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  • --distinction between normal and GERD is blurred because some degree of reflux is physiologic is all folks Physiologic—postprandially, short lived, asymptomatic, not during sleep Pathologic—symptoms or mucosal injury and often with nocturnal symptoms
  • --At level of diaphragmatic hiatus—main deterrant to reflux --disruption due to –review slide--multifactorial
  • --gerd related chest pain may mimic angina—squeezing/burning, substernal, radiates to back, neck, jaw, arms. Minutes to hours. After meals, awakens patient from sleep, exacerbated by emotional stress --water brash—hypersalivation—heartburn and regurg of sour fluid or tasteless saliva into mouth --globus—lump in throat irrespective of swallowing --odynophagia—esophageal ulcer --nausea—infrequent --hrt burn 70-85%//regurg 60%//dysphagi 15-20%//angina 33%//asthma 15-20%
  • --heartburn +/- regurgitation high specificity, low sensitivity
  • --need further eval if any present—egd--
  • Once established h&p dx and no alarm symptoms can proceed with dx/therapeutic trial of tx.
  • --if started with or changed to --prilo 40 qd x 14d as specific/sensitive as pH monitor --remember only works on active pumps. Take 30-60 min prior to eating
  • --if trial of med did not work or if alarm symptoms or long term 5yrs need egd 1a evidence—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia --50-70% of patient’s with gerd will have a neg egd.
  • --Transnasal catheter or a wireless capsule shaped device affixed to distal esophagus --cather positioned 5cm above manometrically defined upper limit of les --capsul attached 6cm proximal to endoscopically defined squamocolumnar jxn --if mucosal changes—have dx and do not need 24hph.
  • --Tums, rolaids, maalox --$1 billion in yearly expenditures --aluminum/calcium—constipation Mag--diarrhea
  • --otc dose uniformly half of standard lowest prescription dose --similar clinical efficacy
  • --no significant differences in symptomatic tx of GERD or healing of erosive esophagitis 1a evidence --works only on active pumps—take 30-60min prior to meals --long-term tx generally benefits outweigh risks
  • candidacy --esophagitis—by egd --need normal manometry/motility --partial response to acid suppression --reduce hh, repair diaphragm, strengthen ge jxn—antireflux barrier --75-90% effective at alleviating hrtburn/regurg --better at helping with hrtburn/regurg than atypical sx
  • --dysphagia, odynophagia, early satiety, gi bleed, anemia, vomit, wt loss
  • --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --ulcerations in 2-7%
  • 4-20% of patients
  • --1950—Norman Barrett --10-15% --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --RFs—male, smoker, age, obese
  • Adenoca with barretts 0.5%/yr--------without barretts 0.07%/yr
  • --alarm symptoms—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia
  • 4

    1. 1. Gastroesophageal Reflux Disease Howard J. McGowan, Maj, USAF, MC
    2. 2. Objectives <ul><li>Definition of GERD </li></ul><ul><li>Epidemiology of GERD </li></ul><ul><li>Pathophysiology of GERD </li></ul><ul><li>Clinical Manisfestations </li></ul><ul><li>Diagnostic Evaluation </li></ul><ul><li>Treatment </li></ul><ul><li>Complications </li></ul>
    3. 3. Definition <ul><li>American College of Gastroenterology (ACG) </li></ul><ul><ul><li>Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus </li></ul></ul><ul><ul><li>Often chronic and relapsing </li></ul></ul><ul><ul><li>May see complications of GERD in patients who lack typical symptoms </li></ul></ul>
    4. 4. Physiologic vs Pathologic <ul><li>Physiologic GERD </li></ul><ul><ul><li>Postprandial </li></ul></ul><ul><ul><li>Short lived </li></ul></ul><ul><ul><li>Asymptomatic </li></ul></ul><ul><ul><li>No nocturnal sx </li></ul></ul><ul><li>Pathologic GERD </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Mucosal injury </li></ul></ul><ul><ul><li>Nocturnal sx </li></ul></ul>
    5. 5. Epidemiology <ul><li>About 44% of the US adult population have heartburn at least once a month </li></ul><ul><li>14% of Americans have symptoms weekly </li></ul><ul><li>7% have symptoms daily </li></ul>
    6. 6. Pathophysiology <ul><li>Primary barrier to gastroesophageal reflux is the lower esophageal sphincter </li></ul><ul><li>LES normally works in conjunction with the diaphragm </li></ul><ul><li>If barrier disrupted, acid goes from stomach to esophagus </li></ul>
    7. 7. Clinical Manisfestations <ul><li>Most common symptoms </li></ul><ul><ul><li>Heartburn—retrosternal burning discomfort </li></ul></ul><ul><ul><li>Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions </li></ul></ul>
    8. 8. Clinical Manisfestations <ul><ul><li>Dysphagia—difficulty swallowing </li></ul></ul><ul><ul><li>Other symptoms include: </li></ul></ul><ul><ul><ul><li>Chest pain, water brash, globus sensation, odynophagia, nausea </li></ul></ul></ul><ul><ul><li>Extraesophageal manifestations </li></ul></ul><ul><ul><ul><li>Asthma, laryngitis, chronic cough </li></ul></ul></ul>
    9. 9. Diagnostic Evaluation <ul><ul><li>If classic symptoms of heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated </li></ul></ul>
    10. 10. Alarms <ul><ul><li>Alarm Signs/Symptoms </li></ul></ul><ul><ul><ul><li>Dysphagia </li></ul></ul></ul><ul><ul><ul><li>Early satiety </li></ul></ul></ul><ul><ul><ul><li>GI bleeding </li></ul></ul></ul><ul><ul><ul><li>Odynophagia </li></ul></ul></ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul><ul><ul><ul><li>Weight loss </li></ul></ul></ul><ul><ul><ul><li>Iron deficiency anemia </li></ul></ul></ul>
    11. 11. Trial of Medications <ul><li>H2RA or PPI </li></ul><ul><ul><li>Expect response in 2-4 weeks </li></ul></ul><ul><ul><li>If no response </li></ul></ul><ul><ul><ul><li>Change from H2RA to PPI </li></ul></ul></ul><ul><ul><ul><li>Maximize dose of PPI </li></ul></ul></ul>
    12. 12. Trial of Medications <ul><li>If PPI response inadequate despite maximal dosage </li></ul><ul><ul><li>Confirm diagnosis </li></ul></ul><ul><ul><ul><li>EGD </li></ul></ul></ul><ul><ul><ul><li>24 hour pH monitor </li></ul></ul></ul>
    13. 13. Esophagogastrodudenoscopy <ul><li>Endoscopy (with biopsy if needed) </li></ul><ul><ul><li>In patients with alarm signs/symptoms </li></ul></ul><ul><ul><li>Those who fail a medication trial </li></ul></ul><ul><ul><li>Those who require long-term tx </li></ul></ul><ul><li>Lacks sensitivity for identifying pathologic reflux </li></ul><ul><li>Absence of endoscopic features does not exclude a GERD diagnosis </li></ul><ul><li>Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD </li></ul>
    14. 14. pH <ul><li>24-hour pH monitoring </li></ul><ul><ul><li>Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes </li></ul></ul><ul><ul><li>Trans-nasal catheter or a wireless, capsule shaped device </li></ul></ul>
    15. 15. Patient with heartburn Iniate tx with H2RA or PPI H2RA taken BID Good response Frequent relapses On demand tx PPI taken QD Good response Maintenance therapy with lowest effective dose Symptoms persist Consider EGD if risk factors present ( > 45, white, male and > 5 yrs of sx) Increase to max dose QD or BID Good response Confirm diagnosis EGD, ph monitor No Yes Yes No Yes Yes No No
    16. 16. GERD vs Dyspepsia <ul><li>Distinguish from Dyspepsia </li></ul><ul><ul><li>Ulcer-like symptoms-burning, epigastric pain </li></ul></ul><ul><ul><li>Dysmotility like symptoms-nausea, bloating, early satiety, anorexia </li></ul></ul><ul><li>Distinct clinical entity </li></ul><ul><li>In addition to antisecretory meds and an EGD need to consider an evaluation for Helicobacter pylori </li></ul>
    17. 17. Treatment <ul><li>Goals of therapy </li></ul><ul><ul><li>Symptomatic relief </li></ul></ul><ul><ul><li>Heal esophagitis </li></ul></ul><ul><ul><li>Avoid complications </li></ul></ul>
    18. 18. Better Living <ul><li>Lifestyle modifications </li></ul><ul><ul><li>Avoid large meals </li></ul></ul><ul><ul><li>Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermint </li></ul></ul><ul><ul><li>Decrease fat intake </li></ul></ul><ul><ul><li>Avoid lying down within 3-4 hours after a meal </li></ul></ul><ul><ul><li>Elevate head of bed 4-8 inches </li></ul></ul><ul><ul><li>Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS) </li></ul></ul><ul><ul><li>Avoid clothing that is tight around the waist </li></ul></ul><ul><ul><li>Lose weight </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul>
    19. 19. Treatment <ul><li>Antacids </li></ul><ul><ul><li>Over the counter acid suppressants and antacids appropriate initial therapy </li></ul></ul><ul><ul><li>Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly </li></ul></ul><ul><ul><li>More effective than placebo in relieving GERD symptoms </li></ul></ul>
    20. 20. Treatment <ul><li>Histamine H2-Receptor Antagonists </li></ul><ul><ul><li>More effective than placebo and antacids for relieving heartburn in patients with GERD </li></ul></ul><ul><ul><li>Faster healing of erosive esophagitis when compared with placebo </li></ul></ul><ul><ul><li>Can use regularly or on-demand </li></ul></ul>
    21. 21. Treatment <ul><li>AGENT EQUIVALENT DOSAGE </li></ul><ul><li>DOSAGES </li></ul><ul><li>Cimetadine 400mg twice daily 400-800mg twice daily </li></ul><ul><li>Tagamet </li></ul><ul><li>Famotidine 20mg twice daily 20-40mg twice daily </li></ul><ul><li>Pepcid </li></ul><ul><li>Nizatidine 150mg twice daily 150mg twice daily </li></ul><ul><li>Axid </li></ul><ul><li>Ranitidine 150mg twice daily 150mg twice daily </li></ul><ul><li>zantac </li></ul>
    22. 22. Treatment <ul><li>Proton Pump Inhibitors </li></ul><ul><ul><li>Better control of symptoms with PPIs vs H2RAs and better remission rates </li></ul></ul><ul><ul><li>Faster healing of erosive esophagitis with PPIs vs H2RAs </li></ul></ul>
    23. 23. Treatment <ul><li>AGENT EQUIVALENT DOSAGE </li></ul><ul><li>DOSAGES </li></ul><ul><li>Esomeprazole 40mg daily 20-40mg daily </li></ul><ul><li>Nexium </li></ul><ul><li>Omeprazole 20mg daily 20mg daily </li></ul><ul><li>Prilosec </li></ul><ul><li>Lansoprazole 30mg daily 15-10md daily </li></ul><ul><li>Prevacid </li></ul><ul><li>Pantoprazole 40mg daily 40mg daily </li></ul><ul><li>Protonix </li></ul><ul><li>Rabeprazole 20mg daily 20mg daily </li></ul><ul><li>Aciphex </li></ul>
    24. 24. Treatment <ul><li>H2RAs vs PPIs </li></ul><ul><ul><li>12 week freedom from symptoms </li></ul></ul><ul><ul><ul><li>48% vs 77% </li></ul></ul></ul><ul><ul><li>12 week healing rate </li></ul></ul><ul><ul><ul><li>52% vs 84% </li></ul></ul></ul><ul><ul><li>Speed of healing </li></ul></ul><ul><ul><ul><li>6%/wk vs 12%/wk </li></ul></ul></ul>
    25. 25. Treatment <ul><li>Antireflux surgery </li></ul><ul><ul><li>Failed medical management </li></ul></ul><ul><ul><li>Patient preference </li></ul></ul><ul><ul><li>GERD complications </li></ul></ul><ul><ul><li>Medical complications attributable to a large hiatal hernia </li></ul></ul><ul><ul><li>Atypical symptoms with reflux documented on 24-hour pH monitoring </li></ul></ul>
    26. 26. Treatment <ul><li>Antireflux surgery candidates </li></ul><ul><ul><li>EGD proven esophagitis </li></ul></ul><ul><ul><li>Normal esophageal motility </li></ul></ul><ul><ul><li>Partial response to acid suppression </li></ul></ul>
    27. 27. Treatment <ul><li>Antireflux surgery </li></ul><ul><ul><li>Tenets of surgery </li></ul></ul><ul><ul><ul><li>Reduce hiatal hernia </li></ul></ul></ul><ul><ul><ul><li>Repair diaphragm </li></ul></ul></ul><ul><ul><ul><li>Strengthen GE junction </li></ul></ul></ul><ul><ul><ul><li>Strengthen antireflux barrier via gastric wrap </li></ul></ul></ul><ul><ul><ul><li>75-90% effective at alleviating symptoms of heartburn and regurgitation </li></ul></ul></ul>
    28. 28. Treatment <ul><li>Postsurgery </li></ul><ul><ul><li>10% have solid food dysphagia </li></ul></ul><ul><ul><li>2-3% have permanent symptoms </li></ul></ul><ul><ul><li>7-10% have gas, bloating, diarrhea, nausea, early satiety </li></ul></ul><ul><ul><li>Within 3-5 years 52% of patients back on antireflux medications </li></ul></ul>
    29. 29. Treatment <ul><li>Endoscopic treatment </li></ul><ul><ul><li>Relatively new </li></ul></ul><ul><ul><li>No definite indications </li></ul></ul><ul><ul><li>Select well-informed patients with well-documented GERD responsive to PPI therapy may benefit </li></ul></ul><ul><li>Three categories </li></ul><ul><ul><li>Radiofrequency application to increase LES reflux barrier </li></ul></ul><ul><ul><li>Endoscopic sewing devices </li></ul></ul><ul><ul><li>Injection of a nonresorbable polymer into LES area </li></ul></ul>
    30. 30. Complications <ul><li>Erosive esophagitis </li></ul><ul><li>Stricture </li></ul><ul><li>Barrett’s esophagus </li></ul>
    31. 31. Complications <ul><li>Erosive esophagitis </li></ul><ul><ul><li>Responsible for 40-60% of GERD symptoms </li></ul></ul><ul><ul><li>Severity of symptoms often fail to match severity of erosive esophagitis </li></ul></ul>
    32. 32. Complications <ul><li>Esophageal stricture </li></ul><ul><ul><li>Result of healing of erosive esophagitis </li></ul></ul><ul><ul><li>May need dilation </li></ul></ul>
    33. 33. Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Columnar metaplasia of the esophagus </li></ul></ul><ul><ul><li>Associated with the development of adenocarcinoma </li></ul></ul>
    34. 34. Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Acid damages lining of esophagus and causes chronic esophagitis </li></ul></ul><ul><ul><li>Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells </li></ul></ul><ul><ul><li>This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma </li></ul></ul>
    35. 35. Complications <ul><ul><li>Patient’s who need EGD </li></ul></ul><ul><ul><ul><li>Alarm symptoms </li></ul></ul></ul><ul><ul><ul><li>Poor therapeutic response </li></ul></ul></ul><ul><ul><ul><li>Long symptom duration </li></ul></ul></ul><ul><ul><li>“Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice </li></ul></ul><ul><ul><li>Many patients with Barrett’s are asymptomatic </li></ul></ul>
    36. 36. Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Manage in same manner as GERD </li></ul></ul><ul><ul><li>EGD every 3 years in patient’s without dysplasia </li></ul></ul><ul><ul><li>In patients with dysplasia annual to shorter interval surveillance </li></ul></ul>
    37. 37. Summary <ul><li>Definition of GERD </li></ul><ul><li>Epidemiology of GERD </li></ul><ul><li>Pathophysiology of GERD </li></ul><ul><li>Clinical Manisfestations </li></ul><ul><li>Diagnostic Evaluation </li></ul><ul><li>Treatment </li></ul><ul><li>Complications </li></ul>
    38. 38. <ul><li>?QUESTIONS? </li></ul>