gerd: the real other silent killerwhat is gerd? classic symptoms: •heartburn –burning sensation...
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GERD: The Real Other Silent Killer
Michael Krease, D.O.
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GERD: The Real Other Silent Killer
Michael Krease, D.O.
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prevalence
20%
Eusebi LH, Ratnakumaran R, Yuan Y, et al Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis Gut 2018;67:430-440.
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• Heartburn - a burning pain
or discomfort behind the
breast bone in the chest
• Acid regurgitation - a bitter-
or sour-tasting fluid coming
into the throat or mouth
Locke et al. Gastroenterology. 1997;112:1448-1456
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• Heartburn - a burning pain
or discomfort behind the
breast bone in the chest
• Acid regurgitation - a bitter-
or sour-tasting fluid coming
into the throat or mouth
Locke et al. Gastroenterology. 1997;112:1448-1456
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What is GERD?
Classic symptoms:
• Heartburn – burning
sensation in retrosternal
area
• Regurgitation – perception
of flow of gastric contents
into mouth
1 Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101:1900.2 http://www.thefdotlife.com/a-few-signs-you-may-be-getting-old/i-think-that-we-have-discovered-the-cause-of-your-severe-heartburn/
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What is GERD? – atypical symptoms
Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now? Vaezi, Michael F. et al. Clinical Gastroenterology and Hepatology, Volume 16, Issue 7, 1018 - 1029
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Pathophysiology – Risk Factors
https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940
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BMI 25-30
BMI >30
Hampel H, et al. Ann Intern Med. 2005;143:199-211
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Pathophysiology – Protection
• Saliva
• Esophageal motility
• GE junction
• Fundic relaxation
• Gastric emptying
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Why does reflux happen? • Part of normal physciologic mechanism of belching
• Last >10s
• Unaccompanied by protective mechanisms
Esophageal dysmotility
Ineffective barrier:
• Hiatal hernia
• TLESR
• Obesity
• Gastroparesis
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Diagnosis
• Presumptive diagnosis of GERD made based on typical sx.
of heartburn / regurgitation
• Upper endoscopy is not required in the presence of typical
GERD symptoms, unless alarm features present
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Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308–328
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Diagnosis – pH monitoring
Bravo pH system – 48-96 hrs.
• Pre-op
• Refractory GERD
• Diagnosis in ?
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Why do we care?• Strictures
• Erosive esophagitis
• Barrett’s esophagus → esophageal adenocarcinoma
https://emedicine.medscape.com/article/175098-overview
https://www.endoscopy-campus.com/en/classifications/reflux-esophagitis-los-angeles-classification/
Eliakim R., Sharma V.K. (2014) Esophageal Capsule Endoscopy. In: Keuchel M., Hagenmüller F., Tajiri H. (eds) Video Capsule Endoscopy. Springer, Berlin, Heidelberg
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Why do we care?• Strictures
• Erosive esophagitis
• Barrett’s esophagus → esophageal adenocarcinoma
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Management• Lifestyle modifications:
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Management• Lifestyle modifications:
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Management• Lifestyle modifications:
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Management• Lifestyle modifications:
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Management• Lifestyle modifications:
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Management• Lifestyle modifications:
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Management• Lifestyle modifications:
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Management• Lifestyle modifications:
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Management• Medication:
• Antacids
• H2 antagonists
• PPIs
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Management• Medication:
• Antacids
• H2 antagonists
• PPIs
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Management• Medication:
• Antacids
• H2 antagonists
• PPIs
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Management• Medication:
• Antacids
• H2 antagonists
• PPIs
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Management – PPI vs. H2
Chiba N , De Gara CJ , Wilkinson JM et al. Speed of healing and symptom relief in grade II to IV gastroesophageal refl ux disease: a meta-analysis . Gastroenterology 1997 ; 112 : 1798 – 810
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Management – PPI vs. H2
Chiba N , De Gara CJ , Wilkinson JM et al. Speed of healing and symptom relief in grade II to IV gastroesophageal refl ux disease: a meta-analysis . Gastroenterology 1997 ; 112 : 1798 – 810
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Management – ACG Guidelines• 8 week course of PPI for symptom control and healing erosive
esophagitis
• PPI therapy initiated at qday dosing, tailor dosing based on
response or switch
• Maintenance PPI should be used for recurrent symptoms after
discontinuation – lowest effective dose
• H2 antagonist can be added at bedtime for nocturnal symptoms,
tachyphylaxis can occur after several weeks
• No role for sucralfate in non pregnant GERD patient
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Management – ACG Guidelines• 8 week course of PPI for symptom control and healing erosive
esophagitis
• PPI therapy initiated at qday dosing, tailor dosing based on
response or switch
• Maintenance PPI should be used for recurrent symptoms after
discontinuation – lowest effective dose
• H2 antagonist can be added at bedtime for nocturnal symptoms,
tachyphylaxis can occur after several weeks
• No role for sucralfate in non pregnant GERD patient
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Management• Omeprazole
• Omeprazole – bicarbonate
• Lansoprazole
• Pantoprazole
• Rabeprazole
• Esomeprazole
• Dexlansoprazole
• No convinving RCT data one is
superior to another
• All dosed 30-60 minutes prior to meal
except:
• Omeprazole – bicarbonate
• Dexlansoprazole