Current Trends and Updates on

Diagnosis and Management of GERD

Jeraldine S. Orlina, MD
Grand Rounds
January 11, 2006
Pathophysiology
• Lower esophageal
sphincter
• Intrinsic muscle of distal
esophagus
• Sling fibers of cardia
• Diaphragm
• Transmitted pressure
of abdominal cavity

• Reflux occurs when the high-pressure zone in

distal esophagus is too low or when sphincter with
normal pressure undergoes spontaneous relaxation
Absite Question
• An operation is the primary initial
management for:
• A) Achalasia
• B) a large sliding esophageal hiatal hernia
• C) an epiphrenic esophageal diverticulum
• D) gastroesophageal reflux
• E) a paraesophageal hiatal hernia
Symptoms
Symptom Predominance (%)
Heartburn 80
Regurgitation 54
Abdominal Pain 29
Cough 27
Dysphagia for solids 23
Hoarseness 21
Belching 15
Aspiration 14
Wheezing 7
Globus 4
Symptoms -- Heartburn
• Epigastric and retrosternal
• Caustic or stinging sensation
• Does not radiate to the back, is not
pressurelike
• Can be confused with symptoms of PUD,
bilary colic, or CAD
Symptoms -- Regurgitation
• Indicates progression of disease
• Distinguish between digested and undigested
food
Diagnostic Studies
• Empirical Therapy
• Upper Gastrointestinal Endoscopy (EGD)
• Upper Gastrointestinal Fluoroscopy with
Barium
• 24-hour pH testing
• Esophageal Manometry
EGD
• Allows examination of the esophageal mucosa
• Identifies presence of esophagitis and grading
of severity
• Can identify other pathology, such as
diverticula, hiatal hernia, webs, rings, or
strictures
• Tissue biopsies to screen for Barrett’s
esophagus
Absite Question
• Four hours following upper esophagogastric
endoscopy for gastroesophageal reflux, a 62 year-old
man returns to the emergency room with chills, chest
pain, and dyspnea. Cardiac work-up is normal, but
esophagography shows a distal esophageal
perforation. The most appropriate management is
• A) nasogastric suction and TPN
• B) reinforced primary esophageal repair
• C) drainage and esophageal diversion
• D) esophagectomy with gastric pull-through
• E) fluoroscopic esophageal stent placement
Absite Question
• A 60 year-old otherwise healthy man has
symptomatic GERD that has not responded to
medical therapy, including PPIs.
Esophagoscopy shows moderately severe
esophagitis. Multiple biopsies of the
esophageal mucosa in the area of esophagitis
show columnar epithelium replacing the
normal squamous epithelium. As the patient’s
treatment is being planned, a biopsy report
shows high-grade dysplasia.
(cont)
• Treatment should be
A. Continued medical treatment with yearly
esophagoscopy and biopsies
B. Laparoscopic Nissen fundoplication
C. Photodynamic therapy
D. Esophagectomy
E. Laser ablation of normal mucosa
24-hour pH test
• Gold Standard for
presence of pathologic
reflux
• Parameters measured
include: total # of reflux
episodes, duration of
longest reflux episode,
percentage of time pH is
less than 4
Ambulatory pH testing – Recent Advances
• Combined impedance
and acid testing
• Allows for the
measurement of both
acid and nonacid
(volume) reflux.
• Important in pt with
persistent symptoms
despite an adequate
medical trial
Ambulatory pH testing – Recent Advances
• Tubeless method– Bravo
System
• Allows a radiotelemetry
capsule to be attached to the
esophageal mucosa
• Decreases patient discomfort,
allows for longer (48h)
monitoring, and may improve
accuracy by allowing the
patient to carry out their usual
activities
Esophageal Manometry
• Lower Esophageal
Sphincter (LES)
• Mean resting pressure
• Total length

• Esophageal Body
• To determine
effectiveness of
peristalsis
• Amplitude of esophageal
wave
Esophagram
• Useful when operation
is planned—shows
anatomy of esophagus
and proximal stomach
• Demonstrates presence
and size of hiatal hernia
if present
Treatment – Lifestyle Modification
• May benefit many patients with GERD,
although these changes alone are unlikely to
control symptoms in the majority of patients
• Elevation of the head of the bed, decreased fat
intake, cessation of smoking, avoiding
recumbency for 3h postprandially, avoidance
of certain foods (chocolate, EtOH,
peppermint)
• No data reflecting the efficacy of these
maneuvers
Treatment – Patient Directed Therapy
• Antacids
• H2 receptor antagonists
• If symptoms persist, continuous therapy is
required, or alarm symptoms/signs develop –
pt should have additional evaluation and
treatment
Treatment – Acid Suppression
• 6-week course of acid-suppression therapy
• Double dose of a proton pump inhibitor
• Irreversible bind the proton pump in parietal cells
of the stomach
• Maximal effect 4 days after initiation of therapy
and lasts for the life of the parietal cell
• More effective than other
antacid regimens
Absite Question
• Proton pump inhibitors used in the treatment
of GERD
A. Cause regression of Barrett’s epithelium
B. Inhibit progression of dysplasia
C. Increase squamous islands in Barrett’s segments
D. Reverse intestinal metaplasia
E. Are effective only if gastric acidity is normalized
Treatment – Promotility Therapy
• May be used as an adjunct to acid suppression
therapy in patients with demonstrated defects
in esophagogastric motility (LES
incompetence, poor esophageal clearance,
delayed gastric emptying)
Absite Question
• Five years after a myocardial infarction, a 55 year-old
woman with HTN and DM has symptomatic
esophagogastric reflux. Medical treatment for the last
year has not been successful. Her BMI is 55.
Esophagoscopy shows severe esophagitis. Multiple
biopsies show inflammatory changes but no columnar
epithelium or cancer. The best treatment would be:
A. Nissen fundoplication
B. Gastric bypass procedure
C. Gastric banding procedure
D. Vertical banded gastroplasty
E. Biliary-pancreatic diversion with duodenal switch
Surgical Therapy
• Indications
• Pt w/ evidence of severe esophageal injury (ulcer,
stricture, or Barrett’s)
• Incomplete resolution of symptoms or relapses
while on medical therapy
• Long duration of symptoms
• Younger patients
• Ideal patient: more than 10-year life expectancy
and are in need of lifelong therapy due to a
mechanically defective sphincter
Trends in the use of surgery for gastroesophageal reflux
disease in Ontario, 1988-2000

Urbach, D. R. et al. CMAJ 2004;170:219-221

Copyright ©2004 CMA Media Inc. or its licensors

Laparoscopic Nissen Fundoplication
• Lafullarde T, Watson DI, Jamieson GG, Myers JC
, Game PA, Devitt PG. Laparoscopic Nissen
fundoplication: five-year results and beyond. Arch
Surg. 2001 Feb;136(2):180-4
• 87% of the 176 patients remained free of
significant reflux. The long-term outcome was
considered "good or excellent" by 90% of patients.
Laparoscopic Nissen Fundoplication
• Success rate of greater than 90%
• Procedure of choice
Absite Question
• A 56 year-old man is seen 2 years after a
laparoscopic Nissen fundoplication for GERD.
His pre-operative work-up 2 years ago
demonstrated normal esophageal motility, and
pH probe testing showed that reflux was the
cause of his symptoms. He now has recurrent
symptoms of GE reflux.

A Barium swallow is performed.

• Which is not true about this
patient?
A. Redo operation is as effective
as primary antireflux operation
for ameliorationg reflux
symptoms
B. Transabdominal laparoscopic
redo operation is
contraindicated
C. Redo operation has an
increased complication rate
D. The cause is related to
technical performance of the
initial operation
E. Manometry is helpful in
planning operative therapy
Absite Question
• Four years ago, a 47 year-old woman had a
laparoscopic fundoplication. It failed after three years
and she had severe, recurrent gastroesophageal
symptoms. Through a celiotomy incision, the surgeon
performed a redo-fundoplication with a 360-degree, 2
cm wrap around a 56 Fr dilator. For the past three
months she has had severe early satiety, postprandial
epigastric pain, and weight loss. The most likely cause
of these symptoms is:
A. The wrap is too tight
B. The wrap is too loose
C. Vagal injury
D. Irritable bowel syndrome
E. Esophageal motor disorder
Absite Question
• Barrett’s esophagus
• A) will usually regress after Nissen fundoplication
• B) carries an increased risk of squamous cell
carcinoma
• C) is an indication for esophagectomy
• D) should be followed by endoscopic surveillance
• E) is a contraindication to laparoscopic Nissen
fundoplication
Endoscopic Therapy
• Attempt to augment the LES by
1. Suturing – EndoCinch
2. Radiofrequency energy – Stretta
3. Plexiglass injection – polymethylmethacrylate
4. Biocompatible polymer injection -- Enteryx
Plication/Sewing Techniques
• First developed in the mid ’80’s
• Allow placement of sutures into the gastric
cardia, thereby augmenting the barrier effect
of the GEJ
• Bard EndoCinch
EndoCinch
• Filipi CJ, Lehman GA, Rothstein RI et al.
“Transoral, flexible endoscopic suturing for
treatment of GERD: a multicenter trial.”
Gastrointestinal Endoscopy 2001; 53: 416-22.
• Suggested that endoscopic gastric plication is a
safe procedure and, at a 6-month follow-up, that
2/3 of pts undergoing the procedure were
successfully treated.
EndoCinch (cont)
• Inclusion Criteria
• Three or more episodes of heartburn a week when off
antisecretory meds
• Successful response to and reliance upon antisecretory
meds for GERD
• Abnormal acid reflux on ambulatory pH monitoring
• Exclusion Criteria
• Dysphagia
• BMI greater than 40
• GERD refractory to PPIs
• Hiatal hernia greater than 2 cm in length
EndoCinch (cont)
• Treatment success defined as a decrease in the
heartburn severity score by 50% in addition to a
reduction in the use of antireflux medications to
fewer to 4 doses per month.
• 64 patients were enrolled
• 33 pts (52%) – gastroplication in a linear configuration
• 31 (48%) – gastroplication in a circumferential plication
• No difference in outcomes between the 2 groups
• Results:
• Mean heartburn scores fell from a preprocedure score of
62.7 to mean scores of 16.7 and 17 and 3 and 6 months
postprocedure
• Percent total time the pH was < 4, total number of reflux
episodes, and percent upright pH time was lower than 4
were all significantly improved, but none returned to
normal range
• Regurgitation scores improved significantly
• Quality of life scores were improved for social functioning
and bodily pain and 62% of pts at 3 and 6 month f/u were
taking less than 4 doses of medication per month
• Results (cont)
• No significant change found in LES resting
pressure or length
• No significant effect on mucosal healing
• Adverse events included pharyngitis (31%),
vomiting (14%), and abdominal pain (14%), and
chest pain (16%)
• One patient experienced a suture microperforation
that was treated conservatively with IV antibiotics
and brief hospitalization
EndoCinch (cont)
• Chen YK, Raijman I, Ben-Menachem T et al.
“Long-term outcomes of endoluminal
gastroplication: a U.S. multicenter trial.”
Gastrointestinal Endoscopy 2003. 61: 434-440
• Prospective, multicenter trial which enrolled 85
patients to be treated with endoluminal
gastroplication followed over 2 years
• Results:
• 51% of patients had no or occasional GERD symptoms
• 73% and 69% were completely off PPIs or at 12 and 24
months postprocedure
• Reduction in the mean annual medication cost from $1564
per year preprocedure to $157 one year postprocedure (cost
redux of 88%)
• Shortcomings of study
• Does not contain a nonplication sham
group
• Trends toward increased symptoms
over time suggestive of degradation
of repair over time
EndoCinch (cont)
• Schiefke I et al. “Long term failure of
endoscopic gastroplication (EndoCinch)”. Gut
2005; 54: 752-758
• Evaluated prospectively long term outcome after
EndoCinch
• 70 patients at a single referral center
• Patients interviewed with a standard questionaire
regarding symptoms, medication use, in addition
to f/u with endoscopy, 24h pH monitoring, and
esophageal manometry
• Results:
• 18 months after EndoCinch 56/70 patients (80%)
were considered treatment failures as their
heartburn symptoms did not improve or PPI
medication exceeded 50% of initial dose
• Endoscopy showed all sutures in situ in 12/70
(17%), while no sutures remained in 18/70 (26%)
• No significant changes in 24h pH monitoring or
LES pressure
• Conclusion:
• Long term outcome is disappointing probably due
to suture loss in the majority of patients
Radiofrequency Thermal Therapy -- Stretta
• Delivery of low-power, temperature-controlled
radiofrequency energy to the GEJ
• Two mechanisms
1. mechanically altering the GEJ
2. inducing the ablation of nerves that trigger
transient lower esophageal relaxation
Radiofrequency Thermal Therapy -- Stretta
Stretta
• Wolfsen HC and Richards WO. “The Stretta
Procedure for the Treatment of GERD: A
registry of 558 patients.” Journal of
Laparoendoscopic and Advanced Surgical
Techniques 2002
• 558 patients, 33 institutions
• 6 months of follow-up
• Survey administered which assessed GERD
severity, percentage of GERD symptom control,
satisfaction, and antisecretory medication use
• Results
• At baseline, the median percentage of GERD
symptom control while on drugs was 50%,
compared with 90% after Stretta
• Satisfaction with symptom control was 26% versus
77% after Stretta
• Median requirement at baseline was double dose
of PPI versus antacids prn after Stretta
• Most subjects (90%) would recommend Stretta to
a friend
Stretta
• Triadafilopolous et al: reported 6- and 12- month
results of an open label trial of Stretta
• Prospective multicenter trial involving 118 patients who
had chronic heartburn or regurgitation, abnormal
esophageal acid exposure, hiatal hernia less than 2 cm,
and mild esophagitis
• At 12 mo: improvement in heartburn score, GERD
score, and quality of life. PPI use decreased from 88%
to 30%. Esophageal acid exposure improved
significantly, although no improvement in the incidence
and severity of esophagitis
• randomized, double-blinded, sham controlled
trial of radiofrequency energy to the
gastroesophageal junction for the treatment of
GERD
Patient Criteria
• heartburn or acid regurgitation at least partially responsive
to and requiring daily antacid medications
• age 18 years
• 24-hour pH study (off medications) showing abnormal
esophageal acid exposure (4%) or a DeMeester score of
14.7
• esophageal manometry showing normal esophageal
peristalsis and sphincter relaxation
• EGD, on medications, showing no esophagitis worse than
grade II (i.e., no substantial ulcerations), no hiatal hernia 2
cm long, and no Barrett’s esophagus
• no coagulation disorders, mechanical prostheses, prominent
dysphagia, or unstable disorders.
Stretta

• Patients were offered the Stretta procedure if they had

documented GERD and did not have a hiatal hernia larger
than 2 cm, LES pressure less than 8 mmHg, or Barrett’s
esophagus.

• Patients with larger hiatal hernias, LES pressure less than

8 mmHg, or Barrett’s were offered LF.
Stretta
• Conclusions – Although the incidence of
complications is decreased compared with
operative intervention, success of therapy does
not approach that of surgical intervention

• After Stretta 30-50% of patients still require

PPI therapy
Injection/implantation techniques -- Enteryx
• Injectable biocompatible solution consisting of
8% ethylene vinyl alcohol copolymer mixed in
dimethyl sulfoxide
• When injected into the LES, the solution
interacts with the surrounding fluid to become
an inert spongy solid mass
• Mechanism: may impart an alteration in the
compliance of tissues preventing sphincter
shortening and improving the barrier function
of the GEJ
Enteryx
Enteryx
• Cohen LB, Johnson DA, Ganz RA et al “Enteryx
implantation for GERD: expanded multicenter
trial results and interim postapproval follow-up
to 24 months.” Gastrointestinal Endoscopy May
2005
• Open-label, international clinical trial conducted in
144 PPI—dependent patients with GERD with f/u at
6 and 12 months
• Primary outcome: PPI use
• Secondary outcome: GERD health-related quality of
life and esophageal acid exposure
• Results:
• At 12 months PPI use was reduced by greater than
50% in 84% of treated pts

• GERD health-related quality of life < 11% in 78%

of patients

• Esophageal acid exposure was reduced by 31%

Enteryx
Conclusions on Endoscopic Mgmt of GERD
• Techniques need to be further studied in sham-controlled
protocol

• Long term follow-up suggest a declining effect of

treatment with pts returning to PPI use -- more long term
f/u studies necessary

• Future studies should improve targeting of which patients

benefit, further elucidate the mechanisms of action, and
provide detailed comparisons to alternative treatments.
Future of Endoscopic Therapy
• As a substitute for long-term medical therapy
for the pt with mildly symptomatic GERD

• As adjuncts to ongoing pharmacologic

treatment

• In patients with a failed surgical

fundoplication