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Evaluation and Management of GERD

MARIAM NAVEED, MDIPAS FALL CME 2018OCTOBER 9T H, 2018

Objectives

oDefinition of GERD

oEpidemiology of GERD

oPathophysiology of GERD

oClinical Manifestations

oDiagnostic Evaluation

oTreatment

oComplications

Definition The condition of chronic, pathologic reflux of acidic stomach contents

◦ Esophagus◦ Oropharynx◦ Larynx, even lungs

Leads to symptoms and/or mucosal damage◦ NERD (non-erosive reflux disease)= symptoms without damage◦ Symptoms may be typical or atypical

EpidemiologyoAbout 44% of the US adult population have heartburn at least once a month

o14% of Americans have symptoms weekly

o7% have symptoms daily

Typical SymptomsHeartburn

◦ Retrosternal burning sensation◦ Most commonly post-prandial, nocturnal◦ Fatty foods, spicy foods, acidic foods◦ Relived with antacids, water, milk◦ Worsened with recumbency

Acid Regurgitation◦ Perception of gastric content reflux in the mouth or hypopharynx◦ AKA water brash: bitter, acidic

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Atypical SymptomsAtypical

◦ Dysphagia, odynophagia◦ Nausea◦ Chest pain◦ Dyspepsia = non-severe upper abdominal discomfort

◦ Epigastric fullness, bloating

◦ Frequent belching◦ Heartburn

Extra-esophageal◦ Chronic cough◦ Hoarseness, laryngitis◦ Vocal Cord Dysfunction, Bronchospasm◦ Globus sensation

Complications of GERDPeptic stricture

Barrett’s Esophagus

Adenocarcinoma

Laryngitis

Pulmonary disease

Red Flags to warrant EGD Dysphagia/odynophagia

Nausea/vomiting

Melena, anemia*

Weight loss, anorexia

Extended duration of symptoms

No response to PPI

Family history of PUD

Caucasian Male, 50+ years old, sx > 10 yrs◦ Concern for Barrett esophagitis

Diagnosis

History

Trial of PPI

Upper Endoscopy

Esophageal pH monitoring (Gold Standard)

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 initiated

Diagnostic ConsiderationsEsophagitis

◦ Infectious: Fungal vs viral◦ Pill◦ Eosinophilic (Allergic)

H. pylori testing prior to PPI

CAD◦ Women◦ Elderly◦ Diabetics

Work-up

History + Empiric treatment

◦ Although a response to PPIs is not a definitive diagnosis of GERD, in clinical practice it is more appropriate to start empiric treatment than to pursue reflux pH monitoring

◦ Symptoms that do not improve warrant further evaluation to demonstrate the existence of GERD and evaluate for an alternate diagnosis

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Endoscopy with biopsyUpper endoscopy is not required for diagnosis

Indicated for suspected GERD plus◦ Red flags, or◦ Symptoms resistant to twice daily PPI therapy

Esophagitis or Barrett’s esophagus = diagnostic

Absence of endoscopic features does not exclude a GERD diagnosis

Remember NERD◦ 62% of patients with typical symptoms of GERD will have a normal EGD

Allows for detection, stratification, and management of esophageal manifestations or complications of GERD

Other diagnostic work up

Ambulatory pH monitoring◦ Persistent symptoms despite medical therapy◦ Confirmatory testing in patients with normal EGD

No Barium

Esophageal manometry for dysmotility

Initial Management of GERD

oAntacids and lifestyle changes

oH2-receptor antagonists

oStandard Proton pump inhibitor therapy

oHigh-dose Proton pump inhibitor therapy

oEndoscopy and/or pH testing followed by therapy based on results

Treatment: Lifestyle modifications

◦ Avoid large meals◦ Avoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate, onions,

garlic, peppermint◦ Decrease fat intake◦ Avoid lying down within 3-4 hours after a meal◦ Elevate head of bed 4-8 inches◦ Avoid meds that may potentiate GERD (CCB, alpha agonists,

theophylline, nitrates, sedatives, NSAID’s)◦ Avoid clothing that is tight around the waist◦ Lose weight◦ Stop smoking

Treatment: H2RA vs PPI H2RAs vs PPI’s

◦ 12 week freedom from symptoms◦ 48% vs 77%

◦ 12 week esophagitis healing rate◦ 52% vs 84%

◦ Speed of healing◦ 6%/wk vs 12%/wk

Proton Pump Inhibitor TestEmpiric therapy with PPI for heartburn

Functions as both diagnostic test and therapeutic trial

Sensitivity 68-80% as defined by abnormal pH test or endoscopy

May be falsely positive (does not actually make a true diagnosis or GERD)

Kahrilas PJ. Am J Gastro 2003;98: S15-23

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H2RAs block the histamine receptor, interfering with one of the stimulation pathways

PPIs block acid at its source in the proton pump

ACh=acetylcholine

PPI Mechanism of ActionAntacids neutralize secreted HCl

HCI

HistamineACh

Gastrin

K+H+

Treatment Modifications for Persistent Symptoms

Improve compliance

Optimize pharmacokinetics

◦ 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 meal

Consider switching to a different PPI

Reasons for PPI “Failure”Patient non-compliance

Persistent esophageal acid exposure ◦ Hypersecretory state◦ Large hiatal hernia◦ Nocturnal acid breakthrough

Acid-sensitive esophagus

Non-acid reflux

Wrong diagnosis

Functional heartburn (NOT GERD!!)

Treatment: Surgical Options Anti-reflux surgery - Indications

◦ Failed medical management◦ Patient preference◦ GERD complications◦ Medical complications attributable to a large hiatal hernia◦ Atypical symptoms with pathologic reflux documented on 24-hour pH monitoring

Anti-reflux surgery candidates◦ EGD proven esophagitis◦ ?Normal esophageal motility◦ Incomplete response to acid suppression

Treatment: Surgical Options Anti-reflux surgery (laparoscopic)

◦ Tenets of surgery◦ Reduce hiatal hernia

◦ Repair diaphragm◦ Strengthen GE junction

◦ Strengthen anti-reflux barrier via gastric wrap

◦ 75-90% effective at alleviating symptoms of heartburn and regurgitation

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

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Anti-reflux surgeryThe efficacy of anti-reflux surgery in controlling GERD is similar to that of chronic PPI therapy.

The outcome of anti-reflux surgery is highly dependent on the skill and experience of the surgeon.

Surgery does not always end the need for antisecretory therapy to control the symptoms of GERD.

Lundell et al 2001; Spechler et al 2001

Treatment: Endoscopic Treatment Endoscopic treatment◦ Relatively new◦ No clearly established indications◦ Well-informed patients with well-documented GERD

responsive to PPI therapy may benefit

Three categories◦ Radiofrequency application to increase LES reflux barrier◦ Endoscopic sewing devices◦ Injection of a non-resorbable polymer into LES region

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 therapywith lowest effective dose

Symptoms persist

Consider EGD if risk factors present(> 45, white, maleand > 5 yrs of sx)

Increase tomax dose QD or BID

Good response

Confirm diagnosisEGD, ph monitor

No

Yes YesNo

Yes

Yes

No

No

?QUESTIONS?