Gastroesophageal Reflux Disease (GERD)Gastroesophageal Reflux Disease (GERD)

• Any symptoms or esophageal mucosal damage,causing Any symptoms or esophageal mucosal damage,causing discomfort, that results from reflux of gastric acid into discomfort, that results from reflux of gastric acid into the esophagusthe esophagus

• GERD resulting in heartburn affects 30% of the general GERD resulting in heartburn affects 30% of the general population population

• Classic GERD symptomsClassic GERD symptoms– Heartburn (pyrosis): substernal burning discomfortHeartburn (pyrosis): substernal burning discomfort

– Regurgitation: bitter, acidic fluid in the mouth when lying Regurgitation: bitter, acidic fluid in the mouth when lying down or bending overdown or bending over

Locke et al. Gastroenterology 1997;112:1148.Locke et al. Gastroenterology 1997;112:1148.

High Prevalence of Gastroesophageal High Prevalence of Gastroesophageal Reflux Symptoms Reflux Symptoms

19.8%

59%

0%10%20%30%40%50%60%

Weekly Monthly

Frequency of heartburn and/or regurgitation

Important Reasons to Diagnose and Treat Important Reasons to Diagnose and Treat GERDGERD

• Negative impact on health-related quality of lifeNegative impact on health-related quality of life11

• Risk factor for esophageal adenocarcinomaRisk factor for esophageal adenocarcinoma22

1.1. Revicki et al. Am J Med 1998;104:252.Revicki et al. Am J Med 1998;104:252.2.2. Lagergren et al. N Engl J Med 1999;340:825.Lagergren et al. N Engl J Med 1999;340:825.

Pathophysiology:Pathophysiology:

• Occasional episodes of GERD are common in health.Occasional episodes of GERD are common in health.

• Reflux is normally followed by oesophageal peristaltic waves Reflux is normally followed by oesophageal peristaltic waves which efficiently clear the eso, alkaline saliva neutralises which efficiently clear the eso, alkaline saliva neutralises residual acid& symptoms do not occur. residual acid& symptoms do not occur.

• GERD develops when the oesophageal mucosa is exposed to GERD develops when the oesophageal mucosa is exposed to gastric contents for prolonged periods of time, resulting in gastric contents for prolonged periods of time, resulting in symptoms & in a proportion of cases, oesophagitis. symptoms & in a proportion of cases, oesophagitis.

• Several factors are known to be involved:Several factors are known to be involved:

1.AbnormaL LES:1.AbnormaL LES:

• In health, LES is tonically contracted, relaxing only during In health, LES is tonically contracted, relaxing only during swallowing. swallowing.

• Some patients with GERD have reduced LES, permitting reflux Some patients with GERD have reduced LES, permitting reflux when intra-abdominal pressure rises.when intra-abdominal pressure rises.

• In others, basal sphincter tone is normal but reflux occurs in In others, basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter response to frequent episodes of inappropriate sphincter relaxation relaxation

2.HH:2.HH:• Hiatus hernia causes reflux because:Hiatus hernia causes reflux because:

• A. The pressure gradient between the abdominal & thoracic A. The pressure gradient between the abdominal & thoracic cavities, which normally pinches the hiatus, is lost.cavities, which normally pinches the hiatus, is lost.

• B. The oblique angle between the cardia& oesophagus B. The oblique angle between the cardia& oesophagus disappears.disappears.

• Many patients who have large hiatus hernias develop reflux Many patients who have large hiatus hernias develop reflux symptoms, but the relationship between the presence of a HH& symptoms, but the relationship between the presence of a HH& symptoms is poor. symptoms is poor.

• Hiatus hernia is very common in individuals who have no Hiatus hernia is very common in individuals who have no symptoms& some symptomatic patients have only a very small symptoms& some symptomatic patients have only a very small or no hernia. or no hernia.

• Nevertheless, almost all patients who develop oesophagitis, Nevertheless, almost all patients who develop oesophagitis, Barrett's oesophagus or peptic strictures have a hiatus hernia.Barrett's oesophagus or peptic strictures have a hiatus hernia.

2.HH:2.HH:• IMPORTANT FEATURES OF HIATUS HERNIAIMPORTANT FEATURES OF HIATUS HERNIA• Herniation of the stomach through the diaphragm into the chest Herniation of the stomach through the diaphragm into the chest • Occurs in 30% of the population > 50 years Occurs in 30% of the population > 50 years • Often asymptomatic Often asymptomatic • Heartburn & regurgitation can occur Heartburn & regurgitation can occur • Gastric volvulus may complicate large para-oesophageal Gastric volvulus may complicate large para-oesophageal

herniashernias

3.Delayed oesophageal clearance3.Delayed oesophageal clearance::

• Defective oesophageal peristaltic activity is commonly found in Defective oesophageal peristaltic activity is commonly found in patients who have oesophagitis.patients who have oesophagitis.

• It is a primary abnormality, since it persists after oesophagitis It is a primary abnormality, since it persists after oesophagitis has been healed by PPI. has been healed by PPI.

• Poor oesophageal clearance leads to increased acid exposure Poor oesophageal clearance leads to increased acid exposure time.time.

4.Gastric contents4.Gastric contents

• Is the most important oesophageal irritant& there is a close Is the most important oesophageal irritant& there is a close relationship between acid exposure time & symptoms.relationship between acid exposure time & symptoms.

5. Defective gastric emptying 5. Defective gastric emptying

• Gastric emptying is delayed in GERD.Gastric emptying is delayed in GERD.

• The reason for this is unknown.The reason for this is unknown.

6. Others 6. Others • Recent attention on the importance of duodenogastro-Recent attention on the importance of duodenogastro-

oesophageal reflux, containing bile, pancreatic enzymes&pepsin oesophageal reflux, containing bile, pancreatic enzymes&pepsin in addition to acid.in addition to acid.

7. Increased inra abd pressure:7. Increased inra abd pressure:• Pregnancy Pregnancy

• Obesity: Weight loss may improve symptomsObesity: Weight loss may improve symptoms

6. Diet 6. Diet / environmental factors/ environmental factors::• Dietary fat, chocolate, alcohol , coffee relax LES & provoke Dietary fat, chocolate, alcohol , coffee relax LES & provoke

symptoms. symptoms.

• There is little evidence to incriminate smoking or NSAIDs as a There is little evidence to incriminate smoking or NSAIDs as a causes.causes.

Clinical featuresClinical features

• The major symptoms are heartburn /regurgitation, often The major symptoms are heartburn /regurgitation, often provoked by bending, straining or lying down.provoked by bending, straining or lying down.

• 'Waterbrash‘: salivation from reflex salivary gland stimulation 'Waterbrash‘: salivation from reflex salivary gland stimulation as acid enters the eso, is often present. as acid enters the eso, is often present.

• A history of weight gain is common. A history of weight gain is common.

• Some patients are woken at night by choking as refluxed fluid Some patients are woken at night by choking as refluxed fluid irritates the larynx. irritates the larynx.

• Others develop odynophagia or dysphagia. Others develop odynophagia or dysphagia.

• A few present with atypical chest pain which may be severe, can A few present with atypical chest pain which may be severe, can mimic angina probably due to reflux-induced oesophageal mimic angina probably due to reflux-induced oesophageal spasm.spasm.

Clinical featuresClinical features

Clinical Presentations of GERDClinical Presentations of GERD

• Classic GERD Classic GERD

• Extraesophageal/Atypical GERDExtraesophageal/Atypical GERD

• Complicated GERDComplicated GERD

Extraesophageal Manifestations of GERDExtraesophageal Manifestations of GERD

• PulmonaryPulmonary

– AsthmaAsthma

– Aspiration Aspiration pneumoniapneumonia

– Chronic bronchitisChronic bronchitis

– Pulmonary fibrosisPulmonary fibrosis• OtherOther

• Chest pain Chest pain

• Dental erosionDental erosion

ENTENTHoarsenessHoarsenessLaryngitisLaryngitisPharyngitisPharyngitisChronic coughChronic coughGlobus sensationGlobus sensationDysphoniaDysphoniaSinusitisSinusitisSubglottic stenosisSubglottic stenosisLaryngeal cancerLaryngeal cancer

Potential Oral & Laryngopharyngeal Signs Associated Potential Oral & Laryngopharyngeal Signs Associated with GERDwith GERD

• Edema /hyperemia of Edema /hyperemia of larynxlarynx

• Vocal cord erythema, Vocal cord erythema, polyps, granulomas, polyps, granulomas, ulcersulcers

• Hyperemia & lymphoid Hyperemia & lymphoid hyperplasia of posterior hyperplasia of posterior pharynx pharynx

• Interarytenyoid changesInterarytenyoid changes

• Dental erosionDental erosion

• Subglottic stenosisSubglottic stenosis

• Laryngeal cancerLaryngeal cancer

Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.

Pathophysiology of Pathophysiology of Extraesophageal GERDExtraesophageal GERD

Complications: 1.Complications: 1.OesophagitisOesophagitis

• A range of endoscopic findings, from mild redness to severe. A range of endoscopic findings, from mild redness to severe. With bleeding, ulceration &stricture formation. With bleeding, ulceration &stricture formation.

• There is a poor correlation between symptoms, histological There is a poor correlation between symptoms, histological &endoscopic findings. &endoscopic findings.

• Significant GERD may be present despite normal endoscopy / Significant GERD may be present despite normal endoscopy / normal oesophageal histology. normal oesophageal histology.

Complications: Complications: OesophagitisOesophagitis

Complications:2.Barrett's oesophagus Complications:2.Barrett's oesophagus

• ‘‘Columnar lined oesophagus'-CLO, is a pre-malignant glandular intestinal Columnar lined oesophagus'-CLO, is a pre-malignant glandular intestinal metaplasia of the lower oeso, in which the normal squamous lining is replaced metaplasia of the lower oeso, in which the normal squamous lining is replaced by columnar mucosa. by columnar mucosa.

• Occurs as an adaptive response to chronic GERD,found in 10% undergoing Occurs as an adaptive response to chronic GERD,found in 10% undergoing gastroscopy for reflux symptoms. gastroscopy for reflux symptoms.

• CLO is the major risk factor for oesophageal adenocarcinoma, with a lifetime CLO is the major risk factor for oesophageal adenocarcinoma, with a lifetime cancer risk of 10%, more closely related to the severity& duration of reflux cancer risk of 10%, more closely related to the severity& duration of reflux rather than the CLO per se. rather than the CLO per se.

• The cancer incidence is estimated at 1/200 patient years (0.5% /year), being The cancer incidence is estimated at 1/200 patient years (0.5% /year), being low& > 95% with CLO die of causes other than oesophageal cancer. low& > 95% with CLO die of causes other than oesophageal cancer.

• Prevalence is increasing, more in men (especially white) &> 50. Prevalence is increasing, more in men (especially white) &> 50.

• It is weakly associated with smoking but not alcohol. It is weakly associated with smoking but not alcohol.

• E-cadherin polymorphisms, p53 mutations, TGF-β, EGF receptors, COX-2& E-cadherin polymorphisms, p53 mutations, TGF-β, EGF receptors, COX-2& TNF-α may play roles.TNF-α may play roles.

Barrett Diagnosis:diagnosisBarrett Diagnosis:diagnosis • Requires multiple systematic biopsies to maximise the chance of Requires multiple systematic biopsies to maximise the chance of

detecting intestinal metaplasia /or dysplasia.detecting intestinal metaplasia /or dysplasia.

Barret:ManagementBarret:Management• Neither PPI nor antireflux surgery will stop progression or Neither PPI nor antireflux surgery will stop progression or

induce regression of CLO& treatment is only indicated for induce regression of CLO& treatment is only indicated for symptoms of reflux or complications such as stricture. symptoms of reflux or complications such as stricture.

• Endoscopic ablation therapy or photodynamic therapy can Endoscopic ablation therapy or photodynamic therapy can induce regression but 'buried islands' of glandular mucosa may induce regression but 'buried islands' of glandular mucosa may persist underneath the squamous epithelium& cancer risk is not persist underneath the squamous epithelium& cancer risk is not eliminated. eliminated.

• At present these therapies remain experimental but show At present these therapies remain experimental but show promise; they are also used in patients with high-grade promise; they are also used in patients with high-grade dysplasia (HGD) or early malignancy who are not suitable for dysplasia (HGD) or early malignancy who are not suitable for surgery. surgery.

Barret: Barret: ManagementManagement• Regular endoscopic surveillance can detect dysplasia& malignancy at Regular endoscopic surveillance can detect dysplasia& malignancy at

an early stage & improve 2-year survival but, because most CLO is an early stage & improve 2-year survival but, because most CLO is undetected until cancer develops, surveillance strategies are unlikely undetected until cancer develops, surveillance strategies are unlikely to influence the overall mortality rate of oesophageal cancer. to influence the overall mortality rate of oesophageal cancer.

• Surveillance is expensive &cost-effectiveness conflicting. Surveillance is expensive &cost-effectiveness conflicting.

• Surveillance is currently recommended every 2-3 years for those Surveillance is currently recommended every 2-3 years for those without dysplasia & at 6-12-monthly intervals for those with low-without dysplasia & at 6-12-monthly intervals for those with low-grade dysplasia. grade dysplasia.

• Oesophagectomy is widely recommended for those with HGD as the Oesophagectomy is widely recommended for those with HGD as the resected specimen harbours cancer in up to 40%. resected specimen harbours cancer in up to 40%.

• Recent data suggest that HGD often remains stable & may not Recent data suggest that HGD often remains stable & may not progress to cancer, at least in the medium term. progress to cancer, at least in the medium term.

• Close follow-up with biopsies every 3 months is an alternative strategy Close follow-up with biopsies every 3 months is an alternative strategy for those with HGD. for those with HGD.

Complications:3. Complications:3. IDAIDA• Occurs as a consequence of chronic, insidious blood loss from Occurs as a consequence of chronic, insidious blood loss from

long-standing oesophagitis.long-standing oesophagitis.

• Almost all such patients have a large hiatus hernia& bleeding Almost all such patients have a large hiatus hernia& bleeding can occur from subtle erosions in the neck of the sac ('Cameron can occur from subtle erosions in the neck of the sac ('Cameron lesionslesions

Complications: 4.Benign oesophageal stricture Complications: 4.Benign oesophageal stricture • Develop as a consequence of long-standing oesophagitis. Develop as a consequence of long-standing oesophagitis.

• Most elderly & have poor oesophageal peristaltic activity. Most elderly & have poor oesophageal peristaltic activity.

• Present with dysphagia which is worse for solids than liquids. Present with dysphagia which is worse for solids than liquids.

• Bolus obstruction following ingestion of meat causes absolute Bolus obstruction following ingestion of meat causes absolute dysphagia. dysphagia.

• A history of heartburn is common but not invariable;as in many A history of heartburn is common but not invariable;as in many elderly patients. elderly patients.

• Diagnosis is made by endoscopy, with biopsies to exclude Cancer. Diagnosis is made by endoscopy, with biopsies to exclude Cancer.

• Endoscopic balloon dilatation or bouginage is helpful. Endoscopic balloon dilatation or bouginage is helpful.

• Subsequently, long-term therapy with a PPI at full dose should be Subsequently, long-term therapy with a PPI at full dose should be started to reduce the risk of recurrent oesophagitis & stricture started to reduce the risk of recurrent oesophagitis & stricture formation.formation.

GERD:InvestigationsGERD:Investigations• Young patients with typical symptoms, without worrying features Young patients with typical symptoms, without worrying features

such as dysphagia, weight loss or anaemia, can be treated such as dysphagia, weight loss or anaemia, can be treated empirically without investigation.empirically without investigation.

• Investigation is advisable if patients present in middle or late age, Investigation is advisable if patients present in middle or late age, if symptoms are atypical or if a complication is suspected. if symptoms are atypical or if a complication is suspected.

• Endoscopy is the investigation of choice, performed to exclude Endoscopy is the investigation of choice, performed to exclude other upper GI diseases & identify complications. other upper GI diseases & identify complications.

• A normal endoscopy in a patient with compatible symptoms A normal endoscopy in a patient with compatible symptoms should not preclude treatment for GERD.should not preclude treatment for GERD.

• Twenty-four-hour pH monitoring is indicated if, despite Twenty-four-hour pH monitoring is indicated if, despite endoscopy, the diagnosis is not clear. endoscopy, the diagnosis is not clear.

• A pH of < 4 for > 6-7% of the study time is diagnostic of GERD.A pH of < 4 for > 6-7% of the study time is diagnostic of GERD.

When to Perform Diagnostic TestsWhen to Perform Diagnostic Tests

• Uncertain diagnosisUncertain diagnosis

• Atypical symptomsAtypical symptoms

• Symptoms associated with complicationsSymptoms associated with complications

• Inadequate response to therapy Inadequate response to therapy

• Recurrent symptomsRecurrent symptoms

• Prior to anti-reflux surgeryPrior to anti-reflux surgery

Diagnostic Tests for GERDDiagnostic Tests for GERD

• Barium swallowBarium swallow

• EndoscopyEndoscopy

• Ambulatory pH monitoringAmbulatory pH monitoring

• Esophageal manometryEsophageal manometry

Barium SwallowBarium Swallow

• Useful first diagnostic test for patients with Useful first diagnostic test for patients with dysphagiadysphagia

– Stricture (location, length)Stricture (location, length)

– Mass (location, length)Mass (location, length)

– Bird’s beakBird’s beak

– Hiatal hernia (size, type)Hiatal hernia (size, type)

• LimitationsLimitations

– Detailed mucosal exam for erosive esophagitis, Detailed mucosal exam for erosive esophagitis, Barrett’s esophagusBarrett’s esophagus

EndoscopyEndoscopy

• Indications for endoscopy Indications for endoscopy

– Alarm symptomsAlarm symptoms

– Empiric therapy failureEmpiric therapy failure

– Preoperative evaluationPreoperative evaluation

– Detection of Barrett’s esophagusDetection of Barrett’s esophagus

– Detect grade: LA grading Detect grade: LA grading classification system for GERD.classification system for GERD.

The LA Classification systemThe LA Classification system– Grade A reflux esophagitis– Grade A reflux esophagitis

Stomach

Grade A: One (or more) mucosal break, no longer than 5 mm, that does not extend between the tops of twomucosal folds.

The LA Classification systemThe LA Classification system– Grade B reflux esophagitis– Grade B reflux esophagitis

Stomach

Grade B: One (or more) mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds.

The LA Classification systemThe LA Classification system– Grade C reflux esophagitis– Grade C reflux esophagitis

Stomach

Grade C: One (or more) mucosal break that is continuous betweenthe tops of two or more mucosal folds, but which involvesless than 75% of the circumference.

The LA Classification systemThe LA Classification system– Grade D reflux esophagitis– Grade D reflux esophagitis

Stomach

Grade D: One (or more) mucosal break that involves at least75% of the esophageal circumference.

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

• Physiologic studyPhysiologic study

• Quantify reflux in Quantify reflux in proximal/distal proximal/distal esophagusesophagus

– % time pH < 4% time pH < 4

– DeMeester scoreDeMeester score

• Symptom correlationSymptom correlation

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

NormalNormal

GERDGERD

Wireless, Catheter-Free Esophageal pH Monitoring

• Improved patient comfort / Improved patient comfort / acceptanceacceptance

• Continued normal work, Continued normal work, activities&diet studyactivities&diet study

• Longer reporting periods Longer reporting periods possible (48 hours)possible (48 hours)

• Maintain constant probe Maintain constant probe position .position .

Potential AdvantagesPotential Advantages

Esophageal ManometryEsophageal Manometry

• Assess LES pressure, Assess LES pressure, location / relaxationlocation / relaxation– Assist placement of 24 hr. Assist placement of 24 hr.

pH catheterpH catheter

• Assess peristalsisAssess peristalsis– Prior to antireflux surgery Prior to antireflux surgery

Limited role in GERDLimited role in GERD

Treatment Goals for GERDTreatment Goals for GERD

• Eliminate symptomsEliminate symptoms

• Heal esophagitisHeal esophagitis

• Manage or prevent complicationsManage or prevent complications

• Maintain remissionMaintain remission

Management: Life-styleManagement: Life-style• Weight lossWeight loss

• Avoidance of dietary items that worsen symptoms.Avoidance of dietary items that worsen symptoms.

• Elevation of the bed head in those who experience nocturnal Elevation of the bed head in those who experience nocturnal symptomssymptoms

• Avoidance of late meals Avoidance of late meals

• Modify dietModify diet– Eat more frequent but smaller mealsEat more frequent but smaller meals– Avoid fatty/fried food, peppermint, chocolate, alcohol, Avoid fatty/fried food, peppermint, chocolate, alcohol,

carbonated beverages, coffee and tea.carbonated beverages, coffee and tea.• Avoid eating within 2-3 hours of bedtime.Avoid eating within 2-3 hours of bedtime.

• Giving up smoking.Giving up smoking.

Management: antacidsManagement: antacids• Proprietary antacids &alginates also provide symptomatic Proprietary antacids &alginates also provide symptomatic

benefit. benefit.

• H2-receptor antagonist drugs also help symptoms without healing H2-receptor antagonist drugs also help symptoms without healing oesophagitis. oesophagitis.

• PPI are the treatment of choice for severe symptoms &for PPI are the treatment of choice for severe symptoms &for complicated reflux diseasecomplicated reflux disease

• PPI are better than H2Bs in healing oesophagitis& relieving PPI are better than H2Bs in healing oesophagitis& relieving symptoms. symptoms.

• Symptoms almost invariably resolve& oesophagitis heals in the Symptoms almost invariably resolve& oesophagitis heals in the majority of patients. majority of patients.

• Recurrence of symptoms is common when therapy is stopped& Recurrence of symptoms is common when therapy is stopped& some require life-long treatment at the lowest acceptable dose.some require life-long treatment at the lowest acceptable dose.

Effectiveness of Medical Effectiveness of Medical Therapies for GERDTherapies for GERD

TreatmentTreatment ResponseResponse

Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %

HH22-receptor antagonists-receptor antagonists 50 %50 %

Single-dose PPI Single-dose PPI 80 %80 %

Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %

Treatment Modifications for Treatment Modifications for Persistent SymptomsPersistent Symptoms

• Improve complianceImprove compliance

• Optimize pharmacokineticsOptimize pharmacokinetics

– Adjust timing of medication to 15 – 30 minutes before meals Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime)(as opposed to bedtime)

– Allows for high blood level to interact with parietal cell proton Allows for high blood level to interact with parietal cell proton pump activated by the mealpump activated by the meal

• Consider switching to a different PPI as esmo or rebeprazol.Consider switching to a different PPI as esmo or rebeprazol.

GERD is a Chronic Relapsing GERD is a Chronic Relapsing ConditionCondition

• Esophagitis relapses quickly after cessation of therapyEsophagitis relapses quickly after cessation of therapy

– > 50 % relapse within 2 months> 50 % relapse within 2 months

– > 80 % relapse within 6 months> 80 % relapse within 6 months

• Effective maintenance therapy is imperativeEffective maintenance therapy is imperative

GERD IN OLD AGEGERD IN OLD AGE• Prevalence: higher. Prevalence: higher. • Severity of symptoms: does not correlate with the degree of Severity of symptoms: does not correlate with the degree of

mucosal inflammation. mucosal inflammation. • Complications: late complications as peptic strictures or bleeding Complications: late complications as peptic strictures or bleeding

from oesophagitis are more common. from oesophagitis are more common. • Recurrent pneumonia: consider aspiration from occult GERD.Recurrent pneumonia: consider aspiration from occult GERD.

Erosive EsophagitisErosive Esophagitis

Peptic StricturePeptic Stricture

Barium SwallowBarium Swallow EndoscopyEndoscopy

Esophageal Stricture: Dilating DevicesEsophageal Stricture: Dilating Devices

TTS Balloon Dilation of a Peptic StrictureTTS Balloon Dilation of a Peptic Stricture

Barrett’s EsophagusBarrett’s Esophagus

Esophageal CancerEsophageal Cancer

Barium SwallowBarium Swallow EndoscopyEndoscopy

When to Discuss Anti-Reflux Surgery with PatientsWhen to Discuss Anti-Reflux Surgery with Patients

• Intractable GERD – rareIntractable GERD – rare– Difficult to manage stricturesDifficult to manage strictures– Severe bleeding from esophagitisSevere bleeding from esophagitis– Non-healing ulcersNon-healing ulcers

• GERD requiring long-term PPI-BID in a GERD requiring long-term PPI-BID in a healthy young patient healthy young patient

• Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms• Not Barrett’s esophagus aloneNot Barrett’s esophagus alone

Endoscopic GERD TherapyEndoscopic GERD Therapy

• Endoscopic antireflux therapiesEndoscopic antireflux therapies– Radiofrequency energy delivered to the LESRadiofrequency energy delivered to the LES

• Stretta procedureStretta procedure– Suture ligation of the cardiaSuture ligation of the cardia

• Endoscopic plicationEndoscopic plication– Submucosal implantation of inert material in Submucosal implantation of inert material in

the region of the lower esophageal sphincterthe region of the lower esophageal sphincter• EnteryxEnteryx

Time is cruel:Time is cruel: