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GERD Treatment and Diagnosis Guide
- 2. Gastro-Esophageal Reflux Disease (GERD) Dr Junaid Saleem MBBS FCPS Consultant Physician Special Interest Gastroenterology and Hepatology Hearts International Hospital The Mall Rawalpindi
- 4. Conflicts of Interest Statement • Honorarium for this lecture by Pakistan
- 5. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 6. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 7. Definition • REFLUX is derived from Greek: – Retro - Back – Flux – Flow
- 8. Definition • American College of Gastroenterology (ACG) – Symptoms and/or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus – Often chronic and relapsing – May see complications of GERD in patients who lack typical symptoms
- 10. Definition • ENRD – Endoscopically Negative Reflux Disease • NERD - Non Erosive Reflux Disease – Symptoms same as GERD but no endoscopic damage visible – An endoscopic diagnosis • Nocturnal GERD – 47 to 79% of GERD patients has Nocturnal GERD (Aliment Pharmacol Ther. 13 (2):117–27)
- 11. Physiologic vs Pathologic • Physiologic GERD – Asymptomatic i. Postprandial Only ii. Short lived iii. No Mucosal injury iv. No nocturnal symptoms • Pathologic GERD – Symptomatic i. Postprandial Aggravation ii. Prolonged iii. Mucosal injury+/- iv. Nocturnal symptoms present
- 12. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 13. Epidemiology • GERD occurs in all ages – But most common in those older than 40 years of age. • No difference in incidence between men and women – Except for NERD and pregnancy • Prevalence is more in white adult males
- 14. Epidemiology • It is common • In USA: – About 44% of the adult population have heartburn at least once a month – 14% of Adults have symptoms weekly – 7% have symptoms daily ACG Guidelines 2013
- 16. Prevalence in Pakistan 24% World Gastroenterology Organisation, 2013. J Coll Physicians Surg Pak 2005;15:532–4.
- 17. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 18. Pathophysiology Lax Lower Esophageal Sphincter (LES) Composition of Refluxate pH of the refluxate <2 Pepsinogen Mucosal Resistance Mucus secreting Delayed Gastric Emptying Hiatal Hernia
- 19. Pathophysiology Lower esophageal sphincter (LES) 1. Intrinsic muscle of distal esophagus 2. Sling fibers of cardia 3. Diaphragm 4. Transmitted pressure of abdominal cavity
- 20. Sliding Rolling Mixed Types of Hiatal Hernias
- 21. Pathophysiology • Primary barrier to GERD is the Lower Esophageal Sphincter (LES) • LES normally works in conjunction with the diaphragm • If anatomical barrier is disrupted, acid goes from stomach to esophagus
- 23. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 24. Sign & Symptoms Hoarseness Frequent heartburn Sour or bitter taste in mouth Coughing Difficulty swallowing (dysphagia) Damaged teeth from stomach acid Frequent or recurrent vomiting Feeling like there's a lump in your throat Belching Disturb Sleep & work Persistent more than one symptoms, one or two days a week
- 25. Clinical Manifestations • Most common symptoms – Heartburn Retrosternal burning discomfort – Regurgitation Effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions – Water Brash Brackish fluid coming up in the throat
- 26. Symptoms Symptom Predominance (%) Heartburn 80 Regurgitation 54 Abdominal Pain 29 Cough 27 Dysphagia for solids 23 Hoarseness 21 Belching 15 Aspiration 14 Wheezing 7 Globus 4
- 27. Clinical Manifestations – Dysphagia Difficulty swallowing – Extra-esophageal manifestations • Asthma - Nocturnal or non- atopic • Hoarseness - Pharyngitis, Laryngitis, Laryngeal edema and nodules • Chronic dry cough • Recurrent Aspiration Pneumonia – Other symptoms include: • Chest pain (retro- sternal) • Water brash • Globus sensation • Odynophagia • Nausea • Dental Erosions
- 28. Alarm Signs / Symptoms • Unexplained Weight loss • GI bleeding • Vomiting • Iron deficiency anemia • Age >50 years • Dysphagia • Odynophagia • Choking • Continual pain • Early satiety • Family History of GI malignancy
- 29. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 30. 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 initiated • Patient needs further work up, IF the patient: – Does not respond to treatment – Has frequent relapses – Has persistent symptoms for long duration – Has “alarm symptoms”
- 31. Visick grading • Visick grading system was originally utilized in postoperative patients following gastric surgery for peptic ulcer disease, it has been used for various other gastric operations. – Grade 1 no symptoms – Grade 2 intermittent/mild symptoms, not affecting life-style – Grade 3 mild symptoms, but refractory to medical therapy – Grade 4 are severe symptoms, not improved
- 32. Diagnostic Studies • Empirical Therapy (Therapeutic Trial) • Upper Gastrointestinal Endoscopy (EGD) • Upper Gastrointestinal Fluoroscopy with Barium • 24-hour pH Monitoring • Esophageal Manometry
- 34. Esophago-Gastro- Duodenoscopy (EGD) • Endoscopy (with biopsy if needed) i. In patients with alarm signs/symptoms ii. Those who fail a medication trial iii. Those who require long-term treatment • Cons: i. Lacks sensitivity for identifying pathologic reflux ii. Absence of endoscopic features does not exclude a GERD diagnosis
- 35. Esophago-Gastro- Duodenoscopy (EGD) • Pros: i. Allows for detection, stratification, and management of esophageal manifestations or complications of GERD Examination of the esophageal mucosa Presence of esophagitis Grading of severity Tissue biopsies to screen for Barrett’s esophagus ii. Can identify other pathology Diverticula Hiatal Hernia Webs Rings, or Strictures
- 36. Esophagogram • Useful when operation is planned—shows anatomy of esophagus and proximal stomach • Demonstrates presence and size of hiatal hernia if present
- 37. 24 hr pH Monitoring • Gold standard for establishing or excluding presence of Pathological GERD (esp for those patients who do not have mucosal changes) • Parameters measured include: i. total number of reflux episodes ii. duration of longest reflux episode iii. percentage of time pH is < 4 • Trans-nasal catheter or a wireless, capsule shaped device
- 38. Ambulatory pH testing – Recent Advances • Combined impedance and acid testing i. Allows for the measurement of both acid and non-acid (volume) reflux. ii. Important in patients with persistent symptoms despite an adequate medical trial
- 39. Manometry • Esophageal Body – To determine effectiveness of peristalsis – Amplitude of esophageal wave • Lower Esophageal Sphincter (LES) – Mean resting pressure – Total length • It is often performed along with 24-hour pH probe study.
- 40. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 41. Treatment • Goals of Therapy – Symptomatic relief – Heal esophagitis – Avoid complications • Options Available – Life Style Modifications – Medical Treatment – Surgery
- 42. Life Style Modifications • Raise Head end of bed (6-8 inches) • Weight loss for over weights • Avoid lying down after meals • Avoid bedtime snacks • Smoking cessation • Alcohol abstinence • Food that may aggravate reflux • Medications that may exacerbate reflux
- 43. Life style Modifications Elevate head of bed 4-8 inches Avoid clothing that is tight around the waist Lose weight Stop smoking
- 44. Life style Modifications • Dietary Habits and Modifications – Avoid large meals – Avoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate, onions, garlic, peppermint – Decrease fat intake – Avoid lying down within 2-3 hours after a meal
- 46. Life style Modifications Foods that Increase Acid Production • Acidic foods – Citrus fruits – tomato • Alcohol • Caffeine • Chocolate • Onions & Garlic • Meats • Peppermint Foods that Decrease Gastric Emptying • Alcohol • Fatty and Fried foods • Caffeine • Chocolate
- 47. Life style Modifications • Drugs – Avoid drugs that may potentiate GERD • CCB – eg nifedipine, verapamil & diltiazem • α-Agonists • Theophylline • Nitrates • Sedatives • NSAIDS • Anticholinergic agents – eg tricyclic antidepressants , antihistamines • Oral contraceptives and Estrogen.
- 49. Treatment • Antacids and Alginates – Over the counter acid suppressants and antacids appropriate initial therapy – Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly – More effective than placebo in relieving GERD symptoms
- 50. Treatment • Histamine H2-Receptor Antagonists – More effective than placebo and antacids for relieving heartburn in patients with GERD – Faster healing of erosive esophagitis when compared with placebo – Can use regularly or on-demand
- 51. Treatment (H2RA) AGENT EQUIVALENT DOSAGE (mg) DOSAGE mg/day Cimetidine 400 400-800 Famotidine 20 20-80 Nizatidine 150 150-600 Ranitidine 150 150-600
- 52. Trial of Medications • H2RA – Expect response in 4-6 weeks – If no response change from H2RA to PPI • PPI – Expect response in 4-6 weeks – If no response maximize dose of PPI
- 53. Treatment • H2RAs vs PPIs – 12 week freedom from symptoms • 48% vs 77% – 12 week healing rate • 52% vs 84% – Speed of healing • 6%/wk vs 12%/wk
- 54. Treatment • Proton Pump Inhibitors – Better control of symptoms with PPIs vs H2RAs and better remission rates – Faster healing of erosive esophagitis with PPIs vs H2RAs
- 56. Treatment (PPIs) AGENT DOSAGES Available in Pakistan Omeprazole 20 – 80 mg daily Omeprazole with NaHO3 20 – 40 mg daily Esomeprazole 20 – 80 mg daily Pantoprazole 40 – 80 mg daily Rabeprazole 10 – 40 mg daily Lansoprazole 15 – 60 mg daily Dexlansoprazole 15 – 60 mg daily Not available in Pakistan Ilaprazole (Noltec) 5 – 20 mg
- 57. Dexlansoprazole Advantages • Can be taken with food • Can be taken with clopidogrel • No dose alteration in renal failure • DDR has longer duration of action than the parent compound • Less Nocturnal Escape symptoms
- 58. Trial of Medications • If PPI response inadequate despite maximal dosage – Confirm diagnosis • EGD • 24 hour pH monitor
- 59. Patient with heartburn Initiate Tx with H2RA or PPI H2RA taken BD Good response Frequent relapses On demand Tx PPI taken OD / BD 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 BID Good response Confirm diagnosis EGD, pH monitor No Yes Yes No Yes Yes No No
- 60. Rome IV 2016
- 61. Treatment • Antireflux surgery – Failed medical management – Patient preference – GERD complications – Medical complications attributable to a large hiatal hernia – Atypical symptoms with reflux documented on 24-hour pH monitoring
- 62. Surgical Options - Fundoplications Conventional • Complete – Nissen Fp (360°) • Partial – Toupet Fp – Watson Fp (270°) – Partial 180° • Anterior • Posterior Laparoscopic
- 63. Treatment • Postsurgery – 10% have solid food dysphagia – 2-3% have permanent symptoms – 7-10% have gas, bloating, diarrhea, nausea, early satiety – Within 3-5 years 52% of patients back on antireflux medications
- 64. Treatment • Endoscopic treatment – Relatively new – No definite indications – Select 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 nonresorbable polymer into LES area
- 65. Objectives • Definition of GERD • Epidemiology of GERD • Pathophysiology of GERD • Clinical Manifestations • Diagnostic Evaluation • Treatment • Complications
- 66. Complications • Erosive esophagitis • Stricture • Barrett’s esophagus
- 67. Complications • Erosive esophagitis – Responsible for 40-60% of GERD symptoms – Severity of symptoms often fail to match severity of erosive esophagitis
- 68. Complications • Esophageal stricture – Result of healing of erosive esophagitis – May need dilation
- 70. Complications • Barrett’s Esophagus – Manage in same manner as GERD – EGD every 3 years in patient’s without dysplasia – In patients with dysplasia annual to shorter interval surveillance
- 71. ?QUESTIONS?