Gastroesophageal Reflux Disease (GERD) Any symptoms or esophageal mucosal damage that results from reflux of gastric acid into the esophagusClassic GERD symptomsHeartburn (pyrosis): substernal burning discomfortRegurgitation: bitter, acidic fluid in the mouth when lying down or bending over

Locke et al. Gastroenterology 1997;112:1148.High Prevalence of Gastroesophageal Reflux Symptoms

Locke et al. Gastroenterology 1997;112:1148.

Important Reasons to Diagnose and Treat GERDNegative impact on health-related quality of life1Risk factor for esophageal adenocarcinoma2

Revicki et al. Am J Med 1998;104:252.Lagergren et al. N Engl J Med 1999;340:825.

Clinical Presentations of GERDClassic GERD Extraesophageal/Atypical GERDComplicated GERD

Extraesophageal Manifestations of GERDPulmonaryAsthmaAspiration pneumoniaChronic bronchitisPulmonary fibrosis

Other Chest pain Dental erosionENTHoarsenessLaryngitisPharyngitisChronic coughGlobus sensationDysphoniaSinusitisSubglottic stenosisLaryngeal cancer

Potential Oral and Laryngopharyngeal Signs Associated with GERDEdema and hyperemia of larynxVocal cord erythema, polyps, granulomas, ulcersHyperemia and lymphoid hyperplasia of posterior pharynx Interarytenyoid changesDental erosionSubglottic stenosisLaryngeal cancerVaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.

Pathophysiology of Extraesophageal GERD

Symptoms of Complicated GERDDysphagiaDifficulty swallowing: food sticks or hangs upOdynophagiaRetrosternal pain with swallowingBleeding

When to Perform Diagnostic TestsUncertain diagnosisAtypical symptomsSymptoms associated with complicationsInadequate response to therapy Recurrent symptomsPrior to anti-reflux surgery

Diagnostic Tests for GERDBarium swallowEndoscopyAmbulatory pH monitoringEsophageal manometry

Barium SwallowUseful first diagnostic test for patients with dysphagiaStricture (location, length)Mass (location, length)Birds beakHiatal hernia (size, type) LimitationsDetailed mucosal exam for erosive esophagitis, Barretts esophagus

EndoscopyIndications for endoscopy Alarm symptomsEmpiric therapy failurePreoperative evaluationDetection of Barretts esophagus

Ambulatory 24 hr. pH MonitoringPhysiologic studyQuantify reflux in proximal/distal esophagus% time pH < 4DeMeester scoreSymptom correlation

Ambulatory 24 hr. pH MonitoringNormalGERD

Wireless, Catheter-Free Esophageal pH Monitoring

Improved patient comfort and acceptance Continued normal work, activities and diet study Longer reporting periods possible (48 hours) Maintain constant probe position relative to SCJ

Potential Advantages

Esophageal ManometryAssess LES pressure, location and relaxationAssist placement of 24 hr. pH catheterAssess peristalsisPrior to antireflux surgery Limited role in GERD

Treatment Goals for GERDEliminate symptomsHeal esophagitisManage or prevent complicationsMaintain remission

Lifestyle Modifications are Cornerstone of GERD TherapyElevate head of bed 4-6 inches Avoid eating within 2-3 hours of bedtimeLose weight if overweightStop smokingModify dietEat more frequent but smaller mealsAvoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and teaOTC medications prn

Acid Suppression Therapy for GERDH2-Receptor Antagonists (H2RAs)

Cimetidine (Tagamet)Ranitidine (Zantac)Famotidine (Pepcid)Nizatidine (Axid) Proton Pump Inhibitors (PPIs)

Omeprazole (Prilosec)Lansoprazole (Prevacid)Rabeprazole (Aciphex)Pantoprazole (Protonix)Esomeprazole (Nexium )

Effectiveness of Medical Therapies for GERDTreatmentResponse

Lifestyle modifications/antacids20 %

H2-receptor antagonists50 %

Single-dose PPI 80 %

Increased-dose PPIup to 100 %

Treatment Modifications for Persistent SymptomsImprove complianceOptimize pharmacokineticsAdjust 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 mealConsider switching to a different PPI

GERD is a Chronic Relapsing ConditionEsophagitis relapses quickly after cessation of therapy> 50 % relapse within 2 months> 80 % relapse within 6 monthsEffective maintenance therapy is imperative

Complications of GERDErosive/ulcerative esophagitisEsophageal (peptic) strictureBarretts esophagusAdenocarcinoma

Erosive Esophagitis

Peptic StrictureBarium SwallowEndoscopy

Esophageal Stricture: Dilating Devices

TTS Balloon Dilation of a Peptic Stricture

Barretts Esophagus

Esophageal CancerBarium SwallowEndoscopy

When to Discuss Anti-Reflux Surgery with PatientsIntractable GERD rareDifficult to manage stricturesSevere bleeding from esophagitisNon-healing ulcersGERD requiring long-term PPI-BID in a healthy young patient Persistent regurgitation/aspiration symptomsNot Barretts esophagus alone

Endoscopic GERD Therapy Endoscopic antireflux therapiesRadiofrequency energy delivered to the LESStretta procedureSuture ligation of the cardiaEndoscopic plicationSubmucosal implantation of inert material in the region of the lower esophageal sphincterEnteryx

****************Figure 11-18. Endoscopic appearance of benign strictures. Acid-septic strictures and Schatzki's rings are the most common strictures requiring dilation. Although in most instances endoscopic examination allows obvious distinction between the two, variation in air insufflation and the differences in magnification over short distances between the lower esophageal sphincter and the endoscope can make the assessment of the lower esophagus difficult in some patients. A subtle peptic stricture may be missed endoscopically, or, more precisely, may be confused with a Schatzki's ring. Contrast radiology can be a more sensitive technique for demonstrating subtle rings and strictures and for calibrating the lumen more precisely. AC, Endoscopic photographs of several Schatzki's rings. DG, peptic strictures. Note the esophageal pseudodiverticula proximal to the peptic stricture in panels F and G. Their presence increases the risk of unguided dilatation of the esophagus and mandates the use of a guidewire technique. H, Tight anastomotic stricture (suture at 10 o'clock) and watermelon esophagus viewed endoscopically. The watermelon seeds and kernel of corn provide a reference for the pinhole quality of this stricture.

*Figure 11-21. Types of dilators: balloons. Balloon dilators are an additional option for the endoscopist approaching an esophageal stricture. They may be placed over a guidewire or through the scope (TTS). Theoretically, balloons have the advantage of being safer because of the radial application of force, and elimination of the shearing effect of rigid dilators. Moreover, dilation can be performed under direct visualization using the TTS balloon. Recent balloon innovations facilitating their use include longer balloons that avoid the tendency for slippage with inflation, and high-pressure balloons that should provide a truer diameter for the dilation of more resistant strictures. In the limited number of randomized studies comparing Savory-type dilators with balloon dilators, they appeared equally safe. Efficacy, as assessed by symptom improvement and luminal patency, has been variably reported in the literature favoring either technique [18], [19], [20]. A, Range of available balloons and an inflation gun. BE, A peptic stricture before and after balloon dilation, thus demonstrating the direct visualization that is possible with the TTS technique.

References:[18]. Saeed ZA, Winchester CB, Ferro PA, et al. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc 1995 41 189-195[19]. Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilation of benign oesophageal stricture? An interim report of a randomized controlled trial. Gut 1988 29 1741-1747[20]. Shemesh E, Czerniak A, Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures. World J Surg 1990 14 518-522***