1. New Techniques and Perspectives Presented on: May 17th 2014
Update in GERD
New Techniques and Perspectives
Presented on: May 17th 2014
John E. Pandolfino, MD, MSCI
Professor of Medicine
Feinberg School of Medicine,
Northwestern University
Chief, Division of Gastroenterology and Hepatology
Northwestern Medicine
Northwestern Memorial Hospital

2. GERD is a condition which develops when
the reflux of stomach content causes troublesome
symptoms and / or complications
Esophageal Syndromes
Extra-esophageal Syndromes
Symptomatic Syndromes
Typical reflux syndrome
Reflux chest pain syndrome
Syndromes with Esophageal Injury
Reflux esophagitis
Reflux stricture
Barrett's esophagus
Adenocarcinoma
Established Association
Reflux cough
Reflux laryngitis
Reflux asthma
Reflux dental erosions
Proposed Association
Sinusitis
Pulmonary fibrosis
Pharyngitis
Recurrent otitis media
Vakil N et al. Am J Gastroenterol 2006;101:1900

3. Functional
Heartburn/Chest Pain
Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation no
Alarm
features?
PPI Trial
yes no
Heartburn resolved?
Reflux disease: titrate PPI therapy
yes
Esophagitis
EoE
Abnormal?
EGD ± biopsy no
pH or impedance-pH monitoring (off of PPIs) no
>5% esophageal acid exposure?
yes
NERD
Esophageal
manometry
Meets esophageal
motor disorder criteria?
Achalasia
DES
yes no
Positive symptom association?
yes no
MII-pH monitoring (on PPIs)
Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747

4. EGD ± biopsy Functional
Heartburn/Chest Pain
Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation
Alarm
features?
PPI Trial
yes no
Heartburn resolved?
Reflux disease: titrate PPI therapy
yes
Esophagitis
EoE
Abnormal?
EGD ± biopsy no
pH or impedance-pH monitoring (off of PPIs) no
>5% esophageal acid exposure?
yes
NERD
Positive symptom association?
yes no
Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747

5. Phenotyping PPI Non-responders:
Low pre-test probability of refractory GERD
Bravo capsule placed
6cm above SCJ
The Bravo system is an FDA class I approved radioltelemtry pH monitoring system that has become extremely popular due to the fact that it is easy to perform and subjects would rather not wear a Ph catheter for 24 hours..
It entails placing a small pH capsule directly onto the esophageal wall. The pH capsule contains an antimony pH electrode on the distal tip along with the reference probe. There is an internal battery which may last 3 to 5 days and an internal transmitter. The electronics are all encapsulated in epoxy. It is 6 mm wide x 5.5 mm high and 25 mm long.
It can be placed orally or transnasally using either manometric or endoscopic landmarks. We prefer to place it orally as there have been anecdotal reports of significant nasal trauma after nasal passage.
Pandolfino et al. Am J Gastroenterol Apr;98(4):740-9

6. Phenotyping PPI Non-responders:
High pre-test probability of refractory GERD
10000
ohms
3 cm
5 cm
7 cm
9 cm
15 cm
17 cm
Bravo capsule placed
6cm above SCJ
Impedance
The Bravo system is an FDA class I approved radioltelemtry pH monitoring system that has become extremely popular due to the fact that it is easy to perform and subjects would rather not wear a Ph catheter for 24 hours..
It entails placing a small pH capsule directly onto the esophageal wall. The pH capsule contains an antimony pH electrode on the distal tip along with the reference probe. There is an internal battery which may last 3 to 5 days and an internal transmitter. The electronics are all encapsulated in epoxy. It is 6 mm wide x 5.5 mm high and 25 mm long.
It can be placed orally or transnasally using either manometric or endoscopic landmarks. We prefer to place it orally as there have been anecdotal reports of significant nasal trauma after nasal passage.
ohms 15 30 45 60
Time (Seconds)
Pandolfino JE, Vela, MF. Gastrointest Endosc Apr;69(4):917-30,

7. PPI Non-responders are Heterogeneousg EGD n
Acid Reflux Symptoms
Abnormal acid exposure
Hypersensitive [(+) S-R correlation]
Non-acid Reflux Symptoms
Volume refluxers
Overlap between well-controlled GERD and Functional Esophageal Disorder
Do Not Have Reflux at ALL
Functional heartburn….or just functional
Unrelated disease (EoE, EMD, Cardiopulm etc..)
Pandolfino JE, Vela, MF .Gastrointest Endosc Apr;69(4):917-30,

8. Evolution of the Hydrostat: EndoFlip™
Kwiatek et al. J Gastrointest Surg Feb;14(2):268-76

9. Gastroesophageal Reflux Disease True Refractory Symptoms
Targets for therapy based on our observations
Alter EGJ mechanical properties
Surgery
Endoscopic procedures
Medications
Promotility agents
Reflux inhibitors
Pandolfino JE, Krishnan, K. . Clin Gastro Hepatol Jun 28. : S

10. Functional
Heartburn/Chest Pain
Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation no
Alarm
features?
PPI Trial
yes no
Heartburn resolved?
Reflux disease: titrate PPI therapy
yes
Esophagitis
EoE
Abnormal?
EGD ± biopsy no
pH or impedance-pH monitoring (off of PPIs) no
>5% esophageal acid exposure?
yes
NERD
Esophageal
manometry
Meets esophageal
motor disorder criteria?
Achalasia
DES
yes no
Positive symptom association?
yes no
MII-pH monitoring (on PPIs)

11. Gastroesophageal Reflux Disease Symptom perceptionMF VS PD HV
Visceral Sensitivity
Hypervigilance
Psychosocial factors
Abnormal Motor Function
Case : Functional Heartburn
Case : Visceral Hypersensitivity MF PD HV HV VS

12. Gut-directed Hypnotherapy Are you getting sleepy?
Deep physical relaxation and deep mental concentration
Alters focus of attention, changes meaning about sensations arising from the gut and encourages body to restore itself to a healthier state
Shown to produce cognitive change and improve pain tolerance
Modifies physiological arousal and hypersensitivity over long-term
Initially performed in a doctors office but can eventually be self-guided
The most scientifically supported non-drug treatment for Functional GI disorders

13. GERD: Pitfalls
Patients may have a good response to PPI and not have GERD.
Patients may have a positive pH study and not have GERD.
Patients may have a good symptom correlation on pH-impedance testing and not have GERD.
Be careful with belching, regurgitation and nausea/vomiting.

14. tLESR
Liquid reflux
LES relaxation
and
crural inhibition
NU IRB

15. Increased IGP pressure
Rumination # 1 HRM only
Liquid reflux
Increased IGP pressure
NU IRB

16. Rumination #2 HRIM Regurgitation with swallowing Liquid reflux
Increased IGP pressure
NU IRB

17. Supragastric Belching
Air reflux
No LES relaxation
NU IRB

18. GERD: Pitfalls

19. Gastroesophageal Reflux Disease Conclusions
Reflux testing is essential to phenotype the patient based on mechanism.
Refractory reflux
Reflux sensitivity
Functional heartburn
Alternative diagnosis- HRIM is extremely helpful

20. Gastroesophageal Reflux Disease Conclusions
Phenotype will dictate therapies
Refractory reflux
Endoscopic/surgery
Reflux sensitivity
Motility agents, TCA, HYPNOSIS
Functional heartburn
TCA, CBT, Hypnosis
Rumination syndrome/supragastric belching
Biofeedback, CBT, hypnosis

21. Thank You