This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses definitions, pathophysiology, epidemiology, clinical presentation, diagnostic tests including 24-hour pH monitoring and endoscopy, and treatment options including lifestyle modifications, medications like PPIs, and surgical procedures. Key recent advances mentioned include new diagnostic markers, multichannel intraluminal impedance pH monitoring, narrow-band imaging, and endoscopic assessment of mucosal impedance. Surgical treatments discussed are laparoscopic anti-reflux surgery and the Linx device, and recent studies comparing partial versus complete fundoplication and surgical versus medical therapy.
3. Gastroesophageal reflux
disease (GERD) : DEFINITION
“Symptoms or complications resulting
from the reflux of gastric contents into
the esophagus or beyond, into the oral
cavity (including larynx) or lung”
The American College of Gastroenterology (ACG) guidelines
Am J Gastroenterol 2016;108:308-328
5. Gasroesophageal reflux (GER)
Intragastric pressure is > high-
pressure zone of the distal
esophagus
LES resting pressure is too low :
Hypotensive LES
LES relax in the absence of
peristaltic contraction of esophagus:
Spontaneous LES relaxation
6. EPIDEMIOLOGY
Prevalence of GERD ranged from 18.1% to
27.8% in North America
8.8% to 25.9% in Europe
2.5% to 7.8% in East Asia
8.7% to 33.1% in the Middle East
Several longitudinal studies have shown a
significant increase in the prevalence of
GERD in the East
El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal
reflux disease: a systematic review. Gut 2017;63:871-880
7. RISK FACTORS
Obesity
Dietary fat intake or alcohol consumption
Ethnic predisposition:Caucasians
ethnicity
Helicobacter pylori infection
With an increase in obesity and Western
diet, the incidence of GERD is rising and
reported to be 10-20% of the population
8. CLINICAL PRESENTATION
Three phenotypic presentations of
GERD
Erosive esophagitis (EE)
Nonerosive reflux disease (NERD)
Barrett’s esophagus
El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the
epidemiology of gastro-oesophageal reflux disease: a systematic review.
Gut 2017;63:871-880
9. Erosive esophagitis : symptoms and
biopsy or visually proven erosion of the
esophagus is present
NERD : Pathologic esophageal acid
exposure is present without evidence of
erosion
Barrett Esophagus : Histologic change of
the distal esophageal mucosa from
normal squamous epithelium to columnar
configuration
10. Symptoms
Troublesome symptoms are defined as
Mild symptoms occurring 2 or more days
a week
• Moderate/severe symptoms occurring
more than once a week.
Vakil N, van Zanten S V., Kahrilas P, Dent J, Jones R, Global Consensus Group.
The Montreal Definition and Classification of Gastroesophageal Reflux Disease:
A Global Evidence-Based Consensus. Am J Gastroenterol. 2016
11. Typical Symptoms
Retrosternal burning sensation
(heartburn)
Perceived reflux of gastric contents
(regurgitation)
Water brash
13. Diagnosis
History and physical examination, noting
typical and atypical reflux symptoms
Most patients with typical symptoms receive
empiric treatment with a proton pump
inhibitor (PPI) ,do not undergo diagnostic
testing
Esophagoduodenoscopy (EGD) - initial
diagnostic test of choice in patients with
alarm symptoms
Dysphagia, odynophagia, anorexia, weight
loss and upper gastrointestinal bleed
15. 24-hour Ambulatory pH
monitoring
Quantifies distal esophageal acid
exposure
“gold standard” test
24-hour pH monitoring
Thin catheter is passed into
esophagus through patient’s nares
Dual –probe pH catheter ,two solid
state electrodes,spaced 10 cm apart
Detects fluctuation in pH b/w 2 and 7
16. Data collected from ambulatory
pH monitoring
Total no. of reflux episode(pH <4)
Longest episode of reflux
No. of episode lasting > 5 minutes
% of time spent in reflux in upright and
supine position
DeMeester score is calculated
Score > 14.7 defines abnormal distal
esophageal acid exposure
17. Esophageal Manometry
Most effective way to assess function of
esophageal body and the LES
Linear tracing of the pressure waves
Can exclude achlasia and identify
patient with ineffective esophageal
body peristalsis
“gold standard” for diagnosis of
Achalasia
18. Esophagoduodenoscopy
(EGD)
Essential for patient who are candidate
for LARS
Examine for mucosal injury , ulceration ,
peptic stricture, and Barrett esohagus
Esophagitis : several scoring system
Savary-Miller and Los Angeles ( LA)
classification
Peptic stricture and grade C and D
esophagitis is pathognomonic for GERD
19. Los Angeles classification
Grade A : 1 or more mucosal breaks no
longer than 5 mm, not extending between
two mucosal folds
Grade B : 1 or more mucosal breaks more
than 5 mm, not extending between two
mucosal folds
Grade C : 1 or more mucosal breaks that is
continuous between two mucosal folds but
involves <75% of the esophageal
circumference
Grade D : 1 or more mucosal breaks that is
continuous between two mucosal folds but
20. Barium esophagram
Provide detailed anatomic evaluation
of esophagus and stomach
Useful for preoperative evaluation
Can identify additional
gasroesophageal conditions
Hiatal hernia, esophageal diverticula ,
tumors , peptic strictures , achalasia ,
dysmotility and gastroparesis
21. Publisher: Taylor & Francis
Journal: Expert Review of Gastroenterology & Hepatology
DOI: 10.1080/17474124.2017.1309286
Article type: Review
Recent advances in diagnostic testing for
gastroesophageal reflux disease
Rishi D Naik1, Michael F Vaezi1
1Division of Gastroenterology, Hepatology, and Nutrition
Center for Swallowing and Esophageal Disorders
Vanderbilt University Medical Center
Expert Review of Gastroenterology &
Hepatology (2017)
22. Immunohistochemical markers
Proteinase-activated receptor -2
(PAR-2) over-expressed in both
erosive and non-erosive GERD
Interleukin-33, G-protein coupled
receptor 84, and triggering receptor
expressed on myeloid cells (TREM)-1
The role of any of the above markers as
diagnostic markers in GERD continues to
evolve
23. Multichannel intraluminal
impedance-pH monitoring
Requires an ambulatory monitoring with
insertion of the impedance catheter
Unlike traditional ambulatory pH
monitoring, impedance testing can detect
non-acidic reflux
Helps determine the extent of reflux
attempt to correlate these findings to
patients’ symptom
24. Narrow-band imaging
Uses spectral narrow band filter for the
visualization of mucosal patterns and
microvasculature
Allows increased contrast for better
enhancement to detect changes in the
microvasculature
NBI findings on endoscopy include
intrapapillary capillary loop dilatation,
microerosions, and vascularity
prominence at the squamocolumnar
junction
25. Endoscopic assessment of
mucosal impedance
Allow real time measurement during
endoscopy
Mucosal impedance (MI) is an
endoscopically placed probe that goes
through the working channel of the
endoscope that makes direct contact with
the mucosa to obtain measurements
26. Diagnostic modalities currently under
clinical investigation
The Endo Functional Luminal Imaging Probe system
(EndoFLIP - Crospon, Ltd., Galway, Ireland) -
dynamic measurements of gastroesophageal
distensibility;
Dx-pH measurement system (Respiratory Technology
Corp., San Diego, CA) -measures aerosolized acid
The pepsin lateral flow device or PEP-Test
(RDBiomed, Hull, UK) - a non-invasive test for
salivary pepsin
Confocal laser and volumetric endomicroscopy-
provide in vivo histologic imaging of mucosa surfaces
28. Lifestyle modifications
The first-line treatment
Raising head end of the bed
Avoiding meals within 3 hours of bedtime
Weight loss for patients with recent weight
gain or BMI >25
Avoidance of acidic foods, carbonated
beverages, alcohol, and tobacco
30. Proton Pump Inhibitors (PPI)
Considered the most effective
medical therapy for GERD
Profound and consistent acid
suppression
With typical symptoms , an 8 week
course of PPI is recommended
Demonstrate different levels of
satisfaction that range between 56%
to 100% as compared with other
antireflux medications
Sandhu DS and Fass R: Current Trends in the Management of
Gastroesophageal Reflux Disease 2017
31. Currently Available Proton Pump
Inhibitors
Omeprazole
Esomeprazole
Lansoprazole
Rabeprazole
Pantoprazole
Dexlansoprazole
Omeprazole with sodium bicarbonate
32. Several large scale studies : PPI
treatment is superior to H2RA treatment
for the symptomatic relief of both EE and
NERD patients
Recently, long-term safety of PPIs have
been called into question with some
evidence of increased infectious
complications and nutritional deficiencies
Sandhu DS and Fass R: Current Trends in the Management of
Gastroesophageal Reflux Disease 2017
33. • PPIs can provide symptom relief in ~
57% to 80% of patients with EE and
about 50% of the patients with NERD.
Healing of EE (all grades) can be
obtained in greater than 85% of GERD
patients undergoing treatment with a
standard dose PPI.
Current Trends in the Management of Gastroesophageal
Reflux Disease
Gut and Liver, Vol. 12, No. 1, January 2018, pp. 7-16
34. Candidates for Surgical
Therapy
Side effects from medical therapy
Poor compliance with medical therapy
Concern about or wish to discontinue
chronic medical therapy
Symptomatic with a large hiatal hernia
Regurgitation
Not interested in medical therapy
Abnormal pH test on maximum PPI dose
Symptoms correlate with nonacid reflux
while on maximum PPI dose
Current Trends in the Management of Gastroesophageal Reflux Disease Gut and
Liver, Vol. 12, No. 1, January 2018, pp. 7-16
35. SURGICAL MANAGEMENT
Laparoscopic antireflux surgery
(LARS)
Gastric Bypass
Linx reflux management system
Electrical Stimulation
Current Trends in the Management of Gastroesophageal Reflux Disease
Gut and Liver, Vol. 12, No. 1, January 2018, pp. 7-16
37. Creation of a partial
fundoplication
• Stomach is wrapped
180 to 270 degree
posterior aspect of
esophagus
Toupet
fundoplication
(Posterior)
• No need to disrupt
posterior attachment of
esophagus
• Fundus is folded over ant.
aspect of esophagus
(180 degree wrap)
Thal or Dor
fundoplication
(Anterior)
40. Operative complications and side
effects of antireflux surgery
Pneumothorax m/c intraoperative
complication yet reported in less than 2%
Gastric and esophageal injury 1 %
Spenic/liver injury or bleeding 2.3 %
Acute herniation
Postoperative ileus
SIDE EFFECTS
Bloating , Dysphagia
Sabiston textook of surgery, 2o th edn.
41. Partial versus Complete
Fundoplication
• Evaluated LNF & Toupet
Fundoplication
• At 1 year, no difference for
heart burn and regurgitation
• Dysphagia more frequent with
LNF
Booth et al,2010 (RCT)
• Evaluated Laproscopic
anterior,posterior and total
fundoplication
• Anterior Fundoplication a/w greater
risk of recurrent GERD
• LNF a/w greater risk of dysphagia,
bloating
Fein and
Seyfried,2011(reviewed 9
RCT)
42. Partial versus Complete
Fundoplication
• Compared LNF and Toupet
Fundoplication
• No d/f in patient satisfaction with
operation or perioperative
morbidity
• Patient with abnormal esophageal
motility, LNF a/w greater rate of
dysphagia
Shan et al, 2010
(reviewed 32
studies)
• Increased rate of postoperative
gas bloat , inability to
belch,dysphagia who underwent
LNF
• Toupet Fundoplication is the
treatment of choice,effective
GERD symptom control and fewer
Meta analysis by
Shan and
colleagues
43. Fundoplication
(Take home message based on
studies) In patients with GERD and esophageal
dysmotility,
partial fundoplication is preferred
Because Nissen fundoplication will lead
to greater postoperative dysphagia
Anterior Fundoplication provide less
durable control of GERD than posterior
and total fundoplication
44. Continued…
Despite numerous RCT and 2
metaanalysis, conflicting evidence about
the fundoplication that provide most
durable control of reflux and best side
effect profile
Because of heterogenicity in terms of
patient characteristics , patient selection ,
operative technique
Surgeons should perform the
fundoplication that they are most
comfortable performing
45. RCT comparing Surgical and
Medical Therapies for GERD
• ARS and PPI provided equal
symptom control
• ARS – more heart-burn free days
Anvari et
al, 2011
• ARS – good symptom control
after 10-year follow-up
Spechler
et al, 2016
• Treatment failure :
• PPI – 55% , ARS – 47 %
Lundell et
al , 2009
46. Gastric Bypass
Laparoscopic Roux-en-Y gastric bypass
American Society for Metabolic and
Bariatric Surgery (ASMBS) qualifications
with refractory or intolerant GERD.
BMI ≥40 , BMI ≥35, and at least two
obesity-related co-morbidities
Type II diabetes (T2DM), hypertension,
sleep apnea and other respiratory
disorders,
non-alcoholic fatty liver disease,
osteoarthritis, lipid abnormalities,
47. Linx reflux management
system
Consists of a series of titanium beads
with a magnetic core connected with
titanium wires to form a ring.
This ring is placed around the lower
end of the distal esophagus by
laparoscopy
Helps to augment the lower
esophageal sphincter and thus
prevent gastroesophageal reflux
Sandhu DS and Fass R: Current Trends in the Management of Gastroesophageal
Reflux Disease2017
49. Electrical Stimulation
Laparoscopic implantation of
electrodes in the lower esophageal
sphincter
(EndoStim LES Stimulation System)
The electrodes are placed anteriorly
along the esophagus at the GEJ and
the generator is implanted in the
abdominal wall.
Decreased distal esophageal acid
exposure, improved GERD-HRQL,
and less use of PPI medications at 3
years.
51. ENDOLUMINAL THERAPIES
FOR GERD
Also known as transoral incisionless
fundoplication (TIF)
EsophyX
The Stretta
MUSE system
Sandhu DS and Fass R: Current Trends in the Management of
Gastroesophageal Reflux Disease2017
52. EsophyX
Used to restore the angle of His by
creating a valve at the
esophagogastric junction (EGJ).
This is achieved by delivering multiple
full thickness, nonabsorbable
fasteners at the EGJ.
Since its first use in 2005, about
17,000 TIF procedures have been
done
Transoral endoscopic fundoplication in the treatment of gastroesophageal reflux disease: the
anatomic and physiologic basis for reconstruction of the esophagogastric junction using a
novel device. Ann Surg. 2017
53. Diagrammatic and anatomic illustration of
a transoral fundoplication using
performed using the Esophyx
54. The Stretta system (Mederi
Therapeutics, Inc., Norwalk, CT)
A balloon-tipped four-needle catheter
that delivers radiofrequency energy
into the smooth muscle of the EGJ.
The first published report in 2001
showed promising results
Over the last 17 years this therapeutic
modality has markedly improved and
has been used in more than 20,000
patients.
TriadafilopoulosG. Stretta: a valuable endoscopic treatment modality for
gastroesophageal reflux disease. World J Gastroenterol. 2014;20(24):7730–7738
55. MUSE system
(Medigus, Israel)
An ultrasonic surgical stapler
embedded
within a custom endoscope to perform
a transoral fundoplication
Kim HJ, Kwon C-I, Kessler WR, et al. Long-term follow-up results of endoscopic
treatment of gastroesophageal reflux disease with the MUSE™ endoscopic stapling
device. Surg Endosc. 2016
57. BACKGROUND AND CONTEXT
The gold standard for anti-reflux
surgery is the Nissen fundoplication.
New endoscopic treatments such as
transoral incisionless fundoplication
(TIF) claim short term efficacy and
safety but there are no direct
comparisons.
58. NEW FINDINGS
LNF has the greatest durability to
increase LES pressure and decreases
% time pH<4 up to 5 years of follow-
up.
TIF was superior in symptom
improvement over 6-12 months but
not years.
Perforation rate was high with TIF
compared to LNF
59. .
LIMITATIONS
No direct comparison between TIF and
LNF necessitating network meta-
analysis.
Quality of studies varied from moderate
to very low.
IMPACT
Until more good quality evidence is
available including direct comparison to
LNF, TIF cannot be recommended as
an alternative to PPI or traditional
Nissen fundoplication.
GERD RESULTS FROM FAILURE OF THESE ENDOGENOUS ANTIREFLUX MECHANISM
Water brash-sour taste after regurgitation ,paient will describe as acid or bile
Responsiveness to medical therapy defined as a decrease in symptoms by >50% after 2-week course of anti-secretory medications, and propensity for malignancy as the cause of persistent symptoms.
MI is undergoing studies at various institutions for validation and will soon be commercially available