CASE-BASED LEARNING (CBL) MODULE

GERD IN DAILY PRACTICE:

HOW TO DIAGNOSE AND TREAT IT EFFECTIVELY ?

DIVISION OF GASTROENTEROLOGY, DEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE UNIVERSITAS INDONESIA
DR. CIPTO MANGUNKUSUMO NATIONAL GENERAL HOSPITAL
JAKARTA 2021
 CASE ILLUSTRATION

• A 40 year-old male comes to your clinic with chief complaint of worsening heartburn
since 1 week ago.
• The heartburn occurs every day within one week. He has been suffering heartburn since
2 months ago
• He has regurgitation every day as well.
• One week ago, he came to the ER due to chest pain. Electrocardiography was normal.
He was discharged home.
• He admits that he has history of hypertension since 1 year ago.
 CASE ILLUSTRATION
• Within one week, every night he does not sleep well due to heartburn and
regurgitation.
• He denies difficulty in swallowing, bloody vomiting, nausea, abdominal pain, and
black or bloody stool.
• He consumes lansoprazole 1x30 mg every day to alleviate the symptoms. Another
medications is amlodipine 1x10 mg.
• He drinks coffee every morning. He comes home at night after working and
always having dinner at 8 to 9 PM and sleep within 1 hour after eating.
 CASE ILLUSTRATION
Physical examination :
• Blood pressure 170/90 mmHg, heart rate: 80 x/minute, respiratory rate: 16
x/minute, temperature: 37°C
• Height: 183 cm, weight :135 kg, body mass index : 40.3 kg/m2
• Other physical examinations are normal
 CASE ILLUSTRATION

Laboratory findings:
• Complete blood count: 13.1/39/5700/234000 MCV/MCH: 82/28
• Differential count: 0/1/57/35/7
• Ureum and creatinine: 37 and 0.6 mg/dL
• AST and ALT: 35 and 38 IU/L
• Random blood glucose: 132 mg/dL
 QUESTION NO 1

What is the most likely (primary) diagnosis in this patient ?

(Hint: use, describe, and apply GERD-Q for this patient)
• Heartburn terjadi setiap hari dalam seminggu
• Regurgitasi setiap hari
• Tidak bisa tidur dengan baik karena heartburn dan
regurgitasi setiap malam dalam seminggu terahir
• Tidak ada mual dan nyeri ulu hati
• Pasien konsumsi lansoprazole 1 x 30 mg setiap hari untuk
mengurangi gejala

Total Skor : 12 (kemungkinan menderita GERD)

 QUESTION NO 2

What is (are) the risk factor(s) of GERD in this patient ?

 ANSWER AND LITERATURE REVIEW

Faktor Risiko GERD pada pasien :

• Obesitas (IMT 40)
• Hipertensi
• Berbaring 1 jam setelah makan
 QUESTION NO 3

What is the relationship between obesity and GERD ? Explain it

thoroughly !
ANSWER AND LITERATURE REVIEW
ASIAN-PACIFIC CONSENSUS
 QUESTION NO 4

Does calcium channel blocker have implications on GERD ? Explain it

thoroughly !
 CASE ILLUSTRATION
• You decide to increase the lansoprazole dose to 2x30 mg.
• You educate him to decrease his weight and consult him to
nutritionist.
• You stop amlodipine and switch it to valsartan 1x80 mg.
• You also educate him to modify lifestyle.
 QUESTION NO 5

What are the life style modifications that you should explain to him ?
(Please use the evidences in the literature)
 ANSWER AND LITERATURE REVIEW

• Lifestyle modifications remain the cornerstone of any thera- peutic intervention for
GERD
• A systematic review of clinical trials that examined the impact of lifestyle
modifications on GERD  there is either lack of or weak evidence that after
cessation of tobacco, alcohol, chocolate, caffeine or coffee, citrus, mint or spicy food
there is improvement in clinical or physiological parameters of GERD
• Obesity has been demonstrated to be an important risk fac- tor for the development or
worsening of GERD.
• A large cohort study (10,545 women)  any increase in body mass index (BMI) was
associated with an increased risk of GERD.
• women who reduced their BMI by 3.5 units or more reported a 40% reduction in the
frequency of GERD symptoms compared with controls
 CASE ILLUSTRATION

• After 4 weeks, he comes to your clinic. He tells you that the symptoms
does not improve.
• He convinces you that he already comply to all life style modifications
• You advise him to undergo esophagogastroduodenoscopy (EGD) and he
agrees.
EGD EXAMINATION

Conclusion: normal EGD

 QUESTION NO 6

Is it refractory GERD ? What is the definition of refractory GERD ?

• persistent and troublesome GORD symptoms unresponsive to at
least 8 weeks of a standard dose of PPI may be termed
refractory GORD symptoms
• Refractory GORD symptoms affect patients’ QOL including
sleep and work
• The main causes of refractory GORD symptoms include:
• insufficient inhibition of gastric acid secretion
• Ongoing weakly acidic (or non-acid) reflux
• non-GORD causes
• reflux sensitivity.
• This terminology was used in patients
with regurgitation and heartburn
symptoms which is not responsive to 8
weeks proton pump inhibitor (PPI)
therapy.
 ANSWER AND
LITERATURE REVIEW
• Refractory GERD was a condition where
GERD symptoms were not improving after
adequate PPI therapy.
• In general, refractory GERD diagnosis was
based on clinical findings, objective
endoscopic exam, ambulatory reflux
monitoring, and response to antiacid-
secretion therapy.

Selfie, Simadibrata M. Diagnosis and treatment of refractory gastroesophageal reflux

disease (GERD).2015
 QUESTION NO 7

What are the complications of GERD ?

 ANSWER AND LITERATURE REVIEW

Ronkainen J, Aro P, Storskrubb T, Johansson SE, Lind T, Bolling-Sternevald E, et al. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a
Kalixanda study report. Scand J Gastroenterol. 2005;40:275–285
Shaheen NJ, Richter JE. Barrett’s oesophagus. Lancet. 2009;373:850–861
 QUESTION NO 8

What is the next diagnostic step for this patient ?

 ANSWER AND LITERATURE REVIEW

• Asia Pacific Consensus on the Management of Gastro-Oesophageal Reflux Disease

(2016):
• Methods that are available for investigation of refractory GERD:
• “After ascertaining medication compliance, further investigations available to better
categorise underlying pathophysiology and target therapy include upper GI
endoscopy ± enhanced imaging and function testing (ambulatory pH monitoring
and 24-hour combined impedance-pH studies/oesophageal manometry”
Gyawal CP, et al. Management of gastroesophageal
reflux disease. Gastroenterology. 2018;154:302-18.
 ANSWER AND LITERATURE REVIEW

• Ambulatory reflux monitoring: can provide confirmatory evidence of GERD, in patients with normal
endoscopy, atypical symptoms and/or when contemplating ARS.
• The primary outcome of a 24-hour pH-metry study is the AET (acid exposure time)
• Wireless pH monitoring system increases the diagnostic yield and test reproducibility, however wireless pH
monitoring is expensive
• Another variation on reflux monitoring is pH-impedance monitoring, which characterises reflux events with
both a pH electrode and a series of impedance electrodes. Since pH-impedance detects all reflux (liquid, gas
or mixed) regardless of acidity, and defines the direction of flow, it is considered the gold standard.
24 HOURS MONITORING PH METRY-IMPEDANCE
 THE RESULT OF 24 HOUR PH-METRY
IMPEDANCE
• Esophageal acid exposure time : 6% (normal < 4%)

• Total distal reflux episodes: 94 (normal: < 81)

• Weakly acidic reflux episodes: 33 (normal: < 26)

 QUESTION NO 9

What is the next treatment that you would suggest for this patient ?
 ANSWER AND LITERATURE REVIEW

Medical management

Anti-reflux surgery

Endoscopic therapies

Subramanian CR, Triadafilopoulos G. Refractory gastroesophageal reflux disease. Gastroenterol Rep (Oxf). 2015
MEDICATION MANAGEMENT
Combination
PPI Others
therapy

Doubling dose of
PPI + H2RA Baclofen
PPI (divided)

Extended release
PPI
Proknetic
(Dexlansoprazole-
MR)

Pantoprazole
magnesium
Rebamipide
(Pantoprazole-
Mg)

Switch to the
other PPI (to Antidepressant
Esomeprazole)

Subramanian CR, Triadafilopoulos G. Refractory gastroesophageal reflux disease. Gastroenterol Rep (Oxf). 2015
 ANSWER AND LITERATURE REVIEW

Subramanian CR, Triadafilopoulos G. Refractory gastroesophageal reflux disease. Gastroenterol Rep (Oxf). 2015
Subramanian CR, Triadafilopoulos G. Refractory gastroesophageal reflux disease. Gastroenterol Rep (Oxf). 2015
END OF DISCUSSION

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