Refractory heartburn


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How to manage a patient with refractory heartburn

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  • The non-erosive reflux disease (NERD) group, which accounts for most of the patients with GERD and demonstrates the lowest response rate to PPI once daily, is the main contributor for the PPI failure phenomenon.
  • It has been estimated that between 10% and 40% of patients with gastro-oeophageal reflux disease(GORD) fail to respond symptomatically, either partially or completely, to a standard dose proton pump inhibitor. What constitutes refractory GORD remains an area of controversy.Most investigators believe that only patients with GORD who exhibit partial or lack of response to PPIs twice daily should be considered as PPI failures.Other potential underlying mechanisms, such as reduced PPI bioavailability, rapid PPI metabolism and, specifically, mutations in the 2C19 isoform of cytochrome p450, PPI resistance, and Helicobacter pylori status have all been shown to play a limited role in PPI failure. Pill-induced oesophagitis, skin diseases with oesophageal involvement, Zollinger–Ellison syndrome, and achalasia are very unusual causes for PPI failure and are rarely confused withGORD alone.
  • Presently, much of the research that is conducted in the area of refractory GORD focuses primarily on weakly acidic reflux, duodenogastro-oesophageal reflux, and oesophageal hypersensitivity.However, it is highly likely that GORD symptoms due to weakly acidic or duodenogastro-oesophageal reflux in patients who failed PPI treatment are related to oesophageal hypersensitivity.
  • Presently, much of the research that is conducted in the area of refractory GORD focuses primarily on weakly acidic reflux, duodenogastro-oesophageal reflux, and oesophageal hypersensitivity.However, it is highly likely that GORD symptoms due to weakly acidic or duodenogastro-oesophageal reflux in patients who failed PPI treatment are related to esophageal hypersensitivity.
  • Subgroups of Endoscopy-Negative reflux disease (ENRD)2 distinctive subgroups exist- Nonerosive reflux disease (NERD) Functional heartburnThese groups are separated by the presence or absence of abnormal levels of acid reflux.
  • High failure rate (25%) of the wireless pH capsule- premature detachment- dropped signals- severe side effects
  • Using the wireless pH system, the 95th percentile for distal esophageal acid exposure for control subjects was 5.3%, a value higher than values reported in several although not all catheter-based system studies. The higher acid exposure threshold reported in healthy controls using the wireless pH system may be the consequence of less restriction in daily activities or the result of a thermal calibration error that existed in the pH catheter systems.The 48-h data could be interpreted using an average of the 2 days or only the 24-h period with the greatest acid exposure (worst day analysis). A significant increase in the sensitivity of pH testing and small decrease in specificity were evident when utilizingthe worst day data compared with either the initial 24-h or overall 48-h data in comparing controls with GERD patients.
  • High failure rate (25%) of the wireless pH capsule- premature detachment- dropped signals- severe side effects
  • A recent, multicenter study examined the impedance characteristics of 60 healthy subjects during 24-h ambulatory monitoring. Based on impedance values 5 cm above the LES, the median number of total reflux episodes per 24 h was 30, the majority of which occurred in the upright position.Approximately two-thirds of the episodes were acid and another third weakly acidic reflux. Weakly alkaline reflux was distinctly uncommon in this healthy cohort. Similar frequencies were recently reported from a multicenter European study. References:Shay S, Tutuian R, Sifrim D, et al. Twenty-four hour ambulatory simultaneous impedance and pH monitoring: A multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol 2004;99:1037–43.Zerbib F, Bruley des Barannes S, Roman S, et al. 24 hour ambulatory esophageal multichannel intraluminal impedance-pH in healthy European subjects. Gastroenterology 2005;128:A396.
  • Weakly acidic gastroesophageal reflux is the reflux of gastric contents into the esophagus with a pH between 4 and 7.Analyzed in a fashion similar to 24 h pH monitoring - Quantitative analysis - Qualitative analysis: SI or SAP
  • Duodenogastroesophageal reflux (DGER) is the reflux of duodenal contents through the stomach and into the esophagus.A recent study demonstrated that DGER was significantly more common (64%) than acid reflux (37%) in patients who continued to have GERD-related symptoms on either standard dose or double-dose PPI therapy. Patients with EE who did not respond to PPI treatment experienced a higher number of DGER episodes (35 vs 15.5) and longer exposure time to DGER (11.9% vs 6.3%) than NERD patients in whom PPI therapy failed.
  • Basal cell hyperplasia Not confirmedPapillary elongation Not confirmed
  • Basal cell hyperplasia and papillary elongation have been suggested as markers of the disorder.However, subsequent studies have not confirmed their diagnostic value.
  • It has been hypothesized that NAB is the underlying pathophysiologic mechanism responsible for refractory GERD.NAB events do not demonstrate a temporal relationship with reflux-related symptoms.
  • Dysphagia, sometimes presenting as acute food impaction, is almost always present in patients with eosinophilicoesophagitis. In contrast, only about a third (range, 10–43%) of these patients also report classic heartburn symptoms. It is very uncommon for patients with eosinophilicoesophagitis to report heartburn as the sole symptom.The relationship between eosinophilicoesophagitis and GORD is unknown, although a recent study ruled that acid or non-acid reflux is a significant contributor to the pathogenesis of eosinophilicoesophagitis. An overlap between eosinophilicoesophagitis and GORD has also been proposed where both disorders coincide in the same individual. Regardless, eosinophilicoesophagitis is a relatively uncommon disorder and is thus unlikely to be responsible for a significant portion of those who do not respond to PPI treatment. Moreover,the prevalence of eosinophilicoesophagitis in GORD patients unresponsive to PPIs is still unknown.
  • In many cases, patients also report dysphagia or have a history of food impaction.Both should serve as alarm symptoms and the impetus for immediate upper gastrointestinal endoscopy.In addition, the relationship between GERD and eosinophilicesophagitis has not been fully explored. It is also possible that the 2 unrelated diagnoses might coincide in the same patient.Overall, eosinophilicesophagitis is relatively uncommon and is thus unlikely to be responsible for a significant portion of those who do not respond to PPI treatment.
  • Various evaluative tools are used in patients who failed PPI therapy, but most appear to have a very low clinical value or still lack supportive evidence for their routine usage in this challenging patient population. In addition, some of the diagnostic tests are still limited to a few centers of excellence and thus are not available to many practicing physicians. At the end, physicians will determine referral patterns for additional testingversus empirical treatment, on the basis of local availability of relevant resources.
  • Various evaluative tools are used in patients who failed PPI therapy, but most appear to have a very low clinical value or still lack supportive evidence for their routine usage in this challenging patient population. In addition, some of the diagnostic tests are still limited to a few centers of excellence and thus are not available to many practicing physicians. At the end, physicians will determine referral patterns for additional testing versus empirical treatment, on the basis of local availability ofrelevant resources.
  • Upper endoscopy is commonly used in clinical practice to evaluate patients with GERD who failed PPI treatment. This clinical strategy has been endorsed by the American Society of Gastrointestinal Endoscopy (ASGE - 2007). Value of endoscopy in discovering GERD-related findings in patients with refractory GERD is very low because of predominance of NERD and functional heartburn patients among this group of patients & high efficacy of PPIs in healing erosive oesophagitis.
  • (GastrointestEndosc 2010;71:28-34.)Background: Failure of proton pump inhibitor (PPI) treatment in patients with heartburn is very common.Because endoscopy is easily accessible, it is commonly used as the first evaluative tool in these patients.Objective: To compare GERD-related endoscopic and histologic findings in patients with heartburn in whomonce-daily PPI therapy failed versus those not receiving antireflux treatment.Design: Cross-sectional study.Setting: A Veterans Affairs hospital.Patients: Heartburn patients from the GI outpatient clinic.Intervention: Recording of endoscopic results.Main Outcome Measurements: Endoscopic findings and association between PPI treatment failure andesophageal mucosal injury by using logistic regression models.Results: A total of 105 subjects (mean age 54.7 ± 15.7 years; 71 men, 34 women) were enrolled in the PPI treatment failure group and 91 (mean age 53.4 ± 15.8 years; 68 men, 23 women) were enrolled in the no-treatment group (P=not significant). Anatomic findings during upper endoscopy were significantly more common in the no-treatment group compared with the PPI treatment failure group (55.2% vs 40.7%, respectively; P=.04). GERD-related findings were significantly more common in the no-treatment group compared with the PPI treatment failure group (erosive esophagitis: 30.8% vs 6.7%, respectively; P< .05). Eosinophilicesophagitis was found in only 0.9% of PPI treatment failure patients. PPI treatment failure was associated with a significantly decreased odds ratio of erosive esophagitis compared with no treatment, adjusted for age, sex, and body mass index (adjusted odds ratio 0.11; 95%CI, 0.04-0.30).Conclusions: Heartburn patients in whom once-daily PPI treatment failed demonstrated a paucity of GERD related findings compared with those receiving no treatment. Eosinophilicesophagitis was uncommon in PPItherapy failure patients. Upper endoscopy seems to have a very low diagnostic yield in this patient population.
  • Surprisingly, more GERD patients who are refractory to PPI are referred today for antireflux surgery.the most common preoperative symptom under failure of medical anti-reflux treatment was regurgitation (54%).
  • The use of health-related quality of life (HRQoL) measures is becoming more frequent in clinical trials and health services research, both as primary and secondary outcomes. It is typically assessed by a self-completed questionnaire which asks a series of standardised questions about various aspects or facets of a person’s HRQoL. The Medical Outcomes Study 36-Item Short Form (SF-36) is the most commonly used HRQoL measure in the world today. It contains 36 questions measuring health across eight dimensions: physical functioning (PF); role limitation because of physical health (RP); social functioning (SF); vitality (VT); bodily pain (BP); mental health (MH); role limitation because of emotional problems (RE) and general health (GH). These eight dimensions are usually regarded as a continuous outcome and are scored on a 0–100 scale, where 100 indicates ‘good health’.
  • In many cases, esophageal impedance is not available to the practicing physician, and empirical therapy is used.
  • Refractory heartburn

    1. 1. Persistent heartburn in a patient on PPISamir Haffar M.D.Associate Professor of GastroenterologyAl-Mouassat University Hospital – Damascus – Syria
    2. 2. Clinical History – 136-year-old woman with 6-year history of heartburnSymptoms occurred from 3 times/day to 3 times/weekSymptoms occasionally awaken her from sleep during nightNo dysphagia, chest pain, epigastric pain, bloating, or vomitingGood appetite, no weight loss, denies smoking or drinking alcoholSocial worker, married, 2 toddlers at homeConsidered her work & her family life to be very stressfulUnremarkable physical examination except for borderline obesity
    3. 3. Clinical History – 2• Seen by her primary care physician: lifestyle modifications, loseweight, less busy work schedule, & H2RA twice daily• No improvement despite 2 months of therapy with H2RAUnable to lose weight or change her work schedule• Three months ago: PPI once daily half an hour before breakfast• PPI help during first 2 weeks, symptoms recurred with less severityShe takes antacids, OTC H2RA, & another PPI before bedtime
    4. 4. Persistent heartburn in a patient on PPI Definition of refractory GERD Putative mechanisms for refractory GERD Diagnostic options for refractory GERD Therapeutic approaches of refractory GERD Recommendations
    5. 5.  Definition of refractory GERD
    6. 6. What constitutes refractory GERD?• PPI one or twice daily Most investigators: bidSome investigators: qd• Duration 8 weeks in EE4 weeks in NERDPatients who failed to obtain satisfactory symptomaticresponse &/or complete esophageal healing after afull course of standard dose PPI (once a day)EE: Ersosive esophagitisNERD: Non Ersosive Reflux diseaseFass R et al. Aliment Pharmacol Ther 2005 ; 22 : 79 – 94.
    7. 7. Refractory GERD in each of the GERD groupsFass R et al. Aliment Pharmacol Ther 2005 ; 22 : 79 – 94.10 – 40% of patients fail to respond symptomatically,either partially or completely, to a standard dose PPI
    8. 8. Symptomatic response to PPI in NERDPPIs once daily for 4 weeksResponse correlated with extent of esophageal acid exposureAliment Pharmacol Ther 2000 ; 14 : 597 – 602.
    9. 9. Healing failure in patients with EEPPI qd for 8 weeksRichter JE et al. Am J Gastroenterol 2001 ; 96 : 3089 – 98.Patients might continue to report GERD symptoms despitecomplete healing of esophageal mucosa (up to 15%)
    10. 10.  Putative mechanisms for refractory GERD
    11. 11. Underlying mechanisms for persistentheartburn despite treatment with PPIsFass R & Sifrim D. Gut 2009 ; 58 : 295 – 309.10 – 40 % of patients
    12. 12. • Non compliance• Improper dosing time• Reduced PPI bioavailability• Rapid PPI metabolism• PPI resistancePutative mechanisms for failure of PPIRelated to PPIsFass R. Clin Gastroenterol Hepatol 2008 ; 6 : 393 – 400.Unrelated to PPIs• Weakly acidic or alcaline reflux• Bile reflux (DGER)• Esophageal hypersensitivity• Nocturnal reflux• HP infection• Delayed gastric emptying• Eosinophilic esophagitis• Psychological co-morbidity• Others (unrelated to GERD)
    13. 13. Non complianceMost common cause for PPI failure• GERD is a symptom-driven disease• By end of 6 months, 30% of patients still consume PPIs• Factors of compliance Presence or absence of symptomsSeverity of symptomsPersonal preference• Compliance should be assessed in all patients withrefractory GERD prior to ordering any evaluative test
    14. 14. Dosing time of PPIsAliment Pharmacol Ther 2000 ; 14 : 1267 – 1272.21 volunteers taking PPI each morningEither 15 min before breakfast or without food or drinkOn day 7, intragastric pH-metry from 8:00 to 16:00 ( 8-h period)17.2%IQR: 4.6 – 45.542.0%IQR: 31.4 – 48.8P ˆ= 0.01
    15. 15. PPIs should be taken 30 minprior to a meal
    16. 16. • Non compliance• Improper dosing time• Reduced PPI bioavailability• Rapid PPI metabolism• PPI resistancePutative mechanisms for failure of PPIRelated to PPIsFass R. Clin Gastroenterol Hepatol 2008 ; 6 : 393 – 400.Unrelated to PPIs• Weakly acidic or alcaline reflux• Bile reflux (DGER)• Esophageal hypersensitivity• Nocturnal reflux• HP infection• Delayed gastric emptying• Eosinophilic esophagitis• Psychological comorbidity• Others (unrelated to GERD)
    17. 17. Esophageal pH monitoring• Catheter esophageal pH monitoringWireless esophageal pH monitoring (Bravo capsule)• Quantitative (DeMeester) & qualitative analysis (SI – SAP)• off PPIs Test if initial diagnosis correcton PPIs Test if symptoms due to residual acid (PPIs bid)• Positive pH Heartburn related to acid refluxNegative pH, positive SI Heartburn related to acid refluxNegative pH, negative SI Heartburn not related to acid reflux
    18. 18. 24 h catheter esophageal pH monitoring5 cm above LES
    19. 19. Normal 24 h esophageal pH monitoringQuantitative analysisQualitative analysisBremner CG et al. Esophageal disease & testing. Taylor & Francis Group, 2005.
    20. 20. Composite scoring systemsJohnson & DeMeester is the most commonly usedPercentage of total time pH < 4Percentage of upright time pH < 4Percentage of supine time pH < 4Number of reflux episodesNumber of reflux episodes >5 minLongest reflux episodeDeMeester scoreNormal ≤ 14,72
    21. 21. Mean SD Median Minimum Maximum 95th %Total time at pH < 4 (%) 1.5 1.4 1.2 0 6.0 4.5Upright time at pH< 4 (%) 2.2 2.3 1.6 0 9.3 8.4Supine time at pH< 4 (%) 0.6 1.0 0.1 0 4.0 3.5Number or reflux episodes 19.0 12.8 16.0 2.0 56.0 46.9Number of episodes > 5 min 0.8 1.2 0 0 5.0 3.5Longest episode (min) 6.7 7.9 4.0 0 46.0 19.8Composite score 6.0 4.4 5.0 0.4 18.0 14.7Normal values of DeMeester’s score50 healthy volunteersDeMeester TR et al. Ann Surg 1976 ; 184 : 459 – 470.
    22. 22. Qualitative analysisSymptom–reflux correlation• Symptom index: Positive if ≥ 50%• Symptom sensitivity index: Positive if > 10 %• Symptom association probability Positive if > 95%Determine relationship between heartburn episodes & acidreflux events, regardless if pH test is normal or abnormal
    23. 23. Percentage of total time pH < 4Normal values• Off therapy5 cm above LES20 cm above LES 1 %Periods of meals or acidic beverages excluded• On therapy5 cm above LES20 cm above LES ?* Based on 95% CI obtained in healthy subjects treated with omeprazole 40 mg qdKuo B et al. Am J Gastroenterol 1996 ; 91 : 1532 – 8.4 – 5.5 %1.6 – 4 %*
    24. 24. Abnormal acid exposure time in heartburnDisease Percentage of total time pH < 4Barrett’s esophagus 93 %* ENRD Endoscpic Negative Reflux Disease* *NERD Non Erosive Reflux DiseaseErosive esophagitis 75 % (in one study)ENRD*NERD**Functional heartburn- SI > 50%- SI < 50%50 %100 %0 %Hypersensitive esophagusNon acid reflux or motor event
    25. 25. 24 hour pH monitoring is not thegold standard for diagnosis of GERD
    26. 26. Bravo system (Medtronics)Esophageal Probe25 x 6 x 5.5 mmBatterypHelectrodeSuctionchamberRadiotransmitterDelivery systemReceiver100 x 70 x 30 mm - 165 g
    27. 27. Wireless esophageal pH monitoringBravo capsule – 48 hoursGastrointest Endoscopy Clin N Am 2005 ; 15 : 307 – 318.Patients might have normal test on day 1 & abnormal test on day 2Increase sensitivity to detect symptoms correlated with acid refluxMore studies needed in patients with refractory GERD
    28. 28. Bravo normal values50 asymptomatic volunteers1st 24 h 2nd 24 hMean(+ SD)95thpercentileMean(+ SD)95thpercentile% total time at pH < 4 1.79 (2.16 5.89 1.78 (1.78) 5.64% upright time at pH < 4 2.45 (3.14) 7.81 2.54 (2.57) 7.46% supine time at pH < 4 0.37 (1.18) 1.58 0.34 (1.28) 1.29Number of reflux episodes 21.2 (18.5) 55.30 22.3 (19.8) 56.15No of reflux episodes >5 min 0.62 (1.21) 3.55 0.75 (1.15) 3.00Longest reflux episode 3.79 (4.31) 11.23 5.95 (4.52) 17.03DeMeester score 6.02 (4.82) 15.93 5.95 (4.52) 15.48
    29. 29. pH testing in refractory GERDVery few studies• Catheter pH monitoring1PPI qd Limited value (normal test in 70%)PPI bid Non-contributory value (normal test in 96%)• Wireless pH monitoring2 days: Normal test on both days in 65%4 days3: More studies neededHigh failure rate: 25%1 Charbel S et al. . Am J Gastroenterol 2005 ; 100 : 283 – 9.2Hirano I et al. Clin Gastroenterol Hepatol 2005 ; 3 : 1083 – 8.
    30. 30. Multichannel Intraluminal ImpedanceAntegrade bolus movement during swallowingProgression of impedance from proximal to distalGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
    31. 31. Multichannel Intraluminal ImpedanceRetrograde bolus movement observed in refluxProgression of impedance from distal to proximalGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
    32. 32. Advantages of MII• Direction of bolus Anterograde – retrograde• Content of refluxate Liquid – Gas – Mixed• Height of refluxate Related to volume of refluxate• pH characteristics Acid reflux(combined MII-pH) Weekly acid refluxWeekly alkaline refluxAcid re-reflux
    33. 33. Combined MII-pH probe• Impedance orifices3, 5, 7, 9, 15, & 17 cm from the tip• pH orifice5 cm from the tip• Ө MII-pH probe = Ө pH probeDo not change patient comfortBremner CG et al. Esophageal disease & testing.Taylor & Francis Group, NY, 1st edition, 2005.
    34. 34. “Sleuth” monitor – SandhillMultichannel Intraluminal Impedance with pH sensor“Sleuth” monitor attached to the catheter& worn around a belt during the recording period
    35. 35. • Analysis similar to esophageal pH monitoring- Quantitative analysis- Qualitative analysis: SI – SSI – SAP• Healthy: Total no of reflux: 40 per 24 h1/3 acid & 2/3 weakly acidic or alkaline• Negative study rules out GERD as cause of symptomsEsophageal MII-pH monitoringMost sensitive method for reflux detection
    36. 36. GERD classification by combined MII-pH• Acid refluxReflux with drop of pH from above 4.0 to below 4.0• Superimposed acid reflux (Acid re-reflux)Acid reflux occurs while pH < 4.0• Weakly acidic refluxReflux results in esophageal pH between 4.0 & 7.0• Weakly alkaline refluxReflux with nadir esophageal pH does not drop < 7.0Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
    37. 37. Combined MII-pH of the esophagusFass R & Sifrim D. Gut 2009 ; 58 : 295 – 309.Weakly acidic reflux4 ≤ pH < 7Weakly alkaline refluxpH ≥ 7
    38. 38. MII-pH in refractory GERD• Shift from acidic reflux to weakly acidic refluxRegurgitation become predominant symptom• off PPI Little value when compared with pH (10%)on PPI Improved diagnostic yield by 20%• Positive SI for acid reflux 10%Positive SI for non-acid reflux 37%Mainie I et al. Gut 2006 ; 55 : 1398 – 402.Zerbib F et al. Am J Gastroenterol 2006 ; 101 : 1956 – 63.
    39. 39. Bilitec recorder*Assess bile reflux by using bilirubin as surrogate marker* Medtronic, Minneapolis, MN, USA
    40. 40. Esophageal BilitecMust be accompanied by 24 h esophageal pH• Fiberoptic probe to detect bilirubin (450 nm absorption)• Presented as per cent time bilirubin absorbance > 0.14• Progressive increase in DGOR across spectrum of GERDParticularly high prevalence in patients with Barrett’s• Medtronic stops commercialization of the product
    41. 41. Esophageal pH & Bilitec studyMaximal bile reflux in the esophagus during supine periodBremner CG et al. Esophageal disease & testing. Taylor & Francis Group, 2005.Limited evidence of increase in DGER in refractory GERD
    42. 42. % of time with bilirubin absorbance > 0.14Duodeno-gastro-esophageal refluxVaezi MF et al. Gastroenterology 1996 ; 111 : 1192 – 9.0.4%3.2%14.6%23%46%
    43. 43. Visceral hypersensitivityNot specifically studied in refractory GERD• Most patients have NERD or functional heartburn• Heartburn associated with weakly acidic reflux• Lower perception thresholds for painBalloon esophageal distentionElectrical stimulation• Dilated intercellular spacesPromotes higher activation of sensory nerve endings
    44. 44. Dilated intercellular spaces (DIS)• Higher activation of sensory nerve endings• Nonspecific Asymptomatic subjectsCandida infection of esophagusFood allergyEosinophilic oesophagitisEsophageal cancer• Disappearance of DIS & symptoms resolution after PPI• NERD patients refractory to PPI have persistence of DIS
    45. 45. Dilated intercellular spacesRabbit oesophageal mucosa at electron microscopyFarre R et al. Gut 2008 ; 57 :1366 – 74.Acid-pepsin solution at pH 5.0Acid-pepsin solution at pH 5.0plus deoxycholic acid 2 mmol/l
    46. 46. Nocturnal acid breakthroughCombined esophageal & gastric 24 h pH monitoringGastric pH < 4 for ≥ 60 min despite twice daily PPIGastrointest Endoscopy Clin N Am 2005; 15: 289 - 306.75% of GERD patients & healthy subjects on PPI bidNo correlation between NAB & nocturnal GERD symptoms
    47. 47. Delayed gastric emptying• Few studies evaluates frequency of gastric emptyingin refractory GERD• Rapidly growing number of patients with DM & thoseusing narcotics for pain syndrome might soon makegastroparesis one of the leading causes of PPI failure
    48. 48. Diagnosis of eosinophilic esophagitisRelatively uncommon disorder• Clinical symptoms of esophageal dysfunction:Dysphagia, food impaction, refractory GERD, chest pain• 15 eosinophils in 1 high-power field• Lack of responsiveness to high-dose PPIor normal pH monitoring of distal esophagusFuruta GT et al. Gastroenterology 2007 ; 133 : 1342 – 1363.
    49. 49. Endoscopic images of eosinophilic esophagitisLinear furrows &adherent white exudatesConcentric ringsSmall calibre esophaguswith strictureMucosal laceration fromDiagnostic endoscopy
    50. 50. Eosinophilic esophagitisThe ringed esophagusHiatus herniaLower esophageal ringAdjacent ringZimmerman SL et al. Radiology 2005 ; 236 : 159 – 165.Most patients have esophageal strictureswith distinctive ring-like indentationsSmooth stricture withdistinctive rings
    51. 51. Psychological comorbidityPatients with poor symptom-reflux correlationexhibit significant psychosocial morbidities• High level of anxiety• Hysteria• Depression
    52. 52. Other diseases unrelataded to GERDRarely confused with GERD• Pill-induced esophagitis• Skin diseases with esophageal manifestations• Zollinger-Ellison syndrome• Achalasia
    53. 53.  Diagnostic options for refractory GERD
    54. 54. Diagnostic techniques for refractory heartburn• UGI Endoscopy Low diagnostic yield• pH testing PPI qd: limited valuePPI bid: non-contributory value• MII-pH Best diagnostic tool on PPI• Bilitec 2000 Limited evidence
    55. 55. UGI endoscopyFirst test used in clinical practice for refractory GERD• Normal endoscopy (most frequent)• Esophageal erosions• Pill-induced esophagitis• Infectious esophagitis• Zollinger-Ellison syndrome• Eosinophilic esophagitisVery low diagnostic yield if no alarm symptomsASGE guidelines. Gastrointest Endosc 2007 ; 66 : 219 – 24.
    56. 56. Erosive esophagitis in refractory GERD & untreated patientsPoh CH et al. Gastrointest Endosc 2010 ; 71 : 28 – 34.OR of erosive esophagitis in refractory GERD: 0.11 (95% CI: 0.04-0.30)Eosinophilic esophagitis: 0.9% of refractory GERDCross-sectional study105 refractory GERD – 91 untreated patints
    57. 57.  Therapeutic approaches of refractory GERD
    58. 58. Therapeutic approaches of refractory GERD• Compliance & dosing time• Lifestyle modifications• Proton-Pump Inhibitors (PPI)• H2RA at bedtime• Baclofen• Promotility drugs & bile acid binders• Pain modulators• Endoscopic treatment for GERD• Antireflux surgery• Alternative medicineFirst managementStandard of care
    59. 59. Compliance & proper dosing timeEvaluation of proper compliance and adequate dosingtime should be the first management when assessingpatients with heartburn who are not responding to PPIsbefore instituting any other intervention
    60. 60. Lifestyle modifications• Only weight loss and elevation of the bed head areeffective in improving GERD• Insufficient data to support other lifestyle modificationsKaltenbach T et al. Arch Intern Med 2006 ; 166 : 965 – 71.Recent systematic review of all publicationsIt is reasonable to recommend avoidance of specificlifestyle activities identified by patients or physiciansto trigger GERD-related symptoms
    61. 61. Proton pump inhibitors• Switching to another PPI• Doubling the PPI dose½ hour before breakfast & before dinnerIncrease in overall symptom relief by 25%No evidence for further escalation of PPI doseTwo therapeutic strategies“Standard of care”
    62. 62. H2RAs at bedtime• Retrospective study: 56 pts – PPIs bid + H2RAs at bedtime*72% long term improvement in overall symptoms• Good experience accumulated so far with H2RA for GERDRackoff A et al. Dis Esophagus 2005 ; 18 : 370 – 3.• H2RAs might improve GERD-related symptoms in longterm in substantial number of patients• If clinical tolerance: H2RAs intermittently or on demand
    63. 63. TLESRPrimary mechanism of reflux in health & GERDThree characteristics: Non-swallow induced Prolonged Triggered by fundic distension
    64. 64. Baclofen*TLESR reducers• Mechanisms Reduced reflux episodes by 40%Increased LES basal pressureAccelerated gastric emptying• Doses Up to 20 mg tid• Side effects Central nervous system side effectsSomnolence, confusion, tremblingImportant limiting factor in routine usage• Indications Weakly acidic reflux by MII-pHRegurgitation, or sour/ bitter taste in mouth* Gamma-aminobutyric acid B receptor agonists
    65. 65. Promotility drugs & bile acid bindersPromotility drugs• Attractive option in delayed gastric emptying• No available data in GERD patients who failed PPIsCholestyramine or sucralfate• Unclear if any of the currently available bile acid bindersare sufficiently efficacious to improve symptoms
    66. 66. Visceral pain modulators• No studies in GERD patients with refractory heartburn• Attractive option Most patients from NERD groupLack of weakly or acidic reflux• Tricyclic antidepressants, trazodone, & SSRIs• Used in non-mood-altering doses• Same recommendations for non-cardiac chest pain
    67. 67. Endoscopic treatment for GERDInteresting topic of investigation• Requirements: efficacy, safety & durability• Two promising techniquesRadiofrequency energy (Stretta) Refractory GERDEndoluminal fundoplication Candidate for surgery• Most studies open & uncontrolled with short-term results• Few RCTs with less impressive results than open trialsLouis H et al. Best Pract Res Clin Gastroenterol 2010 ; 24 : 969 – 979.
    68. 68. Stretta procedure• 109 patients refractory to PPI bid• Endoscopic esophagitis or abnormal pH testing• 4-years follow-up• Assessment: GERD HRQL questionnaireHeartburnSatisfactionPercent without PPI• Data on long-term follow-up (4 y): sustained improvementNoar MD et al. Gastrointest Endosc 2007 ; 65 : 367 – 72.
    69. 69. Anti-reflux surgery• Anti-reflux surgery in refractory GERD scarcely studied• Careful selection of patientsPositive symptom-reflux correlation in MII–pH on PPIsExcellent results for laparoscopic Nissen fundoplication• Postsurgical follow-up relatively shortMainie I et a. Br J Surg 2006 ; 93 : 1483 – 7.del Genio G et al. J Gastrointest Surg 2008 ; 12 : 1491 – 6.
    70. 70. Alternative medicineAcupuncture• 30 patients on PPI qdAcupuncture biw vs doubling PPI dose/4weekAssessment: GERD symptoms diary – HRQoL by SF 36Acupuncture more effective than doubling PPI dose• Additional studies needed to demonstrate value ofacupuncture in this clinical situationDickman R et al. Aliment Pharmacol Ther 2007; 26 : 1333 – 44.
    71. 71. Traditional Chinese Medicine acupuncturepoints used in the treatment protocol.Dickman R et al. Aliment Pharmacol Ther 2007; 26 : 1333 – 44.Per.6 NeiguanSt.36 ZusanliCV12 ZhangwanCV17 ShanzhongLiv.3 TaichongSp.9 Yinlingquan
    72. 72. Health-related quality of lifeAssessment by Short Form 36HRQol assessed by SF-36SF-36 dimensions scored on a 0 (poor) to 100 (good) health scale
    73. 73.  Recommendations
    74. 74. RecommendationsPatient failed full course of PPI once a day• Excluding poor compliance & dosage timing• Switch to another PPI or doubling the PPI dose2-month course of treatment• Maintenance treatment if asymptomatic on PPI bidSame PPI dose inducing remission – PPI qd considered• Lack of symptom improvement → 2 strategiesBased on MII-pH on treatmentEmpirical therapy
    75. 75. Management strategy based on MII-pHPositive for acid reflux (least common scenario)• Review compliance & dosage timing• H2RA at bedtimePositive for weakly acidic reflux• Baclofen Low dose & slow increase in dose approach• Surgery Carefully selected patientPositive SI in esophageal MII–pHNegative• Pain modulators Tricyclics, trazodone, and SSRISame recommendations for NCCP
    76. 76. Empirical therapy for refractory GERDMII-pH not available to many physiciansPatient’s predominant symptom might guide treatment• Heartburn H2RA at bedtime• Regurgitation or sour taste in mouth BaclofenAnti-reflux surgery• Still exhibits lack of response Pain modulatorsFass R. Clin Gastroenterol Hepatol 2008 ; 6 : 393 – 400.
    77. 77. Conclusion• Compliance & dosing time should be evaluated first in patientswith heartburn not responsive to PPI• In patients who failed PPI once daily, doubling PPI dose orswitching to another PPI are potential therapeutic strategies• UGI endoscopy has very limited value if no alarm symptoms• MII-pH monitoring on PPI provides best diagnostic tool:Acid reflux H2RAWeakly acidic reflux Baclofen – Anti-reflux surgeryNo reflux Pain modulators
    78. 78. Thank You