Gastroesophageal Reflux Disease

Howard J. McGowan, Maj, USAF, MC

Objectives
      

Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manisfestations Diagnostic Evaluation Treatment Complications

Definition


American College of Gastroenterology (ACG)

Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus Often chronic and relapsing May see complications of GERD in patients who lack typical symptoms

Physiologic vs Pathologic


Physiologic GERD
Postprandial Short lived Asymptomatic No nocturnal sx

Pathologic GERD
Symptoms Mucosal injury Nocturnal sx

Epidemiology


About 44% of the US adult population have heartburn at least once a month 14% of Americans have symptoms weekly 7% have symptoms daily

Pathophysiology


Primary barrier to gastroesophageal reflux is the lower esophageal sphincter LES normally works in conjunction with the diaphragm If barrier disrupted, acid goes from stomach to esophagus

Clinical Manisfestations
Most common symptoms
Heartburnretrosternal burning Heartburn discomfort Regurgitationeffortless return of Regurgitation gastric contents into the pharynx without nausea, retching, or abdominal contractions

Clinical Manisfestations
Dysphagiadifficulty swallowing Dysphagia Other symptoms include:


Chest pain, water brash, globus sensation, odynophagia, nausea Asthma, laryngitis, chronic cough

Extraesophageal manifestations


Diagnostic Evaluation
If classic symptoms of heartburn and regurgitation exist in the absence of alarm symptoms the diagnosis of GERD can be made clinically and treatment can be initiated

Alarms
Alarm Signs/Symptoms
      

Dysphagia Early satiety GI bleeding Odynophagia Vomiting Weight loss Iron deficiency anemia

Trial of Medications


H2RA or PPI
Expect response in 2-4 weeks 2 If no response
 

Change from H2RA to PPI Maximize dose of PPI

Trial of Medications


If PPI response inadequate despite maximal dosage

Confirm diagnosis
 

EGD 24 hour pH monitor

Esophagogastrodudenoscopy


Endoscopy (with biopsy if needed)

In patients with alarm signs/symptoms Those who fail a medication trial Those who require long-term tx long-

Lacks sensitivity for identifying pathologic reflux Absence of endoscopic features does not exclude a GERD diagnosis Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD

pH


2424-hour pH monitoring
Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes Trans-nasal catheter or a wireless, Transcapsule shaped device

Patient with heartburn

Iniate tx with H2RA or PPI H2RA taken BID PPI taken QD No Good response Good response Yes Frequent relapses No On demand tx Symptoms persist Maintenance therapy with lowest effective dose Yes Good response No Consider EGD if risk factors present (> 45, white, male and > 5 yrs of sx) Confirm diagnosis EGD, ph monitor Increase to max dose QD or BID Yes Yes No

GERD vs Dyspepsia


Distinguish from Dyspepsia

Ulcer-like symptoms-burning, epigastric Ulcersymptomspain Dysmotility like symptoms-nausea, symptomsbloating, early satiety, anorexia

 

Distinct clinical entity In addition to antisecretory meds and an EGD need to consider an evaluation for Helicobacter pylori

Treatment


Goals of therapy
Symptomatic relief Heal esophagitis Avoid complications

Better Living


Lifestyle modifications
Avoid large meals Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermint Decrease fat intake Avoid lying down within 3-4 hours after a meal 3 Elevate head of bed 4-8 inches 4 Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS) Avoid clothing that is tight around the waist Lose weight Stop smoking

Treatment


Antacids
Over the counter acid suppressants and antacids appropriate initial therapy Approx 1/3 of patients with heartburn-related heartburnsymptoms use at least twice weekly More effective than placebo in relieving GERD symptoms

Treatment


Histamine H2-Receptor Antagonists H2 More effective than placebo and antacids for relieving heartburn in patients with GERD Faster healing of erosive esophagitis when compared with placebo Can use regularly or on-demand on-

Treatment
AGENT
Cimetadine Tagamet Famotidine Pepcid Nizatidine Axid Ranitidine zantac

EQUIVALENT DOSAGES
400mg twice daily

DOSAGE
400-800mg twice daily 400-

20mg twice daily

20-40mg twice daily 20-

150mg twice daily

150mg twice daily

150mg twice daily

150mg twice daily

Treatment


Proton Pump Inhibitors

Better control of symptoms with PPIs vs H2RAs and better remission rates Faster healing of erosive esophagitis with PPIs vs H2RAs

Treatment
AGENT
Esomeprazole Nexium Omeprazole Prilosec Lansoprazole Prevacid Pantoprazole Protonix Rabeprazole Aciphex

EQUIVALENT DOSAGES
40mg daily

DOSAGE
20-40mg daily 20-

20mg daily

20mg daily

30mg daily

15-10md daily 15-

40mg daily

40mg daily

20mg daily

20mg daily

Treatment


H2RAs vs PPIs
12 week freedom from symptoms


48% vs 77% 52% vs 84% 6%/wk vs 12%/wk

12 week healing rate



Speed of healing


Treatment


Antireflux surgery
Failed medical management Patient preference GERD complications Medical complications attributable to a large hiatal hernia Atypical symptoms with reflux documented on 24-hour pH monitoring 24-

Treatment


Antireflux surgery candidates

EGD proven esophagitis Normal esophageal motility Partial response to acid suppression

Treatment


Antireflux surgery
Tenets of surgery
   

Reduce hiatal hernia Repair diaphragm Strengthen GE junction Strengthen antireflux barrier via gastric wrap 7575-90% effective at alleviating symptoms of heartburn and regurgitation

Treatment


Postsurgery
10% have solid food dysphagia 2-3% have permanent symptoms 7-10% have gas, bloating, diarrhea, nausea, early satiety Within 3-5 years 52% of patients back 3on antireflux medications

Treatment


Endoscopic treatment
Relatively new No definite indications Select well-informed patients with wellwellwelldocumented GERD responsive to PPI therapy may benefit

Three categories
Radiofrequency application to increase LES reflux barrier Endoscopic sewing devices Injection of a nonresorbable polymer into LES area

Complications
  

Erosive esophagitis Stricture Barretts esophagus

Complications


Erosive esophagitis
Responsible for 40-60% of GERD 40symptoms Severity of symptoms often fail to match severity of erosive esophagitis

Complications


Esophageal stricture
Result of healing of erosive esophagitis May need dilation

Complications


Barretts Esophagus
Columnar metaplasia of the esophagus Associated with the development of adenocarcinoma

Complications


Barretts Esophagus
Acid damages lining of esophagus and causes chronic esophagitis Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma

Complications
Patients who need EGD
  

Alarm symptoms Poor therapeutic response Long symptom duration

Once in a lifetime EGD for patients with chronic GERD becoming accepted practice Many patients with Barretts are asymptomatic

Complications


Barretts Esophagus
Manage in same manner as GERD EGD every 3 years in patients without dysplasia In patients with dysplasia annual to shorter interval surveillance

Summary
      

Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manisfestations Diagnostic Evaluation Treatment Complications

?QUESTIONS?