GERD: An Old Problem with New Approaches

1. GERD:An Old Problem with New Approaches Jason Phillips, MD

2. Case • HPI: 44 y/o M with heartburn • Heartburn symptoms off/on for many years but increasing in severity and frequency in last 6-12 months • Symptoms are described as: • Sternal ‘burning’ with acid taste in mouth • Occurs most frequently at night most days of the week • Last hours • Partially relieved with Mylanta

3. Case • Exacerbated by: • Supine positions after meal • Large meals • Food triggers: pasta, greasy food, coffee, alcohol • Denies weight loss, dysphagia, melena, hematemesis

4. Case PMH: Obesity Meds: Mylanta NKDA SH: smokes 1ppd x 10+years, drinks 2-4 glasses of wine per night FH: No h/o esophageal Ca

5. Case PE: BP 140/86 P 96 Afeb Wt 275 lbs (BMI 36) Gen: obese, NAD Exam essentially normal

6. Case • Pt was seen by his PCP and diagnosed with GERD. • Prescribed a PPI to take once a day. • Advised pt to lose weight and quit smoking • Follow-up in 4-6 weeks

7. Case • At 5 weeks, he called his PCP and complained he was still having daily episodes of heartburn though ‘the medicine helped a little’ • PCP’s 3 options: • Increase PPI to BID • Change PPI • Referral to GI

8. Case PPI was increased to BID and the patient continued to have reflux symptoms Therefore, the pt was referred to GI for further evaluation

9. Case • GI visit: Additional history • Pts symptoms sounded like typical reflux-like symptoms • Symptoms mostly occurred from 8-10 PM after his dinner at 7 PM • Large evening meals most days • Had not tried avoiding typical food triggers • Had not lost weight or stopped smoking

10. Case • GI visit: Additional history • He was taking his PPI 30 minutes after meals (during dessert) twice per day as recommended • His symptoms overall improved by ~50% but as mentioned, he continued to have daily symptoms

11. Case • GI visit: Additional history • Reflux events also increased during the day during stressful moments at work

12. Case • Possible diagnoses • Inadequately treated GERD vs functional heartburn • Malignancy • Esophageal spasm • Peptic ulcer disease • Angina

13. Case • EGD while still taking medications: • normal esophagus with no evidence of esophagitis or Barrett’s esophagus • Normal stomach and duodenum

14. Case Does he have non-erosive acid reflux that is inadequately treated with his current PPI or is this functional heartburn?

15. Case • To distinguish, I arranged for the patient to have a 24 pH probe while still taking his BID PPI • Bravo wireless 24 hour pH probe

19. Case • Diagnosed with acid reflux • Recommendations • BID PPI – taken 30 minutes BEFORE meals • Additional nocturnal H2 blocker • Behavioral modifications • Earlier dinner, smaller portions • Avoidance of trigger foods • Quit smoking • Lose weight

21. GERD Incidence • Complaints of heartburn • 40% of Americans complain of monthly heartburn • 20% complain of weekly heartburn • 7% complain of daily heartburn • Prevalence of GERD is increasing over the 30 years

22. Problem of GERD • Difficult to define • Physiologic vs pathologic acid reflux • Physiologic  postprandial, short lived, asymptomatic, rarely during sleep • Pathologic  symptoms, often include nocturnal episodes

23. Symptoms • Heartburn • Epigastric pain • Regurgitation • Dysphagia • Chest pain • Nausea • Odynophagia • Globus sensation • Supraesophageal symptoms

24. Symptoms • Patient’s descriptions can be difficult to interpret: “Its not heartburn its… • “…bile coming up into my throat.” • “…intense pain in my stomach.” • “…its not pain, its heaviness in my chest.” • “…pain in the back of my throat when I awake.”

25. Pathophysiology • 80% of reflux symptoms occur as a result of transient LES relaxation • Other motility defects • LES incompetence • Gastroparesis • Esophageal body dymotility • Anatomic defects: Hiatal hernia

26. Diagnosis • Symptoms  empiric PPI • Uncomplicated symptoms (no alarm signs – weight loss, GI bleeding, dysphagia) • Age < 65 years • No esophagotoxic medications (e.g, bisphophonates) • 6 weeks trial

27. Diagnosis: Empiric treatment • Sensitivity ~75% • Specificity ~80% • Using 50% improvement as the therapeutic endpoint • Schindlbeck et al…Arch Int Med 155:1808-12, 1995 • Fass et al…Arch Int Med 159:2161-8, 1999

28. Evaluation of GERD • In patients who have ‘red flags’ or fail 6 weeks of a PPI  EGD • EGD: • signs of esophagitis • Barrett’s esophagus • Hiatal hernias • Exclusion of cancer and other diagnoses (PUD)

29. Evaluation of GERD

30. Evaluation of GERD • PillCam may offer a non-invasive method to look for evidence of esophagitis or Barrett’s esophagus

33. PillCam • Identified 97% (32/33) of the cases of Barrett’s esophagus when confirmed by traditional endoscopy • Agreed 99% (72/73) of the time in excluding Barrett’s esophagus confirmed by traditional EGD • Identified 89% (33/37) of the cases of esophagitis • Agreed 99% (68/69) of the cases of ‘no evidence of esophagitis’ • Eliakim et al… Preliminary results. ACG 2004.

34. Evaluation • 75% of community based EGD for evaluation of GERD have NO evidence of mucosal injury • 50% of patients with endoscopy negative reflux disease have abnormal esophageal acid exposure • In these cases, other tests are needed

35. Ambulatory pH monitor • Considered to be the most sensitive test for diagnosing reflux • Traditional  transnasal catheter with probe situated 5 cm above LES • Bravo pH system  wireless technology

38. Treatment • PPI are standard medical therapy • Daily PPI generally has a 80% healing rate for moderate to severe esophagitis and relief of symptoms in up to 90% of patients • Overall, all PPI are equally effective in treating symptoms. However, there is some variability in response from patient to patient

39. Treatment • Proper timing of PPI administration is critical for efficacy • 30 minutes before breakfast or other large meal • In select patients, a second dose can be added before the evening meal

40. Surgical Treatment • Indications • Esophagitis • Stricture • Barrett’s metaplasia • Medication failure • Purpose of surgery  restoration the LES

42. Surgical Treatment • Most studies indicate that the majority of patients are symptom-free (70-95%) • Recent studies suggest that after 5 years, up to 1/3 of patients required PPI to control symptoms. At 10 years, up to 50% require PPIs • Side-effects: gas-bloat symptoms, diarrhea, dysphagia

43. Endoscopic Treatments • In development with ongoing studies • Most try to improve LES function in some manner • Not quite ready for prime time in community practice

44. Stretta procedure

45. Decrease in symptom score Decreased PPI No effect on LESP No effect on acid exposure Some serious thermal injury complications Stretta procedure

46. Enteryx injection

47. Enteryx injection • Decreased in heartburn symptoms • Decreased 24 hour acid exposure • Decreased need for PPI • No improvement in severity of esophagitis at EGD • Long term safety issues not known

48. Endoscopic suturing

49. Endoscopic suturing • Decreased heartburn symptoms • PPI eliminated in 74% of patients at 6 months • Decreased esophageal acid exposure; however, only 30% completely normalized • Long term follow-up needed

50. Questions?