration (FDA) is informing the public that the use of stomach acid drugs known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that does not improve. Patients should immediately contact their healthcare professional and seek care if they take PPIs and develop diarrhea that does not improve.

Antisecretory Medications Percentage of patients experiencing breakthrough symptoms while on a PPI (among all patients) Why might medication not be effective? Disease is progressing – sphincter is getting worse and medication no longer is enough They have symptoms that do not respond well to medication ie:  regurgitation, chronic cough, hoarseness or asthma Reflux is not the primary cause of their symptoms – need to see Reflux Specialist for testing 62% NO Breakthrough Symptoms 38% Breakthrough Symptoms

Patient profile with Progressive disease Family history of GERD Takes PPIs with complusive regularity Has increased symptom severity after 1 year of PPI therapy Requires dose escalation of PPIs to control symptoms Esophagitis on baseline endoscopy Esophagitis remaining unhealed after PPI therapy Barrett’s esophagus

Surgical Options for GERD Medically refractory GERD Esophagitis despite meds History of Barrett’s Concerned with PPI side effects Intolerant of meds/side effects Interest in alternative options Concern/awareness of Barrett’s esophagus or esophageal cancer QOL Hiatal hernia

Surgery options Nissen fundoplication LINX-magnetic sphincter augmentation

Dr. Jassim’s presentation