acid reflux in the 21 century - boca raton regional...
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Acid Reflux in the 21st Century
Stephen E. Steinberg, MD, FACP
Affiliate Professor of Medicine
Florida Atlantic University
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GERD is a common and significant problem: US study
Prevalence (%)
0
20
40
60
80
25–34 35–44 45–54 55–64 65–74 Age (years)
Any episode of GERD symptoms
At least weekly episodes of GERD symptoms
females
males
Locke GR et al. Gastroenterology 1997;112:1448.
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Hypertension, untreated
Normal female
Angina pectoris
Duodenal ulcer, untreated
Psychiatric patients
110
Normal male
Heart failure (mild)
Esophagitis, untreated
PGWB Index score
GERD has a greater impact on quality of life than other common diseases
60 70 80 90 100
Dimenas E. Scand J Gastroenterol 1993;28 Suppl 199:18.
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Clinical Presentation of GERD
Typical/
Esophageal • Heartburn
• Acid regurgitation
Atypical/
Supraesophageal
• Chest pain
• Laryngitis
• Asthma
• Sinusitis
• Chronic cough
• Aspiration pneumonia
• Tooth decay
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Pathophysiology of GERD
Impaired acid neutralization by saliva and HCO3
Impaired esophageal motility
Hiatal hernia
LES (inappropriate
relaxation)
Delayed gastric emptying/
gastroparesis
LES=lower esophageal sphincter
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Medications may aggravate GERD symptoms
Impairment of LES function:
• beta-adrenergic agonists
• theophylline
• anticholinergics
• tricyclic antidepressants
• progesterone
• alpha-adrenergic antagonists
• diazepam
• calcium channel blockers.
Damage to the esophageal mucosa:
• acetylsalicylic acid and other NSAIDs
• tetracycline
• quinidine
• bisphosphates.
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Phenotypic Classification of GERD
GERD
NERD*
60-70%
Erosive
Esophagitis
20-30%
Barrett’s
Esophagus
6-10%
Fass et al. Alim Pharm Ther 2005
*NERD: Non-Erosive
Reflux Disease
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Symptomatic NERD
• Heartburn
• Regurgitation
• Chest pain
• Impaired QOL
• Others (burning mouth/tongue)
• Atypical (“supraesophageal”) symptoms • These are the same symptoms as patients with erosive
esophagitis and Barrett’s esophagus • The severity of these symptoms CANNOT PREDICT the subtype
of GERD into which a patient falls prior to endoscopic examination
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Taken from Medscape.com
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Endoscopic Images
Normal Squamo-columnar junction
LA Grade A Esophagitis
LA Grade D Esophagitis
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Esophageal stricture – endoscopic appearance
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Metaplasia of the esophagus: Barrett’s esophagus
Definition: a change in the esophageal epithelium of any length that can be recognised at endoscopy and is confirmed to have intestinal metaplasia by biopsy of the tubular esophagus and excludes intestinal metaplasia of the cardia.
Squamous epithelium Columnar epithelium
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20
0
5
10
15
Number of
episodes
0
1
2
3
Time
(minutes)
Barrett’s esophagus is associated with prolonged acid reflux
Reflux episodes >5 minutes Mean duration of reflux episode
Barrett’s esophagus n=51 severe esophagitis n=30 moderate esophagitis n=45 controls n=24
Coenraad M et al. Am J Gastroenterol 1998;93:1068.
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The prevalence of Barrett’s esophagus increases with the duration of reflux symptoms
<1 1–5 5–10 >10 Duration of symptoms (years)
Prevalence of endoscopic Barrett's esophagus
(%)
0
5
10
15
20
25
Lieberman DA et al. Am J Gastroenterol 1997;92:1293.
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Does Barrett’s Esophagus Occur in
the Absence of Heartburn?
• EGD done on 961 pts scheduled for colonoscopy; 556 never had heartburn
• Conclusions:
– BE is relatively common in persons age >40 years with no prior endoscopy
– LSBE is very uncommon in patients who have no history of heartburn
HB (-)
(n=556)
Overall
(n=961)
Barrett’s 5.6% 6.8%
LSBE 0.36% 1.2%
Rex D et al. Gastro 2003
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Good News
• Protects against chemical injury
• Symptoms improve
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Barrett’s Esophagus
0.5%/patient/year cancer
0.9%/patient/year HGD
Colon Polyp
0.5%/patient/year cancer
7.5M colonoscopies/year
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Accumulate
Genetic
Changes
Injury:
Acid & bile reflux
Genetics:
Gender, race,
?other factors (cox-2)
Evolution of
Barrett’s
(The Bad News)
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Pt. IHC Ki-67 IHC p53 CEP 1 CEP 9 p16 p53
1 + + Gain N Loss Loss
2 + + N N Loss Loss
3 + - Gain Gain Loss N
4 + + Gain N Loss N
5 + + N N N Loss
6 + + Gain N N Loss
7 + + Gain N N N
8 + + Gain Gain Loss Loss
9 + + N N N Loss
10 + + N N N Loss
Baseline Mutations
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Chak, Gut, 2002
Gopal, Dig Dis Sci, 2003
Weston, Am J Gastroenterol, 2004
Hage, Scand J Gastroenterol, 2004
Iftikhar, Gut, 1992
Bani-Hani, World J Gastroenterol, 2005
Ramus, Eur J Cancer Prev, 2012
de Jonge, Gut, 2010
Prasad, Am J Gastroenterol, 2010
Reid, Am J Gastroenterol, 2000
Weston, Am J Gastroenterol, 2001
Suspiro, Am J Gastroenterol, 2003
Sikkema, Am J Gastroenterol, 2011
Sappati Biyyani , Dis Esophagus, 2007
Munitiz, J Clin Gastroenterol, 2008
Abnet, Eur J Cancer, 2008
de Jonge, Am J Gastroenterol, 2006
Lagergren, Ann Intern Med, 1999
Jung, Am J Gastroenterol, 2011
Risk of Progression to EAC
• Male
• Caucasian
• Smoker
• Obese
• Family history
• Length of Barrett’s
• Size of hiatal hernia
• Duration of Barrett’s
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Esophageal Cancer
Esophagus
Melanoma
Colorectal
Lung/Breast
Prostate
From: Pohl H, Welch HG. Natl Cancer Inst 2005
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Esophageal Cancer: 5-Year Survival
37%
19%
3%
17%
0
5
10
15
20
25
30
35
40
Localized Regional Distant All Stages
5-Y
ear
Su
rviv
al (%
)
Stage at Diagnosis
All Races
Siegel R, et al. CA Cancer J Clin. 2011
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Treatment
• GERD
• Barrett’s
• Esophageal adenocarcinoma
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A 35-year old woman presents to her primary care physician because of six months of heartburn. Her medical history is only notable for chronic migraines. She has no dysphagia, odynophagia, or weight loss. She experiences symptoms several times a week, usually during stressful days at her job as a high school teacher.
• What should be done at this point?
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Initial Management of GERD
Step-up vs Step-down
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Initial Management of GERD
A. Antacids and lifestyle changes
B. H2-receptor antagonists
C. Standard Proton pump inhibitor therapy
D. High-dose Proton pump inhibitor therapy
• Continuous?
• On-Demand?
E. Endoscopy and/or pH testing followed by therapy based on results
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Changes to diet and lifestyle can impair quality of life without improving
GERD symptoms
• Changes to diet and lifestyle are difficult for some patients and can significantly impair patient quality of life.
• Studies into the negative effects of diet and lifestyle on GERD are few in number and the findings are statistically weak.
• The criteria for evidence-based medicine are not met when diet and lifestyle changes are recommended.
Dent 1992; Meining & Classen 2000
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Treatment Goals for GERD
• Eliminate symptoms
• Heal esophagitis
• Manage or prevent complications
• Maintain remission
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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
Mechanisms of Action of GERD Pharmacotherapy
Antacids
neutralize
secreted HCl
HCI
Histamine ACh
Gastrin
K+ H+
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Proton Pump Inhibitor Test
• Empiric 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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PPI Complications
• Dementia: increased likelihood in observational study
• Chronic Kidney Disease
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The PCP places her on H2-receptor antagonists and recommends lifestyle changes and intermittent antacids. She returns a month later with no change in her symptoms. She is placed on once daily PPI therapy and 2 weeks later, she is still symptomatic.
What should be done now?
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Indications for additional investigations
• Symptoms are frequent and long-standing or do not respond to therapy.
• Atypical history. • Alarm symptoms are present:
– severe dysphagia – weight loss – bleeding – hematemesis – mass in the upper abdomen – anemia
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A. Refer for endoscopy
B. Increase proton pump inhibitor to BID
C. Perform pH study
D. Refer for surgical treatment
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Why Do PPI’s Fail to Control Symptoms?
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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!!)
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Placement of Bravo® capsule
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Antireflux surgery – an alternative to pharmacological therapy
• The efficacy of antireflux surgery in controlling GERD is similar to that of chronic PPI therapy.
• The outcome of antireflux 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
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Nissen fundoplication and the Toupet procedure
Nissen fundoplication Toupet procedure
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Medication use in follow-up of patients from VA cooperative GERD study
Spechler et al, JAMA 2001; 285: 2331
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Barrett’s HGD Management Then: pre- 2009
• Dysplasia and Early Cancer
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Ablation Depth Control
Micro-array at Tissue Interface
RFA depth
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Treatment options IM
• Radio frequency ablation (RFA)
• Cryotherapy
• Photodynamic therapy
• Endoscopic mucosal resection (EMR)
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Radio Frequency Ablation
HALO360+
HALO90
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Radio Frequency Ablation
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RFA
Post-RFA: 2 years Post-RFA Baseline
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Pt. IHC Ki-
67
IHC p53 CEP
1
CEP
9
p16 p53
1 - - N N N N
2 - - N N N N
3 - - N N N N
4 - - N N N N
5 - - N N N N
6 - - N N N N
7 - - N N N N
8 - - N N N N
9 - - N N N N
10 - - N N N N
Post-Treatment
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Clinical Data Summary n FU CR-IM CR-D CR-HGD
Buried Glands
Stricture Rate
AIM-II Trial 61 30 mo 98.4% -- -- None 0%
50 60 mo 92% -- -- None 0%
AIM-LGD 10 24 mo 90% 100% -- None 0%
HGD Registry 92 12 mo 54% 80% 90% None 0.4%
AMC-I 11 14 mo 100% 100% -- None 0%
AMC-II 12 14 mo 100% 100% -- None 0%
AMC Long-term FU 23 52 mo 100% 100% -- None --
Comm Registry 429 20 mo 77% 100% -- None 1.1%
EURO-I 24 15 mo 96% 100% -- None 4.0%
EURO-II 119 12+ mo 91% 96% None 0%
Emory 27 <12 mo 100% 100% -- None 0%
Dartmouth 25 20 mo 78% --
Henry Ford 66 varied 93% -- -- None 6.0%
Mayo 63 24 mo 79% 89% -- None 0%
LGD 39 24 mo 87% 95% -- None 0%
HGD 24 23mo 67% 79% -- None 0%
AIM RCT (primary) 127 (RFA
84) 12 mo 77% (83%) 86% (92%) -- 5.1% 6.0%
Long-term FU 106 24 mo 93% 95% -- 3.8% 7.6%
RFA/ER vs. SRER RT 47 24 mo -- -- --
RFA/ER 22 22 mo 96% 96% -- None 14.0%
SRER 25 25 mo 92% 100% -- 8.0% 88.0% 52
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Barrett’s: Whom to treat
• High grade dysplasia
• Low grad dysplasia
• Long Segment Barrett’s: ?
• Patients “at risk” ??
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Confocal Laser Endomicroscopy
Physical Biopsy Optical Biopsy
En-face view
In-vivo
Microscopic
Minimally invasive
Instantaneous imaging
Transverse view
Ex-vivo
Microscopic
Invasive
Delayed imaging
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Confocal Microscopy for IM surveillance
1. Sharma P. et al. Real-time Increased Detection of
Neoplastic Tissue in BE with pCLE GI Endoscopy, 2011.
pCLE
or WLE
pCLE
or WLE
or NBI
WLE
WLE or
NBI
WLE : White Light Endoscopy
NBI : Narrow Band Imaging
multi-center, randomized controlled trial,
101 patients, 2 arms 1
Sensitivity for neoplasia detection
x2
x1.7
68% 76%
sensitivity
Intestinal metaplasia High-grade dysplasia
Adenocarcinoma
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pCLE: Normal
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pCLE: IM
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pCLE: HGD
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pCLE: EAC
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EAC Management Then: pre- 2009
• Dysplasia and Early Cancer
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Ablation Depth Control
Micro-array at Tissue Interface
RFA depth
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Endoscopic Mucosal Resection
15 minutes…Outpatient
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Treatment of Early Cancers
• 92% 5 yr survival = surgery
• Success requires:
– eradication of Barrett’s
– surveillance
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Summary
• Acid reflux = GERD
• GERD not = Barrett’s
• Barrett’s: small percentage progress
• Barrett’s: treatable
• Early cancers: curable (>92%)