Download GERD: An Old Problem with New Approaches

GERD:
An Old Problem with New
Approaches
Jason Phillips, MD
Case
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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:
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Sternal ‘burning’ with acid taste in mouth
Occurs most frequently at night most days of the
week
Last hours
Partially relieved with Mylanta
Case
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Exacerbated by:
• Supine positions after meal
• Large meals
• Food triggers: pasta, greasy food,
coffee, alcohol
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Denies weight loss, dysphagia,
melena, hematemesis
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
Case
PE: BP 140/86 P 96 Afeb
Wt 275 lbs (BMI 36)
Gen: obese, NAD
Exam essentially normal
Case
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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
Case
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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:
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Increase PPI to BID
Change PPI
Referral to GI
Case
PPI was increased to BID and the
patient continued to have reflux
symptoms
Therefore, the pt was referred to GI
for further evaluation
Case
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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
Case
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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
Case
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GI visit: Additional history
Reflux events also increased during
the day during stressful moments at
work
Case
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Possible diagnoses
• Inadequately treated GERD vs
functional heartburn
• Malignancy
• Esophageal spasm
• Peptic ulcer disease
• Angina
Case
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EGD while still taking medications:
• normal esophagus with no evidence of
esophagitis or Barrett’s esophagus
• Normal stomach and duodenum
Case
Does he have non-erosive acid reflux
that is inadequately treated with his
current PPI or is this functional
heartburn?
Case
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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
Case
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Diagnosed with acid reflux
Recommendations
• BID PPI – taken 30 minutes BEFORE
meals
• Additional nocturnal H2 blocker
• Behavioral modifications
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Earlier dinner, smaller portions
Avoidance of trigger foods
Quit smoking
Lose weight
GERD Incidence
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Complaints of heartburn
• 40% of Americans complain of monthly
heartburn
• 20% complain of weekly heartburn
• 7% complain of daily heartburn
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Prevalence of GERD is increasing over the
30 years
Problem of GERD
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Difficult to define
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Physiologic vs pathologic acid reflux
• Physiologic  postprandial, short lived,
asymptomatic, rarely during sleep
• Pathologic  symptoms, often include
nocturnal episodes
Symptoms
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Heartburn
Epigastric pain
Regurgitation
Dysphagia
Chest pain
Nausea
Odynophagia
Globus sensation
Supraesophageal symptoms
Symptoms
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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.”
Pathophysiology
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80% of reflux symptoms occur as a
result of transient LES relaxation
Other motility defects
• LES incompetence
• Gastroparesis
• Esophageal body dymotility
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Anatomic defects: Hiatal hernia
Diagnosis
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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
Diagnosis: Empiric treatment
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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
Evaluation of GERD
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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)
Evaluation of GERD
Evaluation of GERD
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PillCam may offer a non-invasive
method to look for evidence of
esophagitis or Barrett’s esophagus
PillCam
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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’
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Eliakim et al… Preliminary results. ACG 2004.
Evaluation
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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
Ambulatory pH monitor
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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
Treatment
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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
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Overall, all PPI are equally effective
in treating symptoms. However,
there is some variability in response
from patient to patient
Treatment
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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
Surgical Treatment
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Indications
• Esophagitis
• Stricture
• Barrett’s metaplasia
• Medication failure
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Purpose of surgery  restoration
the LES
Surgical Treatment
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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
Endoscopic Treatments
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In development with ongoing studies
Most try to improve LES function in
some manner
Not quite ready for prime time in
community practice
Stretta procedure
Stretta procedure
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Decrease in
symptom score
Decreased PPI
No effect on LESP
No effect on acid
exposure
Some serious
thermal injury
complications
Enteryx injection
Enteryx injection
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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
Endoscopic suturing
Endoscopic suturing
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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
Questions?