1. Gastroesophageal Reflux Disease Arthur Harris, M.D. GI Division, Jacobi Medical Center/NCBH Assistant Professor of Medicine, AECOM

2. Objectives Definition of GERD Definition of GERD Epidemiology of GERD Epidemiology of GERD Pathophysiology of GERD Pathophysiology of GERD Clinical Manifestations Clinical Manifestations Diagnostic Evaluation Diagnostic Evaluation Treatment Treatment Complications Complications

3. Definition American College of Gastroenterology (ACG) American College of Gastroenterology (ACG) Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagusSymptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus Often chronic and relapsingOften chronic and relapsing May see complications of GERD in patients who lack typical symptomsMay see complications of GERD in patients who lack typical symptoms

4. Physiologic vs Pathologic Physiologic GERD Physiologic GERD Post-prandialPost-prandial Short-livedShort-lived Often asymptomaticOften asymptomatic TLSER’sTLSER’s No nocturnal sxNo nocturnal sx Pathologic GERD Pathologic GERD Symptoms Mucosal injury Nocturnal sx

6. Epidemiology About 44% of the US adult population have heartburn at least once a month About 44% of the US adult population have heartburn at least once a month 14% of Americans have symptoms weekly 14% of Americans have symptoms weekly 7% have symptoms daily 7% have symptoms daily

7. Pathophysiology Primary barrier to gastroesophageal reflux is the lower esophageal sphincter Primary barrier to gastroesophageal reflux is the lower esophageal sphincter LES normally works in conjunction with the diaphragm LES normally works in conjunction with the diaphragm If barrier disrupted, acid goes from stomach to esophagus If barrier disrupted, acid goes from stomach to esophagus

8. Clinical Manifestations Most common symptoms Most common symptoms Heartburn—retrosternal burning discomfortHeartburn—retrosternal burning discomfort Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractionsRegurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions

9. Clinical Manifestations Dysphagia—difficulty swallowingDysphagia—difficulty swallowing Other symptoms include:Other symptoms include: Chest pain, water brash, globus sensation, odynophagia, nausea Chest pain, water brash, globus sensation, odynophagia, nausea Extraesophageal manifestationsExtraesophageal manifestations Asthma, laryngitis, chronic cough Asthma, laryngitis, chronic cough

10. Diagnostic Evaluation If classic symptoms of heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiatedIf classic symptoms of heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated

11. Potential Oral and Laryngopharyngeal Signs Associated with GERD Edema and hyperemia of larynx Edema and hyperemia of larynx Vocal cord erythema, polyps, granulomas, ulcersVocal cord erythema, polyps, granulomas, ulcers Hyperemia and lymphoid hyperplasia of posterior pharynx Hyperemia and lymphoid hyperplasia of posterior pharynx Interarytenyoid changes Interarytenyoid changes Dental erosion Dental erosion Subglottic stenosis Subglottic stenosis Laryngeal cancer Laryngeal cancer

12. Alarms Alarm Signs/SymptomsAlarm Signs/Symptoms Dysphagia Dysphagia Early satiety Early satiety GI bleeding GI bleeding Odynophagia Odynophagia Vomiting Vomiting Weight loss Weight loss Iron deficiency anemia Iron deficiency anemia

13. Trial of Medications H2RA or PPI H2RA or PPI Expect response in 2-4 weeksExpect response in 2-4 weeks If no responseIf no response Change from H2RA to PPI Change from H2RA to PPI Maximize dose of PPI Maximize dose of PPI

14. Trial of Medications If PPI response inadequate despite maximal dosage If PPI response inadequate despite maximal dosage Confirm diagnosisConfirm diagnosis EGD EGD 24 hour pH monitoring 24 hour pH monitoring

15. Esophagogastrodudenoscopy Endoscopy (with biopsy if needed) Endoscopy (with biopsy if needed) In patients with alarm signs/symptomsIn patients with alarm signs/symptoms Those who fail medication trialThose who fail medication trial Those who require long-term RxThose who require long-term Rx Lacks sensitivity for identifying pathologic reflux Lacks sensitivity for identifying pathologic reflux Absence of endoscopic features does not exclude a GERD diagnosis Absence of endoscopic features does not exclude a GERD diagnosis Allows for detection, stratification, and management of esophageal manifestations or complications of GERD Allows for detection, stratification, and management of esophageal manifestations or complications of GERD

16. Ambulatory pH Testing 24-hour pH monitoring 24-hour pH monitoring Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changesAccepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes Trans-nasal catheter or a wireless, capsule shaped deviceTrans-nasal catheter or a wireless, capsule shaped device

17. Ambulatory 24 hour pH Monitoring -1 Physiologic study Physiologic study Quantify reflux in proximal/distal esophagus Quantify reflux in proximal/distal esophagus % time pH < 4 DeMeester score Symptom correlation Symptom correlation

18. Ambulatory 24 hour pH Monitoring -2 Normal GERD

19. Wireless, Catheter-Free Esophageal pH Monitoring Potential Advantages ●Improved patient comfort and acceptance ●Continued normal work, activities and diet during study ●Continued normal work, activities and diet during study ●Longer reporting periods possible (up to 48 hours) ●Longer reporting periods possible (up to 48 hours) ●Maintain constant probe position relative to SCJ ●Maintain constant probe position relative to SCJ

20. Esophageal Manometry Limited role in GERD Assess LES pressure, location and relaxation Assess LES pressure, location and relaxation Assist placement of 24 hour pH catheter Assess peristalsis Assess peristalsis Prior to anti-reflux surgery

21. Patient with heartburn Initiate Rx with H2RA or PPI H2RA taken BID Good response Frequent relapses On demand Rx PPI taken QD Good response Maintenance therapy with lowest effective dose Symptoms persist Consider EGD if risk factors present (> 45, white, male and > 5 yrs of sx) Increase to max dose QD or BID Good response Confirm diagnosis EGD, ph monitor No Yes No Yes No

22. GERD vs Dyspepsia Distinguish from Dyspepsia Distinguish from Dyspepsia Ulcer-like symptoms-burning, epigastric painUlcer-like symptoms-burning, epigastric pain Dysmotility like symptoms-nausea, bloating, early satiety, anorexiaDysmotility like symptoms-nausea, bloating, early satiety, anorexia Distinct clinical entity Distinct clinical entity In addition to anti-secretory meds and an EGD, need to consider testing for Helicobacter pylori In addition to anti-secretory meds and an EGD, need to consider testing for Helicobacter pylori

23. Treatment Goals of therapy Goals of therapy Symptomatic reliefSymptomatic relief Heal esophagitisHeal esophagitis Avoid complicationsAvoid complications

24. Better Living Lifestyle modifications Lifestyle modifications Avoid large mealsAvoid large meals Avoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate, onions, garlic, peppermintAvoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate, onions, garlic, peppermint Decrease fat intakeDecrease fat intake Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAID’s)Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAID’s) Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist Lose weightLose weight Stop smokingStop smoking

25. Treatment Antacids Antacids O-T-C acid suppressants and antacids may be appropriate initial therapyO-T-C acid suppressants and antacids may be appropriate initial therapy Approx 1/3 of patients with heartburn-related symptoms use at least twice weeklyApprox 1/3 of patients with heartburn-related symptoms use at least twice weekly More effective than placebo in relieving GERD symptomsMore effective than placebo in relieving GERD symptoms

26. Treatment Histamine H2-Receptor Antagonists Histamine H2-Receptor Antagonists More effective than placebo and antacids for relieving heartburn in patients with GERDMore effective than placebo and antacids for relieving heartburn in patients with GERD Faster healing of erosive esophagitis when compared with placeboFaster healing of erosive esophagitis when compared with placebo Can use regularly or on-demandCan use regularly or on-demand

27. Treatment AGENT EQUIVALENT DOSAGE DOSAGES DOSAGES Cimetadine 400mg twice daily 400-800mg twice daily Tagamet Famotidine 20mg twice daily 20-40mg twice daily Pepcid Nizatidine 150mg twice daily 150mg twice daily Axid Ranitidine 150mg twice daily 150mg twice daily Zantac

28. Treatment Proton Pump Inhibitors Proton Pump Inhibitors Better control of symptoms with PPI’s vs H2RAs and better remission ratesBetter control of symptoms with PPI’s vs H2RAs and better remission rates Faster healing of erosive esophagitis with PPIs vs H2RAsFaster healing of erosive esophagitis with PPIs vs H2RAs

29. Treatment AGENT EQUIVALENT DOSAGE DOSAGES DOSAGES Esomeprazole 40mg daily 20-40mg daily Nexium Omeprazole 20mg daily 20mg daily Prilosec Lansoprazole 30mg daily 15-30mg daily Prevacid Pantoprazole 40mg daily 40mg daily Protonix Rabeprazole 20mg daily 20mg daily Aciphex

30. Treatment H2RAs vs PPI’s H2RAs vs PPI’s 12 week freedom from symptoms12 week freedom from symptoms 48% vs 77% 48% vs 77% 12 week esophagitis healing rate12 week esophagitis healing rate 52% vs 84% 52% vs 84% Speed of healingSpeed of healing 6%/wk vs 12%/wk 6%/wk vs 12%/wk

31. Treatment Modifications for Persistent Symptoms Improve compliance Improve compliance Optimize pharmacokinetics Optimize pharmacokinetics Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime)Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime) Allows for high blood level to interact with parietal cell proton pump activated by the mealAllows for high blood level to interact with parietal cell proton pump activated by the meal Consider switching to a different PPI Consider switching to a different PPI

32. Treatment Anti-reflux surgery - Indications Anti-reflux surgery - Indications Failed medical managementFailed medical management Patient preferencePatient preference GERD complicationsGERD complications Medical complications attributable to a large hiatal herniaMedical complications attributable to a large hiatal hernia Atypical symptoms with pathologic reflux documented on 24-hour pH monitoringAtypical symptoms with pathologic reflux documented on 24-hour pH monitoring

33. Treatment Anti-reflux surgery candidates Anti-reflux surgery candidates EGD proven esophagitisEGD proven esophagitis ?Normal esophageal motility?Normal esophageal motility Incomplete response to acid suppressionIncomplete response to acid suppression

34. Treatment Anti-reflux surgery (laparoscopic) Anti-reflux surgery (laparoscopic) Tenets of surgeryTenets of surgery Reduce hiatal hernia Reduce hiatal hernia Repair diaphragm Repair diaphragm Strengthen GE junction Strengthen GE junction Strengthen anti-reflux barrier via gastric wrap Strengthen anti-reflux barrier via gastric wrap 75-90% effective at alleviating symptoms of heartburn and regurgitation 75-90% effective at alleviating symptoms of heartburn and regurgitation

36. Treatment Post-surgery Post-surgery 10% have solid food dysphagia10% have solid food dysphagia 2-3% have permanent symptoms2-3% have permanent symptoms 7-10% have gas, bloating, diarrhea, nausea, early satiety7-10% have gas, bloating, diarrhea, nausea, early satiety Within 3-5 years, up to 52% of patients back on anti-reflux medicationsWithin 3-5 years, up to 52% of patients back on anti-reflux medications

37. Treatment Endoscopic treatment Endoscopic treatment Relatively newRelatively new No clearly established indicationsNo clearly established indications Well-informed patients with well-documented GERD responsive to PPI therapy may benefitWell-informed patients with well-documented GERD responsive to PPI therapy may benefit Three categories Three categories Radiofrequency application to increase LES reflux barrierRadiofrequency application to increase LES reflux barrier Endoscopic sewing devicesEndoscopic sewing devices Injection of a non-resorbable polymer into LES regionInjection of a non-resorbable polymer into LES region

38. Complications Erosive esophagitis Erosive esophagitis Stricture Stricture Barrett’s esophagus Barrett’s esophagus

39. Complications Erosive esophagitis Erosive esophagitis Responsible for 40-60% of GERD symptomsResponsible for 40-60% of GERD symptoms Severity of symptoms often fail to match severity of erosive esophagitisSeverity of symptoms often fail to match severity of erosive esophagitis

40. Complications Esophageal stricture Esophageal stricture Occurs as a result of healing of erosive esophagitisOccurs as a result of healing of erosive esophagitis May need dilationMay need dilation

41. Peptic Stricture Barium swallow Endoscopy

42. Complications Barrett’s Esophagus Barrett’s Esophagus Columnar metaplasia of the esophagusColumnar metaplasia of the esophagus Associated with the development of adenocarcinomaAssociated with the development of adenocarcinoma

43. Complications Barrett’s Esophagus Barrett’s Esophagus Acid damages lining of esophagus and causes chronic esophagitisAcid damages lining of esophagus and causes chronic esophagitis Damaged area heals in a metaplastic process with abnormal columnar cells replacing squamous cellsDamaged area heals in a metaplastic process with abnormal columnar cells replacing squamous cells This specialized intestinal metaplasia can progress to dysplasia and adenocarcinomaThis specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma

44. Complications Patient’s who need EGDPatient’s who need EGD Alarm symptoms Alarm symptoms Poor therapeutic response Poor therapeutic response Long symptom duration Long symptom duration “Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice“Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice Many patients with Barrett’s are asymptomaticMany patients with Barrett’s are asymptomatic

45. Complications Barrett’s Esophagus Barrett’s Esophagus Manage in same manner as GERDManage in same manner as GERD EGD every 3 years in patient’s without dysplasiaEGD every 3 years in patient’s without dysplasia In patients with dysplasia, annual to even shorter interval surveillance is recommendedIn patients with dysplasia, annual to even shorter interval surveillance is recommended

46. Summary Definition of GERD Definition of GERD Epidemiology of GERD Epidemiology of GERD Pathophysiology of GERD Pathophysiology of GERD Clinical Manifestations Clinical Manifestations Diagnostic Evaluation Diagnostic Evaluation Treatment Treatment Complications Complications

47. ?QUESTIONS?