Hard Core CME GERD Robert A.Solomon M.D. Associate Director Montgomery Family Practice Residency Program Norristown, PA
GERD Objectives <ul><li>Cost effective treatment </li></ul><ul><li>Complications of GERD </li></ul><ul><li>Beyond medicati...
GERD <ul><li>Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus </li></ul><...
GERD
GERD Only 2-3 % of acid reflux events reach the level of  perception by the patient
GERD statistics <ul><li>Monthly GERD symptoms- 44 % or 61 million Americans </li></ul><ul><li>Weekly GERD symptoms- 14 % <...
GERD etiology
GERD Diagnosis <ul><li>Symptoms </li></ul><ul><li>Heartburn (pyrosis)  </li></ul><ul><li>Regurgitation-especially after la...
 
Atypical GERD Presentations <ul><li>Asthma </li></ul><ul><li>Chest pain </li></ul><ul><li>Chronic cough </li></ul><ul><li>...
GERD Alarm Symptoms <ul><li>Dysphagia </li></ul><ul><li>Early satiety </li></ul><ul><li>GI bleeding </li></ul><ul><li>Iron...
GERD-Etiology of Complications
GERD Complications Esophagitis
GERD-Etiology of Complications
GERD-Barrett’s Esophagus Normal endoscopy Barrett’s esophagus
Barrett’s Esophagus <ul><li>Progression to adenocarcinoma of esophagus </li></ul><ul><li>0.2-2 % annual incidence of CA in...
Esophageal Stricture
Esophageal Stricture Balloon dilator Stricture  Balloon  Post dilation
Complications of GERD <ul><li>Reflux induced asthma </li></ul><ul><li>Laryngeal and tracheal stenosis </li></ul><ul><li>La...
Treatment of GERD <ul><li>Lifestyle modifications </li></ul><ul><li>Antacids </li></ul><ul><li>Histamine-2 receptor antago...
GERD-Lifestyle Modifications <ul><li>Elevate head of bed </li></ul><ul><li>Decrease fat intake </li></ul><ul><li>Stop smok...
GERD-Antacids <ul><li>Good for milder forms of GERD </li></ul><ul><li>Gaviscon-antacid/alginic acid may be superior to ant...
 
GERD H2 Blockers <ul><li>Multiple trials showed faster healing vs. placebo of erosive esophagitis </li></ul><ul><li>Four a...
 
GERD- PPIs <ul><li>Proton pump inhibitors provide the most rapid symptomatic relief </li></ul><ul><li>Five available-esome...
GERD- PPIs <ul><li>Administer  prior  to meals  </li></ul><ul><li>Side effects-headache, diarrhea, abdominal pain </li></u...
 
 
Suggested algorithm for treatment of GERD
GERD-Beyond Meds <ul><li>Antireflux surgery </li></ul><ul><li>Endoscopic treatment </li></ul>
Refractory GERD <ul><li>Failed medical management </li></ul><ul><li>Patient preference for surgery despite successful medi...
GERD-Antireflux Surgery <ul><li>Nissen fundoplication </li></ul><ul><li>complete (360 degree) wrap of stomach </li></ul><u...
 
GERD-Endoscopic Therapy <ul><li>Stretta-radiofrequency </li></ul><ul><li>Endocinch-endoscopic sewing </li></ul><ul><li>Ful...
 
Endocinch
 
Enteryx-Polymer injection
GERD-Summary <ul><li>Cost effective treatment </li></ul><ul><li>Complications of GERD </li></ul><ul><li>Newer treatments b...
References <ul><li>1.Devault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux...
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  1. 1. Hard Core CME GERD Robert A.Solomon M.D. Associate Director Montgomery Family Practice Residency Program Norristown, PA
  2. 2. GERD Objectives <ul><li>Cost effective treatment </li></ul><ul><li>Complications of GERD </li></ul><ul><li>Beyond medications </li></ul>
  3. 3. GERD <ul><li>Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus </li></ul><ul><li>American College of Gastroenterology </li></ul>
  4. 4. GERD
  5. 5. GERD Only 2-3 % of acid reflux events reach the level of perception by the patient
  6. 6. GERD statistics <ul><li>Monthly GERD symptoms- 44 % or 61 million Americans </li></ul><ul><li>Weekly GERD symptoms- 14 % </li></ul><ul><li>Daily GERD symptoms- 7 % </li></ul>
  7. 7. GERD etiology
  8. 8. GERD Diagnosis <ul><li>Symptoms </li></ul><ul><li>Heartburn (pyrosis) </li></ul><ul><li>Regurgitation-especially after large meal </li></ul><ul><li>Aggravated by recumbency/bending over </li></ul><ul><li>Relieved with antacids </li></ul><ul><li>Difficult cases </li></ul><ul><li>24 hr pH monitoring </li></ul>
  9. 10. Atypical GERD Presentations <ul><li>Asthma </li></ul><ul><li>Chest pain </li></ul><ul><li>Chronic cough </li></ul><ul><li>Recurrent laryngitis </li></ul><ul><li>Recurrent sore throat </li></ul><ul><li>Globus sensation </li></ul>
  10. 11. GERD Alarm Symptoms <ul><li>Dysphagia </li></ul><ul><li>Early satiety </li></ul><ul><li>GI bleeding </li></ul><ul><li>Iron deficiency anemia </li></ul><ul><li>Odynophagia </li></ul><ul><li>Vomiting </li></ul><ul><li>Weight loss </li></ul>
  11. 12. GERD-Etiology of Complications
  12. 13. GERD Complications Esophagitis
  13. 14. GERD-Etiology of Complications
  14. 15. GERD-Barrett’s Esophagus Normal endoscopy Barrett’s esophagus
  15. 16. Barrett’s Esophagus <ul><li>Progression to adenocarcinoma of esophagus </li></ul><ul><li>0.2-2 % annual incidence of CA in Barrett’s </li></ul><ul><li>Aggressive acid suppression (high dose PPI) may not lead to regression in transformation to malignancy </li></ul><ul><li>Surveillance endoscopy- looking for dysplasia-intervals are controversial </li></ul>
  16. 17. Esophageal Stricture
  17. 18. Esophageal Stricture Balloon dilator Stricture Balloon Post dilation
  18. 19. Complications of GERD <ul><li>Reflux induced asthma </li></ul><ul><li>Laryngeal and tracheal stenosis </li></ul><ul><li>Laryngeal cancer </li></ul>
  19. 20. Treatment of GERD <ul><li>Lifestyle modifications </li></ul><ul><li>Antacids </li></ul><ul><li>Histamine-2 receptor antagonists </li></ul><ul><li>Proton pump inhibitors </li></ul><ul><li>Anti-reflux surgery </li></ul><ul><li>Endoscopic treatment </li></ul>
  20. 21. GERD-Lifestyle Modifications <ul><li>Elevate head of bed </li></ul><ul><li>Decrease fat intake </li></ul><ul><li>Stop smoking </li></ul><ul><li>Avoid lying down 3 hrs post prandially </li></ul><ul><li>Avoid chocolate, alcohol, peppermint, coffee, ?onions/garlic= all lower LES pressure </li></ul>
  21. 22. GERD-Antacids <ul><li>Good for milder forms of GERD </li></ul><ul><li>Gaviscon-antacid/alginic acid may be superior to antacid alone </li></ul>
  22. 24. GERD H2 Blockers <ul><li>Multiple trials showed faster healing vs. placebo of erosive esophagitis </li></ul><ul><li>Four available-cimetidine (Tagamet),famotidine (Pepcid), nizatidine (Axid), ranitidine (Zantac)-all equally effective </li></ul><ul><li>Side effects-drug interactions with cimetidine, confusion in elderly,rare cytopenias, elevated LFTs, gynecomastia </li></ul>
  23. 26. GERD- PPIs <ul><li>Proton pump inhibitors provide the most rapid symptomatic relief </li></ul><ul><li>Five available-esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex) </li></ul><ul><li>All are generally equal </li></ul>
  24. 27. GERD- PPIs <ul><li>Administer prior to meals </li></ul><ul><li>Side effects-headache, diarrhea, abdominal pain </li></ul><ul><li>Long term safety </li></ul><ul><li>?gastric atrophy </li></ul><ul><li>?impaired B12 absorption </li></ul><ul><li>?increase in community acquired pneumonia </li></ul><ul><li>?decreased absorption of calcium- </li></ul><ul><li>osteoporosis </li></ul>
  25. 30. Suggested algorithm for treatment of GERD
  26. 31. GERD-Beyond Meds <ul><li>Antireflux surgery </li></ul><ul><li>Endoscopic treatment </li></ul>
  27. 32. Refractory GERD <ul><li>Failed medical management </li></ul><ul><li>Patient preference for surgery despite successful medical management </li></ul><ul><li>Complications of GERD </li></ul>
  28. 33. GERD-Antireflux Surgery <ul><li>Nissen fundoplication </li></ul><ul><li>complete (360 degree) wrap of stomach </li></ul><ul><li>around esophagus </li></ul><ul><li>Toupet fundoplication </li></ul><ul><li>partial (270 degree) wrap of stomach </li></ul><ul><li>around esophagus </li></ul>
  29. 35. GERD-Endoscopic Therapy <ul><li>Stretta-radiofrequency </li></ul><ul><li>Endocinch-endoscopic sewing </li></ul><ul><li>Full thickness plication </li></ul><ul><li>Enteryx-Injection of a nonresorbable polymer </li></ul>
  30. 37. Endocinch
  31. 39. Enteryx-Polymer injection
  32. 40. GERD-Summary <ul><li>Cost effective treatment </li></ul><ul><li>Complications of GERD </li></ul><ul><li>Newer treatments beyond meds </li></ul>
  33. 41. References <ul><li>1.Devault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterology 2005;100:190-200 </li></ul><ul><li>2.Heidelbaugh JJ,Nostrant TT et al. Management of Gastroesophageal Reflux Disease. Am Fam Physician 2003;68:1311-16 </li></ul><ul><li>3.Richter JE, Bradley LC.Psychophysiological interactions in esophageal diseases. Semin Gatrointest Dis 1995;7:169-84 </li></ul><ul><li>4.DaCosta LR. Value of a therapeutic trial to diagnose gastroesophageal reflux disease:step up versus step down therapy. Can J Gastroenter 1997;11(suppl B):788-818 </li></ul><ul><li>5.Van Pinxteren B, Numans ME et al. Short term treatment with proton pump inhibitors,H2-receptor antagonists and prokinetics for gastroesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2001;(4):CDO02095 </li></ul><ul><li>6.Inadomi JM, Jamal R et al. Step-down management of gastroesophageal reflux disease. Gastroenterology 2001;121:1095-100 </li></ul><ul><li>7.Up to Date On Line </li></ul><ul><li>8.Society of American Gastrointestinal Endoscopic Surgeons website- SAGES.org </li></ul>
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