GERD IN THE 21ST CENTURY: More than just a spoonful of sugar

UPMASA A G CJuly 2015

DAVID ESTORES, MDDavid.Estores@medicine.ufl.edu

Learning ObjectivesBecome familiar with:

• Pathophysiology of GERD– Acid pocket– Belts

• Evolution of the definition of GERD• Symptoms of GERD

– Definitions– Ability of symptoms to predict GERD

Learning Objectives (2)Become familiar with:

• Use of PPI Test in GERD– Definition– Test characteristics

• pH and Impedance testing• Patient with GERD Best candidate for

surgery

40 yr old male with reflux

• For the past 3 months• Takes a standard dose of PPI BID• Reflux symptoms immediately after a

meal• Relief with antacids

The Acid Pocket The Acid Raft

Does this even make sense?

ACID POCKET

Fletcher et al. Gastro 2001

STOMACH ESOPHAGUS

NORMAL/CONTROL LARGE HIATAL HERNIA

Acid Pocket (Beaumont et al.)

52 yr old man walks into your office

• Worsening heartburn for the past 2 years

• Unresponsive to once a day PPI• Had an endoscopy (Normal)• Weight gain of 20 lbs

Belts and reflux (Lee et al.)

• 16 Patients (8 obese and 8 non-obese)• Test meal = french fries and battered fish• Application of “belt”

– Nike weight belt– Standard blood pressure cuff inflated to have a

constant pressure of 50 mmHg

Lee Gut 2013

• SCJ = squamocolumnar junction

• HPZ = high pressure zone• PIP = Pressure inversion

point (separates the intrathoracic LES from the intraabdominal LES)

• pLOS (pLES) = Peak LES pressure (apex of triangle

ESOPHAGUS

STOMACH

Postprandial Effects of a Belt

Lee et al Gut 2013

John D. (78 y.o. man)

• Retired university faculty member• Stated that “you have to do something about

my heartburn due to GERD”– for 20+ years• Points to his epigastrium• Pain is NOT associated with meals• <25% relief with PPIs (BID)• Undergone an extensive work-up

Jane D. (52 y.o. woman)

• University faculty member• Substernal burning pain for over 10 years

– Mostly post-prandial– No relief with PPI (BID)

• Subsequently underwent extensive work-up

History of the Definition of GERD

Montreal definition, 2006

Vaezi M, et al GI and Hepatology 2003

ENDOSCOPY +

ENDOSCOPY -, pH +

GERD SPECTRUM PYRAMID

Practical Manual of GERD- Eds. Vela, Richter, Pandolfino 2013

RESPONSE RATE DATA ON RCT’S (ACID SUPPRESSION)

Practical Manual of GERD- Eds. Vela, Richter, Pandolfino 2013

Why is symptom evaluation in GERD important?

• Make the initial diagnosis• Assess the severity of disease• Formulate a diagnostic work-up• And/or starts treatment• Assess the response to treatment

SYMPTOMS ARE WHAT MATTERS MOST!!!

HRQL dimensions (assessed by SF-36) in German patients with GERD vs. general population

Kullig et al. Alimen Pharm Therap 2003Managing GERD in Primary Care: The Patient Perspective

Spectrum of GERD

• Normal GE reflux• When does GER become

GERD?• What is the gold standard??

Definition of heartburn and regurgitation

• Heartburn - burning retrosternal painful sensation of short duration associated with a meal

• Regurgitation - the retrograde flow of presumed gastric contents or sensation of bitter contents in the mouth without associated nausea or retching

John D. (78 y.o. man)

• Retired university faculty member• Stated that “you have to do something about

my heartburn due to GERD”– for 20+ years• Points to his epigastrium• Pain is NOT associated with meals• <25% relief with PPIs (BID)• Underwent an extensive work-up

Jane D. (52 y.o. woman)

• University faculty member• Substernal burning pain for over 10 years

– Mostly post-prandial– No relief with PPI (BID)

• Subsequently underwent extensive work-up

What GERD associated HB is not!

• Dyspepsia (epigastric discomfort)– Uninvestigated dyspepsia

• NSAIDs• H. pylori

– Functional dyspepsia after testing/ endoscopy negative Professor John D

• Functional heartburn Professor Jane D

Functional dyspepsia

• The most common form of dyspepsia presenting to primary care physicians and gastroenterologists

• Approach to diagnosis

Gillen and McColl Medicine 2010

• Jaundice

Zerbib et al. Curr Gastroenterol Rep (2012)

FUNCTIONAL HEARTBURN

Zerbib et al. Curr Gastroenterol Rep (2012)

Fass & TougatGut 2002

Rome III

ROUGHLY 1 IN 5 PATIENTS PRESENTING WITH HEARTBURN

HOW COMMON IS FUNCTIONAL HEARTBURN?

NERD = 60 to 75%

INTERESTING NUMBERS!!!

• Heartburn is NOT well understood (65.9%)– % who understood (35% W, 54% B, 13% A)

• 29.7% did not describe symptoms that a reasonable clinician would define as heartburn

• 22.8% of patients who denied having heartburn in fact experienced symptoms that physicians might consider to be heartburn

Spechler et al Aliment Pharmacol Tx 2002

Diagnosis - GERD in PC setting based on symptoms / PPI test

Dent J et al. Gut 2010;59:714-721

Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

Sensitivity and specificity• Based on data from the Diamond study• HB or regurgitation as the most troublesome symptom

overall sensitivity of 49% with a specificity of 74%. • If either HB or regurgitation is the most or second most

troublesome symptom, the sensitivity is increased to 69% accompanied by an expected decrease in specificity to 62%.

• (Sens/Spec) Marginally higher among gastroenterologists at 67%/70% vs. family practitioners at 63%/63%.

The PPI test in GERD diagnosis

Lack of consensus•What PPI to use?•Dosage of the PPI? QD or BID?•How long do we use it?•Definition of treatment response?

– Complete– Partial

Estores GICNA 2014

Bytzer, et al. Clin Gastro Hep 2012

Proportion of patients with relief of reflux symptoms in response to PPI day by day.

Sensitivity/Specificity for the PPI Test – Dx of GERD

• Meta analysis by Numans (Ann Int Med 2004)– sensitivity of 78% (95% CI = 66 to 86) – specificity of 54% (95% CI = 44 to 65)

• Bytzer et al re-analyzed Diamond study data– positive PPI test in 69% of patients with GERD

(confirmed by pH and/or esophagitis on endoscopy) compared to 51% of patients without GERD Clin Gastro Hep 2012

Why use the PPI test in GERD dx?

• Convenient• Cost effective• A positive response is a positive

response, no matter what the primary diagnosis is!

Estores GICNA 2014

Impedance pH

Bravo pH

Length of study 24 hours 48 hours

Wires in use Yes No

Information about Non-acid reflux Yes No

Requires Esophageal Manometry for placement

Yes No

Valid for atypical symptoms NO NO

Direction of reflux Yes NO

Requires an endoscopy No YES

Practical Manual of GERD- Eds. Vela, Richter, Pandolfino 2013

RESPONSE RATE DATA ON RCT’S (ACID SUPPRESSION)

Best patient to send to a surgeon?

• Progressive damage demonstrated/physiology– Esophagitis– Hiatal hernia– Regurgitation– Nocturnal

• Abnormal acid exposure time• Some response to PPI

Take Home Points

• Implications of acid pocket– Use of antacids with alginate– Not all patients will have relief from PPIs

• Loosen belts or switch to suspenders• Symptom definition and accuracy of history• Sensitivity and specificity for symptoms alone• Use of the PPI test for diagnosis of GERD• Approach to GERD in primary care setting

Take home points

• Diagnosis of GERD = clinical + endoscopy + pH testing– NO further w/u (do not need endoscopy/ pH testing)

• Classic symptoms• Relief w/ PPIs• NO Red flags

• Utility of a PPI test = 2 weeks, BID• Testing for GERD

– pH Monitoring (pros and cons)• pH Impedance• Bravo wireless

Take home points

• Treatment– Typical vs atypical– Esophagitis

• Surgery– Exclude achalasia– Patients with esophagitis– Large hiatal hernias– Medical co-morbidities