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  • 1. Hard Core CME GERD Robert A.Solomon M.D. Associate Director Montgomery Family Practice Residency Program Norristown, PA
  • 2. GERD Objectives
    • Cost effective treatment
    • Complications of GERD
    • Beyond medications
  • 3. GERD
    • Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
    • American College of Gastroenterology
  • 4. GERD
  • 5. GERD Only 2-3 % of acid reflux events reach the level of perception by the patient
  • 6. GERD statistics
    • Monthly GERD symptoms- 44 % or 61 million Americans
    • Weekly GERD symptoms- 14 %
    • Daily GERD symptoms- 7 %
  • 7. GERD etiology
  • 8. GERD Diagnosis
    • Symptoms
    • Heartburn (pyrosis)
    • Regurgitation-especially after large meal
    • Aggravated by recumbency/bending over
    • Relieved with antacids
    • Difficult cases
    • 24 hr pH monitoring
  • 9.  
  • 10. Atypical GERD Presentations
    • Asthma
    • Chest pain
    • Chronic cough
    • Recurrent laryngitis
    • Recurrent sore throat
    • Globus sensation
  • 11. GERD Alarm Symptoms
    • Dysphagia
    • Early satiety
    • GI bleeding
    • Iron deficiency anemia
    • Odynophagia
    • Vomiting
    • Weight loss
  • 12. GERD-Etiology of Complications
  • 13. GERD Complications Esophagitis
  • 14. GERD-Etiology of Complications
  • 15. GERD-Barrett’s Esophagus Normal endoscopy Barrett’s esophagus
  • 16. Barrett’s Esophagus
    • Progression to adenocarcinoma of esophagus
    • 0.2-2 % annual incidence of CA in Barrett’s
    • Aggressive acid suppression (high dose PPI) may not lead to regression in transformation to malignancy
    • Surveillance endoscopy- looking for dysplasia-intervals are controversial
  • 17. Esophageal Stricture
  • 18. Esophageal Stricture Balloon dilator Stricture Balloon Post dilation
  • 19. Complications of GERD
    • Reflux induced asthma
    • Laryngeal and tracheal stenosis
    • Laryngeal cancer
  • 20. Treatment of GERD
    • Lifestyle modifications
    • Antacids
    • Histamine-2 receptor antagonists
    • Proton pump inhibitors
    • Anti-reflux surgery
    • Endoscopic treatment
  • 21. GERD-Lifestyle Modifications
    • Elevate head of bed
    • Decrease fat intake
    • Stop smoking
    • Avoid lying down 3 hrs post prandially
    • Avoid chocolate, alcohol, peppermint, coffee, ?onions/garlic= all lower LES pressure
  • 22. GERD-Antacids
    • Good for milder forms of GERD
    • Gaviscon-antacid/alginic acid may be superior to antacid alone
  • 23.  
  • 24. GERD H2 Blockers
    • Multiple trials showed faster healing vs. placebo of erosive esophagitis
    • Four available-cimetidine (Tagamet),famotidine (Pepcid), nizatidine (Axid), ranitidine (Zantac)-all equally effective
    • Side effects-drug interactions with cimetidine, confusion in elderly,rare cytopenias, elevated LFTs, gynecomastia
  • 25.  
  • 26. GERD- PPIs
    • Proton pump inhibitors provide the most rapid symptomatic relief
    • Five available-esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex)
    • All are generally equal
  • 27. GERD- PPIs
    • Administer prior to meals
    • Side effects-headache, diarrhea, abdominal pain
    • Long term safety
    • ?gastric atrophy
    • ?impaired B12 absorption
    • ?increase in community acquired pneumonia
    • ?decreased absorption of calcium-
    • osteoporosis
  • 28.  
  • 29.  
  • 30. Suggested algorithm for treatment of GERD
  • 31. GERD-Beyond Meds
    • Antireflux surgery
    • Endoscopic treatment
  • 32. Refractory GERD
    • Failed medical management
    • Patient preference for surgery despite successful medical management
    • Complications of GERD
  • 33. GERD-Antireflux Surgery
    • Nissen fundoplication
    • complete (360 degree) wrap of stomach
    • around esophagus
    • Toupet fundoplication
    • partial (270 degree) wrap of stomach
    • around esophagus
  • 34.  
  • 35. GERD-Endoscopic Therapy
    • Stretta-radiofrequency
    • Endocinch-endoscopic sewing
    • Full thickness plication
    • Enteryx-Injection of a nonresorbable polymer
  • 36.  
  • 37. Endocinch
  • 38.  
  • 39. Enteryx-Polymer injection
  • 40. GERD-Summary
    • Cost effective treatment
    • Complications of GERD
    • Newer treatments beyond meds
  • 41. References
    • 1.Devault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterology 2005;100:190-200
    • 2.Heidelbaugh JJ,Nostrant TT et al. Management of Gastroesophageal Reflux Disease. Am Fam Physician 2003;68:1311-16
    • 3.Richter JE, Bradley LC.Psychophysiological interactions in esophageal diseases. Semin Gatrointest Dis 1995;7:169-84
    • 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
    • 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
    • 6.Inadomi JM, Jamal R et al. Step-down management of gastroesophageal reflux disease. Gastroenterology 2001;121:1095-100
    • 7.Up to Date On Line
    • 8.Society of American Gastrointestinal Endoscopic Surgeons website- SAGES.org