gastroesophageal reflux objectives disease (gerd) · and treatment of gerd and h-pylori know...

GastroesophagealGastroesophageal Reflux Reflux

Disease (GERD)Disease (GERD)

Greg W. Mennie,Greg W. Mennie,MSEdMSEd, PA, PA--CC

PIH Family Medicine ResidencyPIH Family Medicine Residency

Objectives

� Have working knowledge of the anatomy and physiological mechanisms that contribute to GERD

� Gain knowledge to develop a consistent format for identifying GERD risk factors

� Know the epidemiology of GERD as it relates to patients lifestyle and healthcare delivery

� Know the atypical symptoms associated with GERD

� Know the alarm symptoms associated with GERD

� Understand the relationship of H-Pylori and GERD

� Know the treatment modalities for GERD and H-Pylori

� Know the relevant laboratory testing guidelines for the diagnosis and treatment of GERD and H-Pylori

� Know indications for referral and invasive evaluation of GERD

� Know the lifestyle modification issues for reducing GERD symptoms

GERDGERD

PepticPeptic EsophagitisEsophagitis dates back to the dates back to the

mid 1930mid 1930’’s s –– WinkelsteinWinkelstein A. PepticA. Peptic esophagitisesophagitis: a new clinical : a new clinical

entity. JAMA 1935;104:906entity. JAMA 1935;104:906--909.909.

RefluxReflux EsophagitisEsophagitis introduced by introduced by

Allison in 1946Allison in 1946 -- Allison PR. Peptic ulcer of the esophagus. Allison PR. Peptic ulcer of the esophagus.

JJ Thorac SUrgThorac SUrg. 1946;15:308. 1946;15:308--317.317.

GERDGERD

Difficult to obtain accurate epidemiological Difficult to obtain accurate epidemiological information due to the lack of information due to the lack of standardized definition and diagnostic standardized definition and diagnostic goldgold--standard.standard.

Most epidemiological statistics assumeMost epidemiological statistics assume

Heartburn = GERDHeartburn = GERD

Spechler SJ. Epidemiology and natural history

of gastro-oesophageal reflux disease. Digestion 1992;51 suppl1:24-9

GERD GERD –– Gallup Poll 2000Gallup Poll 2000

Most common complaints among U.S. adults (18 y.o or older)

65% Heartburn – Daytime and Nocturnal

62% Gas

55% Burning Sensation in Chest

52% Burning Sensation in Throat

50% Acid Reflux

�� A description of a symptomatic A description of a symptomatic condition or pathological condition or pathological alteration resulting from alteration resulting from repeated episodes of gastric repeated episodes of gastric reflux.reflux.

�� A digestive disorder affectingA digestive disorder affecting

the LES.the LES.

�� Multiple symptoms with Multiple symptoms with esophageal andesophageal and extraesophagealextraesophagealmanifestations.manifestations.

GERD or GORDGERD or GORD

GERD GERD -- EpidemiologyEpidemiology

19931993--

““100 million adults suffer from heartburn100 million adults suffer from heartburn””

1995 1995 --

““17 17 ––40 million adults40 million adults””

2001 2001 --

““60 million adults60 million adults””

2525--40% experience GERD 40% experience GERD

77--10% daily10% daily

Herbella FA, Sweet MP, Tedesco P, Nipomnick I, Patti MG. Gastroesophageal reflux disease and obesity.Pathophysiology and implications for treatment. J Gastrointest Surg. Mar 2007;11(3):286-90

Difficult to obtain exact figures


EL-Serag H. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut

doi:10.1136/gutjnl-2012-304269

Increasing global presence of GERD

18%–28% in North America

ETHNICITYETHNICITY

White population White population 556/100,000556/100,000

AfricanAfrican--Americans Americans 288/100,000 288/100,000

Hispanics Hispanics 48/100,00048/100,000

Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American

Gastroenterological Association 2001;1:1-86

AGE and GENDERAGE and GENDER

74% of all GERD cases occur in women74% of all GERD cases occur in women

Other studies have noted = prevalence but Other studies have noted = prevalence but higher amounts ofhigher amounts of esophagitisesophagitis in Men (2:1) in Men (2:1) andand BarretsBarrets in Men (10:1)*in Men (10:1)*

>90% of GERD sufferers >25 y.o.>90% of GERD sufferers >25 y.o.

Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86

*Sleisenger and Fordtrans Textbook of Gatrointestinal and Liver Disease, Seventh Ed. 2002, Saunders.

216 percent increase

1998 - 995,402

2005 - 3,141,965

GERD DiagnosisGERD Diagnosis

Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005 -

HCUP-US http://www.hcup-us.ahrq.gov/reports/statbriefs/sb44.jsp

� 122% rise in Yearly hospitalizations with obesity diagnoses 1996-2004

� Casual association with obesity and gerd

El-Serag H, The Association Between Obesity and GERD: A Review of the Epidemiological Evidence. Dig Dis Sci. Sep

2008; 53(9): 2307–2312.

ATYPICALATYPICAL

TYPICALTYPICAL

ALARMALARM

GERD GERD –– SymptomsSymptoms

ATYPICALChest Pain Voice changeDysphagia GlobusDyspepsia BronchitisAsthma Pneumonia

At least one atypical symptom was present in patients with typical symptoms

lOCKE, GR, et al. Prevalence and Clinical Spectrum of

Gastroesophageal Reflux: A population-Based Study in Olmstead County, Minnesota. Gastroenterology 1997;112:1448-56

GERD GERD –– SymptomsSymptoms

� TYPICAL

• Heartburn

• Acid Regurgitation

�Dysphagia

�Odynophagia

�Early Satiety

�Weight loss

�GI blood loss

�Anemia

�New age >45

�Non-cardiac "angina-like" chest pain

�Failure of 4 wk acid suppression trial

�Breakthrough sxs

Alarm SymptomsAlarm Symptoms

AsymptomaticAsymptomatic

• 1993 study pH monitoring

� Reported in Hospital Physician August 1999 Estimated 30% of patients with GERD have no symptoms.

COSTSCOSTS

GERD GERD ––COSTSCOSTS

DIRECTDIRECT -- 9.6 Billion dollars (Year 2000)

INDIRECT INDIRECT -- consumption of health care and the lost days of work

479 Million dollars (Year 1998)

Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American

Gastroenterological Association 2001;1:1-86

Direct Cost of Gastroesophageal Reflux Disorder (in millions)

Drugs,

$5,892.20

Hospital

Inpatient,

$2,539.50

Office Visits,

$603.10

Hospital ER,

$77.50

Hospital OPD,

$212.90

Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The

Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86

““PLOPPLOP--PLOP PLOP

FIZZFIZZ--FIZZ FIZZ

OH WHAT A RELIEF OH WHAT A RELIEF

IT ISIT IS””

GERD GERD ––Direct COSTSDirect COSTS

GE

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$0

$1

$2

$3

$4

$5

$6

$7

$8

$9

$10

Billion

57%

39%

27%

40%

48%

0%

10%

20%

30%

40%

50%

60%

Mo

od

So

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Sle

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Da

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Severe

Moderate

Mild

Combined

Affects of Heartburn on Quality of Life

Gallup 2000

Clinical Diagnosis

vs Dyspepsia

“Tests” are not necessary in patients

with typical reflux symptoms

Trial of Therapy

GERD GERD --DiagnosisDiagnosis

No gold standard exists for the diagnosis of GERD

Endoscopy - appropriate first-line investigation

? Once in lifetime with chronic

symptoms (No ALARM)

24-hour pH monitoring reserved for atypical

symptoms or fail to respond to proton pump inhibitor

therapy.

DiagnosticsDiagnosticsGERD GERD –– Contributing FactorsContributing Factors

Dietary and lifestyle choices: certain foods, smoking, obesity

Pregnancy – Most common condition predisposing to GERD 50 – 80% of pregnant patients report heartburn*.

Genetics plays a role; a recent study indicates that a family member of someone with GERD is four times more likely to experience the disorder

Meds

Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86

*Sleisenger and Fordtrans Textbook of Gatrointestinal and Liver Disease, Seventh Ed. 2002, Saunders.

MythsMyths

�� OccOcc reflux isnreflux isn’’t badt bad

�� Mint, milk will help soothe theMint, milk will help soothe the sxssxs�� +licorice (anise helps)+licorice (anise helps)

�� Avoid coffee, wine, juice, chocolateAvoid coffee, wine, juice, chocolate

�� Avoid spicy foodsAvoid spicy foods

FactFact

�� There is no evidence to show that any of the dietary There is no evidence to show that any of the dietary

restrictions usually recommended make a difference. restrictions usually recommended make a difference.

�� Evidence of a clear benefit from 2 lifestyle changesEvidence of a clear benefit from 2 lifestyle changes�� Weight loss Weight loss

�� raising the head of your bedraising the head of your bed

Kaltenbach T, Crockett S, Gerson L. Are Lifestyle Measures Effective in Patients With Gastroesophageal Reflux

Disease? Arch Intern Med. 2006;166:965-971

TreatmentTreatment

�� Head of bed Head of bed –– laryngeallaryngeal sxssxs, cough, , cough,

throat clearing,throat clearing, pharyngitispharyngitis avoidavoid

recumbancyrecumbancy

�� Small mealsSmall meals

�� Food restrictionsFood restrictions

STEPSTEP--UPUP

Proton pump

inhibitor therapy

Lifestyle modification + 8 week trial

b.i.d. H2RA

No relief with H2 at

2 weeks

Good response with H2

move to on- demand therapy

STEPSTEP--DOWNDOWN

H2receptor antagonist

or stop therapy

Proton pump

inhibitor therapy x

6-8 weeks

Step-down therapy has the merits of faster symptom relief,

faster healing and over all costs less.

GERDGERD


1998 Mortality Rate 0.48 deaths /100,000

-Centers for Disease Control

Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The

Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86


GERD GERD –– High Risk PatientHigh Risk Patient

Patient with Alarm symptom

Age of onset > 45 y.o. (> white males)

Significant ETOH of Tobacco use

Duration of symptomsweekly heartburn sxs > 5 years = 20-fold increased risk ofadenocarcinoma of the distal esophagus or gastric cardia

compared to non-heartburn patients.(NEJM)

GERD GERD -- EspohagitisEspohagitis

� Esophagitis – The squamous epithelium becomes altered secondary to excessive exposure of gastric juice from reflux.

� Low Grade – seen histopathologically

� High Grade – seen endoscopically

� Less than half of all GERD patients have EE

� Mantynen, et al. The impact of GI endoscopy referral volume on the diagnosis of GERD and its complications: a 1-year cross-sectional study. Am J Gastro. 2002 Oct; 97 (10) 2524-29.

EndoscopyEndoscopy ScreenScreen

�� GERD symptoms that are persistent or progressive despite GERD symptoms that are persistent or progressive despite

appropriate medical therapyappropriate medical therapy

�� DysphagiaDysphagia oror odynophagiaodynophagia

�� Involuntary weight loss > 5%Involuntary weight loss > 5%

�� Evidence of GI bleeding or anemiaEvidence of GI bleeding or anemia

�� Finding of a mass, stricture, or ulcer on imaging studiesFinding of a mass, stricture, or ulcer on imaging studies

�� Evaluation of patients with suspected extraEvaluation of patients with suspected extra--esophagealesophageal

�� manifestations of GERDmanifestations of GERD

�� Screening for BE in selected patients (as clinicallyScreening for BE in selected patients (as clinically

�� Indicated Indicated –– if negative no further screening)if negative no further screening)

�� Persistent vomitingPersistent vomiting

�� Evaluation of patients with recurrent symptoms afterEvaluation of patients with recurrent symptoms after endoscopicendoscopic

or surgicalor surgical antirefluxantireflux proceduresprocedures

American Society for GI Endsocopy. Role of Endoscopy in the Management of GERD. Gastrointestinal

endoscopy journal. Volume 66, No. 2 : 2007

GERD GERD –– BarrettBarrett MetaplasiaMetaplasia

�� Severe outcome of chronic GERDSevere outcome of chronic GERD

•• MetaplasticMetaplastic columnar cells replace nativecolumnar cells replace native

squamoussquamous epithelium.epithelium.

� Prevalence rate of less than 20% in the GERD patient population with African Americans having a higher rate than caucasians.*

� Patients at highest risk for Barrett’s are Caucasian males

with long duration (>5yrs) of reflux symptoms.


*lOCKE, GR, et al. Prevalence and Clinical Spectrum of

Gastroesophageal Reflux: A population-Based Study in Olmstead County, Minnesota. Gastroenterology 1997;112:1448-56

EndoscopyEndoscopy SurveillanceSurveillance

The cost effectiveness for patients without dysplasia is controversial.

Appropriate for patients fit to undergo therapy.

Barret’s - Initial 2 screenings within one year.

�No dysplasia, after 2 consecutive examinations

• surveillance is every 3 years.

�LGD

• No specific protocol – consider f/u eval and bx in 6 mos from dx. If continued dysplasis consider yearly

eval

�HGD

• Q 3mos x 1 year with multiple large capacity bx obtained at 1 cm intervals.

• If Neg after 1 year for CA the interval may lengthen if no dysplastic changes are noted on 2 subsequent

endoscopies performed at 3-month intervals.

American Society for GI Endsocopy. ASGE guideline: the role of endoscopy in the surveillance

of premalignant conditions of the upper GI tract. Gastrointestinal Endoscopy Journal Volume 63, No. 4 : 2006

ROME III

The Rome criteria is a system developed to classify the functional gastrointestinal disorders (FGIDs), disorders of the digestive system in which symptoms cannot be explained by the presence of structural or tissue abnormality, based on clinical symptoms.

Drossman D, The Functional Gastrointestinal Disorders and the Rome III Process. Gastroenterology 2006;130:1377–1390

My Tummy Hurts

FUNCTIONAL HEARTBURN

• Burning retrosternal discomfort

• Absence of evidence that gastroesophageal acid reflux is the cause of the symptom

• Absence of histopathology-based esophageal motility

disorders

� FUNCTIONAL DYSPEPSIA

• Bothersome postprandial fullness

• Early satiation

• Epigastric pain/burning

• No evidence of structural disease (including at upper

endoscopy)

3 mo sx onset 6 months prior to dx

HH--PyloriPylori

GERD may worsen or develop for the

first time after H pylori eradication.

�� No effect on EGJNo effect on EGJ

�� No effect on LESNo effect on LES

�� Unlikely effectsUnlikely effects esophesoph peristalsis or acid peristalsis or acid

clearanceclearance

�� IncreasesIncreases GastrinGastrin levels but decreased acid levels but decreased acid

secretion secretion –– cytokines inflammationcytokines inflammation

HH--PyloriPylori EpidemiolgyEpidemiolgy

�� 20% < age 4020% < age 40

�� 50% > age 60 50% > age 60

�� Uncommon in young children. Uncommon in young children.

�� > Low socio> Low socio--economic status economic status

�� Immigration is responsible for isolated Immigration is responsible for isolated

areas of high prevalence in some Western areas of high prevalence in some Western

countries. countries.

�� Lowering ratesLowering rates

HH-- PyloriPylori

�� No effect on EGJNo effect on EGJ

�� No effect on LESNo effect on LES

�� Unlikely effectsUnlikely effects esophesoph peristalsis or peristalsis or

acid clearanceacid clearance

�� IncreasesIncreases GastrinGastrin levels but levels but

decreased acid secretion decreased acid secretion –– cytokines inflammationcytokines inflammation

HH--Pylori and CancerPylori and Cancer

� ~ 6 fold risk of gastric cancer

� Mucosa associated lymphoid tissue (MALT)� ~90% are associated with H.pylori.

� ~50% cure for localized MALT after cure of H.pylori.

Eurogast Study Group

HH-- Pylori EradicationPylori Eradication

�� Increased risk of GERDIncreased risk of GERD

�� Increased severity ofIncreased severity of esophagitisesophagitis

�� Lower prevalence ofLower prevalence of barretsbarrets andand

esoph adenoesoph adeno –– gene dependentgene dependent

�� None of the above applicable in PUDNone of the above applicable in PUD

To Treat or not to TreatTo Treat or not to Treat

� H Pylori = 10 percent lifetime risk of developing peptic ulcer

disease and 2-3x’s increase of gastric adenocarcinoma.

• Corpus dominant or Pan gastritis mild worsen GERD sxs

Antral-dominant gastritis improvement of GERD sxs

• H Pylori and GERD� H. pylori improves the ability of proton pump inhibitors (PPIs) to suppress

acid.

• Chronic NSAID user� 61x’s more likely to develop ulcer with H-Pylori presence

Must TreatMust Treat

� Standard of care is to treat and test to cure:• Relatives of persons with gastric cancer

• Patients in whom intestinal metaplasia has been detected on gastric biopsy

• Infected spouses of patients who have beenreinfected with H.pylori a second or third time after initial antibiotic treatment.

• H Pylori and PUD � 60 to 100 percent annual ulcer recurrence rate compared to 10 percent after eradication.

� >85% Duodenal ulcers CagA strain

TestsTests

�� PYPY--TestTest

•• Carbon 13 or 14 Urea Breath TestsCarbon 13 or 14 Urea Breath Tests

�� Antibody testing*Antibody testing*•• IgmIgm -- uselessuseless

•• IggIgg -- best (+ up to 1 yr. negative could be toobest (+ up to 1 yr. negative could be too ealryealry assess assess

with either treatment or length ofwith either treatment or length of sxssxs))

�� Stool AntigenStool Antigen

�� EndoscopyEndoscopy with biopsywith biopsy

* She R. Evaluation of Helicobacter pylori Immunoglobulin G

(IgG), IgA, and IgM Serologic Testing Compared to Stool

Antigen Testing. Clin Vaccine Immunol

v.16(8); Aug 2009

HH--Pylori MedsPylori Meds

�� Antibiotics Antibiotics •• Amoxicillin,Amoxicillin, ClarithromycinClarithromycin,, MetronidazoleMetronidazole, Tetracycline , Tetracycline

�� H2H2--BlockersBlockers•• CimetidineCimetidine ((TagametTagamet),), FamotidineFamotidine ((PepcidPepcid),), NizatidineNizatidine((AxidAxid), Ranitidine (Zantac) ), Ranitidine (Zantac)

�� Proton Pump Inhibitors (Proton Pump Inhibitors (PPIsPPIs))•• EsomeprazoleEsomeprazole ((NexiumNexium),), LansoprazoleLansoprazole ((PrevacidPrevacid),),OmeprazoleOmeprazole ((PrilosecPrilosec),), PantoprazolePantoprazole ((ProtonixProtonix),),RabeprazoleRabeprazole ((AciphexAciphex))

�� CytoprotectiveCytoprotective Agents Agents •• BismuthBismuth subsalicylatesubsalicylate, bismuth, bismuth subcitratesubcitrate potassium,potassium,sucralfate sucralfate

�� Combination ProductsCombination Products•• HelidacHelidac,, PrevpacPrevpac,, PyleraPylera

Regimen Side Effect Rating Cure Rate

Two-Drug Regimens

Amoxicillin + PPI Low-Medium less than 70-80%

Clarithromycin + PPI Low-Medium greater than 70-90%

Three-Drug Regimens

Clarithromycin + Metronidazole + PPI Medium greater than 80 to greater than 90%

Clarithromycin + Amoxicillin + PPI Low-Medium greater than 80 to greater than 90%

Amoxicillin + Metronidazole + PPI Medium greater than 80-90%

Tetracycline + Metronidazole + Sucralfate Medium greater than 80-90%

Four-Drug Regimens

Bismuth + Metronidazole + Tetracycline + H2 Blocker

(H2Blocker needs to be taken for 4-6 weeks)Medium-High greater than 80 to greater than 90%

Bismuth + Metronidazole + Amoxicillin + PPI Medium-High greater than 70-90%

Bismuth + Metronidazole + Tetracycline + PPI Medium-High greater than 80 to greater than 90%

Bismuth + Metronidazole + Clarithromycin + PPI Medium-High greater than 80 to greater than 90%

Combination Products*

Helidac + H2 Blocker Medium-High up to 82%

Prevpac Low-Medium 81-92%

Pylera + PPI Low-Medium 84-94%

H-PYLORI TREATMENT REGIMENS

Omeprazole 40 mg QD + clarithromycin 500 mg TID x 2 wks,then omeprazole 20 mg QD x 2 wks

Ranitidine bismuth citrate (RBC) 400 mg BID +clarithromycin 500 mg TID x 2 wks, then RBC 400 mg BID x 2 wks

Bismuth subsalicylate (Pepto Bismol®) 525 mg QID + metronidazole 250 mg QID +

tetracycline500 mg QID* x 2 wks + H2 receptor antagonist therapy as directed x 4 wks

Lansoprazole 30 mg BID + amoxicillin 1 g BID + clarithromycin 500 mg TID x 10 days

Lansoprazole 30 mg TID + amoxicillin 1 g TID x 2wks**

Rantidine bismuth citrate 400 mg BID +clarithromycin 500 mg BID x 2 wks, then RBC 400

mg BID x 2 wks

Omeprazole 20 mg BID + clarithromycin 500 mg BID + amoxicillin 1 g BID x 10 days

Lansoprazole 30 mg BID + clarithromycin 500 mg BID + amoxicillin 1 g BID x 10 days

CDC treatmentCDC treatment

Sequential TreatmentSequential Treatment

�� 10 day treatment10 day treatment

•• PPI bid andPPI bid and AmoxAmox 1gm bid x 5 days1gm bid x 5 days

�� Then Then --

•• ClarithromycinClarithromycin 500mg bid500mg bid

•• TindazoleTindazole 500mg bid 500mg bid

Vakil, N. Sequential Therapy for Heliobacter Pylori JAMA, 2008;300(11)

Potential proton pump inhibitor safety concerns

Safety concern

PPI studied Duration of studies Evidence

Gastric carcinoidsOmeprazole, lansoprazole,

pantoprazole,

rabeprazole

1–8 years No increased risk1-5

Gastricmetaplasia/adenocarcinoma

Omeprazole 1–5 years No increased risk1-3,5

Enteric infections Omeprazole 1 year No increased risk6

Mineral malabsorption Omeprazole 6 months–2 years No increased risk1,3

B12 malabsorption Omeprazole 10 yearsDecreased B12 levels with

high-dose therapy1,2

Laine L, Ahnen D, McClain C, Solcia E, Walsh JH. Review article: potential gastrointestinal effects of long-term acid suppression with proton pump inhibitors. Aliment Pharmacol Ther 2000;14:651–668. Garnett WR. Considerations for long-term use of protonpump inhibitors. Am J Health Syst Pharm 1998;55:2268–2279.Freston JW. Long-term acid control and proton pump inhibitors: interactions and safety issues in perspective. Am JGastroenterol 1997;92(4 Suppl):51S–57S.Freston JW, Rose PA, Heller CA, Haber M, Jennings D. Safety profile of Lansoprazole: the US clinical trial experience. DrugSaf 1999;20:195–205.Thjodleifsson B, Rindi G, Fiocca R, et al. A randomized double-blind trial of the efficacy and safety of 10 or 20 mg rabeprazolecompared with 20 mg omeprazole in the maintenance of gastro-oesophageal reflux disease over 5 years. Aliment Pharmacol Ther 2003;17:343–351. Garcia Rodriguez LA, Ruigomez A. Gastric acid, acid-sup-pressing drugs, and bacterial gastroenteritis: how much of a risk? Epidemiology 1997;8:571–574.

PPIPPI’’ss and Hipsand Hips

�� 10,834 hip fractures among nonusers of acid 10,834 hip fractures among nonusers of acid suppression agents and 2,722 hip fractures suppression agents and 2,722 hip fractures among PPI users. among PPI users.

�� Patients usingPatients using PPIsPPIs for longer than one year for longer than one year were estimated to have a hip fracture rate were estimated to have a hip fracture rate of 4.0 per 1,000 personof 4.0 per 1,000 person--years compared years compared with 1.8 per 1,000 personwith 1.8 per 1,000 person--years in acid years in acid suppression nonusers. suppression nonusers.

�� Higher doses and longer use ofHigher doses and longer use of PPIsPPIs were were associated with higher fracture risk. The associated with higher fracture risk. The association also was stronger in men than in association also was stronger in men than in women.women.

Yang YX, et al. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA December 27, 2006;296:2947-53

Summary Summary

� Difficult to obtain accurate epidemiological information due to the lack of standardized definition and diagnostic gold-standard.

� More prevalent in Whites

� Studies suggest may be more Prevalent in Women

� More prevalent in adults over 25


Summary Summary

� May present with multiple symptoms, however Heartburn and Acid regurgitation considered most prevalent and synonymous with GERD.

� 50% state nighttime symptoms affect them more than daytime symptoms


Summary Summary

� One of the top five prevalent and costly conditions affecting adults.

� 9.6 Billion Dollars in Direct Costs

� 5.9 billion dollars spent on GERD medications.

� Low Mortality Rate

� Significant disruption in life activities


gastroesophageal reflux objectives disease (gerd) · and treatment of gerd and h-pylori know...

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