Gastroesophageal Gastroesophageal Reflux DiseaseReflux Disease

Howard J. McGowan, Maj, USAF, MCHoward J. McGowan, Maj, USAF, MC

ObjectivesObjectives

Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManisfestationsClinical Manisfestations Diagnostic EvaluationDiagnostic Evaluation TreatmentTreatment ComplicationsComplications

DefinitionDefinition American College of American College of

Gastroenterology (ACG)Gastroenterology (ACG)• Symptoms OR mucosal Symptoms OR mucosal

damage produced by the damage produced by the abnormal reflux of gastric abnormal reflux of gastric contents into the esophaguscontents into the esophagus

• Often chronic and relapsingOften chronic and relapsing• May see complications of May see complications of

GERD in patients who lack GERD in patients who lack typical symptomstypical symptoms

Physiologic vs PathologicPhysiologic vs Pathologic

Physiologic GERDPhysiologic GERD• PostprandialPostprandial• Short livedShort lived• AsymptomaticAsymptomatic• No nocturnal sxNo nocturnal sx

Pathologic GERDPathologic GERD• SymptomsSymptoms• Mucosal injuryMucosal injury• Nocturnal sxNocturnal sx

EpidemiologyEpidemiology

About 44% of the US adult population About 44% of the US adult population have heartburn at least once a have heartburn at least once a monthmonth

14% of Americans have symptoms 14% of Americans have symptoms weeklyweekly

7% have symptoms daily7% have symptoms daily

PathophysiologyPathophysiology Primary barrier to Primary barrier to

gastroesophageal gastroesophageal reflux is the lower reflux is the lower esophageal sphincteresophageal sphincter

LES normally works in LES normally works in conjunction with the conjunction with the diaphragmdiaphragm

If barrier disrupted, If barrier disrupted, acid goes from acid goes from stomach to esophagusstomach to esophagus

Clinical Manisfestations Clinical Manisfestations

Most common symptomsMost common symptoms• Heartburn—retrosternal burning Heartburn—retrosternal burning

discomfortdiscomfort• Regurgitation—effortless return of Regurgitation—effortless return of

gastric contents into the pharynx gastric contents into the pharynx without nausea, retching, or without nausea, retching, or abdominal contractionsabdominal contractions

Clinical ManisfestationsClinical Manisfestations

• Dysphagia—difficulty swallowingDysphagia—difficulty swallowing• Other symptoms include:Other symptoms include:

Chest pain, water brash, globus sensation, Chest pain, water brash, globus sensation, odynophagia, nauseaodynophagia, nausea

• Extraesophageal manifestationsExtraesophageal manifestations Asthma, laryngitis, chronic coughAsthma, laryngitis, chronic cough

Diagnostic EvaluationDiagnostic Evaluation

• If classic symptoms of heartburn and If classic symptoms of heartburn and regurgitation exist in the absence of regurgitation exist in the absence of “alarm symptoms” the diagnosis of “alarm symptoms” the diagnosis of GERD can be made clinically and GERD can be made clinically and treatment can be initiatedtreatment can be initiated

AlarmsAlarms

• Alarm Signs/SymptomsAlarm Signs/Symptoms DysphagiaDysphagia Early satietyEarly satiety GI bleedingGI bleeding OdynophagiaOdynophagia VomitingVomiting Weight lossWeight loss Iron deficiency anemiaIron deficiency anemia

Trial of MedicationsTrial of Medications

H2RA or PPIH2RA or PPI• Expect response in 2-4 weeksExpect response in 2-4 weeks• If no responseIf no response

Change from H2RA to PPIChange from H2RA to PPI Maximize dose of PPIMaximize dose of PPI

Trial of MedicationsTrial of Medications

If PPI response inadequate despite If PPI response inadequate despite maximal dosage maximal dosage • Confirm diagnosisConfirm diagnosis

EGDEGD 24 hour pH monitor24 hour pH monitor

EsophagogastrodudenoscopyEsophagogastrodudenoscopy Endoscopy (with biopsy if Endoscopy (with biopsy if

needed)needed)• In patients with alarm In patients with alarm

signs/symptomssigns/symptoms• Those who fail a medication Those who fail a medication

trialtrial• Those who require long-term txThose who require long-term tx

Lacks sensitivity for Lacks sensitivity for identifying pathologic refluxidentifying pathologic reflux

Absence of endoscopic Absence of endoscopic features does not exclude a features does not exclude a GERD diagnosisGERD diagnosis

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

pHpH

24-hour pH monitoring24-hour pH monitoring• Accepted standard for establishing or Accepted standard for establishing or

excluding presence of GERD for those excluding presence of GERD for those patients who do not have mucosal patients who do not have mucosal changeschanges

• Trans-nasal catheter or a wireless, Trans-nasal catheter or a wireless, capsule shaped devicecapsule shaped device

Patient with heartburn

Iniate tx with H2RA or PPI

H2RA taken BID

Good response

Frequent relapses

On demand tx

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

GERD vs DyspepsiaGERD vs Dyspepsia

Distinguish from DyspepsiaDistinguish from Dyspepsia• Ulcer-like symptoms-burning, epigastric Ulcer-like symptoms-burning, epigastric

painpain• Dysmotility like symptoms-nausea, Dysmotility like symptoms-nausea,

bloating, early satiety, anorexiabloating, early satiety, anorexia Distinct clinical entityDistinct clinical entity In addition to antisecretory meds and In addition to antisecretory meds and

an EGD need to consider an an EGD need to consider an evaluation for Helicobacter pylorievaluation for Helicobacter pylori

TreatmentTreatment

Goals of therapyGoals of therapy• Symptomatic reliefSymptomatic relief• Heal esophagitisHeal esophagitis• Avoid complicationsAvoid complications

Better LivingBetter Living Lifestyle modificationsLifestyle modifications

• Avoid large mealsAvoid large meals• Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate,

onions, garlic, peppermintonions, 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, Avoid meds that may potentiate GERD (CCB, alpha agonists,

theophylline, nitrates, sedatives, NSAIDS)theophylline, nitrates, sedatives, NSAIDS)• Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist• Lose weightLose weight• Stop smokingStop smoking

TreatmentTreatment AntacidsAntacids

• Over the counter acid Over the counter acid suppressants and suppressants and antacids appropriate antacids appropriate initial therapyinitial therapy

• Approx 1/3 of patients Approx 1/3 of patients with heartburn-related with heartburn-related symptoms use at least symptoms use at least twice weeklytwice weekly

• More effective than More effective than placebo in relieving placebo in relieving GERD symptomsGERD symptoms

TreatmentTreatment

Histamine H2-Receptor AntagonistsHistamine H2-Receptor Antagonists• More effective than placebo and More effective than placebo and

antacids for relieving heartburn in antacids for relieving heartburn in patients with GERDpatients with GERD

• Faster healing of erosive esophagitis Faster healing of erosive esophagitis when compared with placebowhen compared with placebo

• Can use regularly or on-demandCan use regularly or on-demand

TreatmentTreatment

AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESCimetadine 400mg twice daily 400-800mg twice dailyCimetadine 400mg twice daily 400-800mg twice dailyTagametTagamet

Famotidine 20mg twice daily 20-40mg twice dailyFamotidine 20mg twice daily 20-40mg twice dailyPepcidPepcid

Nizatidine 150mg twice daily 150mg twice dailyNizatidine 150mg twice daily 150mg twice dailyAxidAxid

Ranitidine 150mg twice daily 150mg twice dailyRanitidine 150mg twice daily 150mg twice dailyzantaczantac

TreatmentTreatment

Proton Pump InhibitorsProton Pump Inhibitors• Better control of symptoms with PPIs vs Better control of symptoms with PPIs vs

H2RAs and better remission ratesH2RAs and better remission rates• Faster healing of erosive esophagitis Faster healing of erosive esophagitis

with PPIs vs H2RAswith PPIs vs H2RAs

TreatmentTreatment

AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESEsomeprazole 40mg daily 20-40mg dailyEsomeprazole 40mg daily 20-40mg dailyNexiumNexium

Omeprazole 20mg daily 20mg dailyOmeprazole 20mg daily 20mg dailyPrilosecPrilosec

Lansoprazole 30mg daily 15-10md dailyLansoprazole 30mg daily 15-10md dailyPrevacidPrevacid

Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg dailyProtonixProtonix

Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg dailyAciphexAciphex

TreatmentTreatment

H2RAs vs PPIsH2RAs vs PPIs• 12 week freedom from symptoms12 week freedom from symptoms

48% vs 77%48% vs 77%

• 12 week healing rate12 week healing rate 52% vs 84%52% vs 84%

• Speed of healingSpeed of healing 6%/wk vs 12%/wk6%/wk vs 12%/wk

TreatmentTreatment

Antireflux surgeryAntireflux surgery• Failed medical managementFailed medical management• Patient preferencePatient preference• GERD complicationsGERD complications• Medical complications attributable to a Medical complications attributable to a

large hiatal hernialarge hiatal hernia• Atypical symptoms with reflux Atypical symptoms with reflux

documented on 24-hour pH monitoringdocumented on 24-hour pH monitoring

TreatmentTreatment

Antireflux surgery candidatesAntireflux surgery candidates• EGD proven esophagitisEGD proven esophagitis• Normal esophageal motilityNormal esophageal motility• Partial response to acid suppressionPartial response to acid suppression

TreatmentTreatment

Antireflux surgeryAntireflux surgery• Tenets of surgeryTenets of surgery

Reduce hiatal herniaReduce hiatal hernia Repair diaphragmRepair diaphragm Strengthen GE junctionStrengthen GE junction Strengthen antireflux barrier via gastric Strengthen antireflux barrier via gastric

wrapwrap 75-90% effective at alleviating symptoms of 75-90% effective at alleviating symptoms of

heartburn and regurgitationheartburn and regurgitation

TreatmentTreatment

PostsurgeryPostsurgery• 10% have solid food dysphagia10% have solid food dysphagia• 2-3% have permanent symptoms2-3% have permanent symptoms• 7-10% have gas, bloating, diarrhea, 7-10% have gas, bloating, diarrhea,

nausea, early satietynausea, early satiety• Within 3-5 years 52% of patients back Within 3-5 years 52% of patients back

on antireflux medicationson antireflux medications

TreatmentTreatment

Endoscopic treatmentEndoscopic treatment• Relatively newRelatively new• No definite indicationsNo definite indications• Select well-informed patients with well-Select well-informed patients with well-

documented GERD responsive to PPI therapy may documented GERD responsive to PPI therapy may benefitbenefit

Three categoriesThree categories• Radiofrequency application to increase LES reflux Radiofrequency application to increase LES reflux

barrierbarrier• Endoscopic sewing devicesEndoscopic sewing devices• Injection of a nonresorbable polymer into LES areaInjection of a nonresorbable polymer into LES area

ComplicationsComplications

Erosive esophagitisErosive esophagitis StrictureStricture Barrett’s esophagusBarrett’s esophagus

ComplicationsComplications

Erosive esophagitisErosive esophagitis• Responsible for 40-60% of GERD Responsible for 40-60% of GERD

symptomssymptoms• Severity of symptoms often fail to match Severity of symptoms often fail to match

severity of erosive esophagitisseverity of erosive esophagitis

ComplicationsComplications

Esophageal Esophageal stricturestricture• Result of healing Result of healing

of erosive of erosive esophagitisesophagitis

• May need May need dilationdilation

ComplicationsComplications

Barrett’s EsophagusBarrett’s Esophagus• Columnar metaplasia Columnar metaplasia

of the esophagusof the esophagus• Associated with the Associated with the

development of development of adenocarcinomaadenocarcinoma

ComplicationsComplications Barrett’s EsophagusBarrett’s Esophagus

• Acid damages lining of Acid damages lining of esophagus and causes esophagus and causes chronic esophagitischronic esophagitis

• Damaged area heals in Damaged area heals in a metaplastic process a metaplastic process and abnormal columnar and abnormal columnar cells replace squamous cells replace squamous cellscells

• This specialized This specialized intestinal metaplasia intestinal metaplasia can progress to can progress to dysplasia and dysplasia and adenocarcinomaadenocarcinoma

ComplicationsComplications

• Patient’s who need EGDPatient’s who need EGD Alarm symptomsAlarm symptoms Poor therapeutic responsePoor therapeutic response Long symptom durationLong symptom duration

• ““Once in a lifetime” EGD for patient’s Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted with chronic GERD becoming accepted practicepractice

• Many patients with Barrett’s are Many patients with Barrett’s are asymptomaticasymptomatic

ComplicationsComplications

Barrett’s EsophagusBarrett’s Esophagus• Manage in same manner as GERDManage in same manner as GERD• EGD every 3 years in patient’s without EGD every 3 years in patient’s without

dysplasiadysplasia• In patients with dysplasia annual to In patients with dysplasia annual to

shorter interval surveillanceshorter interval surveillance

SummarySummary

Definition of GERDDefinition of GERD Epidemiology of GERDEpidemiology of GERD Pathophysiology of GERDPathophysiology of GERD Clinical ManisfestationsClinical Manisfestations Diagnostic EvaluationDiagnostic Evaluation TreatmentTreatment ComplicationsComplications

?QUESTIONS??QUESTIONS?