Dr. Leong Wai Sam

1. Management of GERD
Speaker: Leong Wai Sam (IC of family
medicine)
Tutor: Dr Choi Nim
Date:2022/10/28 11:30

2. 1
2
3
4
CONTENTS
Case
Introduction
Pathophysiology
and Risk factor
Clinical feature
5
Investigation and
diagnosis
6 Management
5

3. Case
64Y/O male
• Past history:
Ex-smoker 1-2packs/D for 40 Ys, quit for 7 Ys
Anxiety for 20 yrs, follow up at psychiatric clinic
History of hypertension, dyslipidemia and obesity for 5 yrs follow up at HC.
GERD for 6 yrs follow up at HC on PPI.
Right inguinal hernia for 2 years
Chief complain:
Regurgitation and heart burn for 6 years, worsening for 3 years. Marked
nocturnal regurgitation even on PPI. Symptom worsening after heavy meal

4. Case
• PE:173cm, 98.5Kg, BMI 32.9, other vital sign stable
APC : bilateral breath sound clear, no rales, no wheeze. HR regular, no
murmur.
Abdomen: Soft, no tenderness, no rebound tenderness, BS normoactive.no
visible bulging at groin.
Investigation:
EGD: Esophagitis; Hiatal hernia; Gastritis
Impression: Hiatal hernia with GERD, right indirect inguinal hernia, morbid
obesity

5. Case
Plan for Roux-en-Y Gastric Bypass (RYGB)+Lap hiatal hernia repairing +
hernioplasty.
But the patient refused RYGB and prefer fundoplication.
( Laparoscopic right hernioplasty (TAP), repair of hiatal hernia with mesh,
NISSEN's fundoplication ) was done.
POD 6, tolerated soft diet, no dysphagia, no abdominal pain and discharge
without PPI use.
OPD 1 month later, no more heart burn and regurgitation

6. Introduction
• Gastroesophageal reflux disease(GERD):
reflux of gastric content into the esophagus
leads to troublesome symptom and/or
complication
• Diagnosis in GI OPD in USA (15- 20%)
• In Japan, Medical cost aged(20-59)
:$266/person/ Month
Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review on the management of gastroesophageal
reflux disease. Gastroenterology 2008;

7. Pathophysiology(Multifactorial)
An Evidence-Based Approach to the Treatment of Gastroesophageal Reflux Disease Marco G. Patti, MD，JAMA Surg. doi:10.1001/jamasurg.2015.4233
Gastric refluxate
Esophageal
peristalsis
Hiatal hernia
Lower esophageal
sphincter pressure
Transdiaphragmatic
pressure gradient

8. Pathophysiology
Multifactorial pathophysiology
• Lower esophageal sphincter
• Esophageal peristalsis
• Hiatal hernia
• Gastric refluxate
• Transdiaphragmatic pressure gradient
Pathophysiology and treatment options for gastroesophageal reflux disease: looking beyond acid Priya Sharma1 and Rena Yadlapati2 doi:
10.1111/nyas.14501
Ann. N.Y. Acad. Sci. xxxx (2020) 1–12 © 2020 New York Academy of Sciences.

9. Medication
• Anticholinergics
• SSRI
• Antidepressant
• Inhaled bronchodilators
• Birth control pills
Lifestyle
• Heavy lifting
• Over-eating
• Eating before bedtime
• Sleeping in supine position
Foods
• High-fat diet
• tomato products
• Carbonated
Beverages
• Caffeine/Alcohol
Chocolate/
Peppermint
• Onion
Risk factor of GERD

10. Clinical feature
Typical symptoms Atypical symptoms Alarm symptoms Complication
• Heart burn
• Regurgitation
• Chronic cough
• Hoarseness
• Non-cardiac
chest pain
• Throat
irritation
• Sleeping
disturbance
• Dysphagia
• Weight loss
• Melena
• Hematemesis
• Esophagitis
• Esophageal
ulcer
• Peptic Stricture
• Barrett’s
esophagus
• Adenocarcino
ma

11. Investigation
•Upper GI Endoscopy
•Esophageal PH monitoring
•Esophageal manometry

12. Upper endoscopy
• For alarm symptoms and PPI
failed GERD
• Stop PPI for 2-4 W
• Typical GERD symptom: normal
mucosa common
• Specific diagnosis: Erosive
esophagitis and Barrett’s
esophagus
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease Am J Gastroenterol 20

13. Los Angeles classification for EE

14. Esophageal manometry
• Not alone diagnostic test
• Weak LES pressure and motility often with severe GERD
• Indicate in unresponsive to PPI when un-diagnostic impedance PH
monitoring test, pre-operation assessment
• For rule out achalasia
Anti-reflex procedure for mistaken diagnosis can result in devastating
dysphagia
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease Am J Gastroenterol 20

15. Esophageal manometry

16. PH monitoring
• For esophageal acid exposure and
correlating symptoms
• Stopped PPI for 7 days
• Assess with Symptom index:
positive if <50% / Symptom
association probability
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis

17. PH monitoring

18. Diagnosis of GERD
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol

19. Refractory GERD
• Definition: persistent symptom despite 8 weeks of double-dose PPI therapy
Management:
• Optimization of PPI
Compliance( 30-60 mins before breakfast for daily dose and before
breakfast/ dinner for twice daily dose)
• After extensive evaluation, only 21% of refractory GERD truly PPI refractory
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol
2022;117:27–56.

20. Management
Management of GERD
Life style Change
Medical treatment
H2RA
PPI
Other
Surgical treatment
Laparoscopic
Fundoplication
Magnetic sphincter
augementation
Roux-en-Y gastric bypass
Endoscopic
Stretta procedure
Transoral incisionless
fundoplication(TIF)

21. GERD incompletely responsive to PPIs
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG
Clinical Guideline for the Diagnosis and Management
of Gastroesophageal Reflux Disease Am J
Gastroenterol 2022;117:27–56.

22. Life style change
Life style change for GERD
Weight loss for overweight patient
Avoiding meal within 2-3 hours of bedtime or bedtime snacks
Staying upright during and after meals
Left side down during sleep
Elevating head of bed for night time GERD symptoms
Avoid Smoking and alcohol
Avoid trigger food( coffee, chocolate, carbonated beverages, spicy, acidic
food, high fat content)
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol

23. Medical treatment
• Proton pump inhibitors (PPI)
Most common medication for heartburn and regurgitation
• Compare to H2RA
Faster healing rate
Symptom improve rate
Typically 8-12 weeks treatment
30-60mins before meal
Maintenance PPI therapy for severe EE grade C or D/ Barrett’s esophagus
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol

24. Medical treatment
• H2RA
Indicate: Bed time H2RA for PPI with persistent nocturnal symptoms
• Prokinetic(Metoclopramide)
Increase LES pressure, peristalsis, gastric emptying
Limited data and side effect if long term or high dose(drowsiness, agitation, irritability, depression,
dystonic reactions, and tardive dyskinesia )
Not recommend
• Baclofen
GABA agonist, reduces transient LES relaxations
Decreased postprandial acid reflex, nocturnal reflux and belching
5-20mg tid for patient with symptomatic reflux under PPI treatment
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol

25. Surgery
Anti-reflux Surgery indicate
• Fails to medical therapy
• Long term treatment with objective evidence of GERD
• Severe reflux esophagitis(LA grade C or D):
• Large Hiatal hernia and / or persistent troublesome GERD
Better success rate than medication and avoid long term PPI
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol

26. Surgery
• Fundoplication
• Magnetic sphincter augementation
• Roux-en-Y gastric bypass
• Endoscopic anti-reflux therapies

27. Fundoplication
• Gold standard
• Improving LES pressure and esophageal
acid exposure time
Complete
fundoplication(Nissen)
Incomplete
fundoplication(Toupet)
Procedure 360° "wrap" or collar
around the esophagus
a collar of approximately
270° around the esophagus
Efficacy in
improve
symptom
80% post op wean off anti-reflex medication
Advantage Less recurrent rate Less dysphagia, gas bloat,
and inability to belch and
vomit

28. LARS Fundoplication
• 17.7 % had recurrence, Risk factor: female,
older age, comorbidity
• Mortality rate: 0.1% and not surgery-related
• Complication 4.1% within 30 Days
Infection, bleeding, esophageal perforation
Postoperative dysphagia: 0.8%
need endoscopic dilatation: 60%

29. Magnetic sphincter augmentation
• Titanium beads bolster LES and
prevent reflux
• Indicate: GERD with acid reflex that
partial relief with PPI and severe reflux
esophagitis
• Less invasive and reversible
• 92% patient improved >50 % quality of
life scores
• 93% patient reduced PPI use
Ganz RA, Edmundowicz SA, Taiganides PA, et al. Long-term outcomes of patients receiving a magnetic sphincter
augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol 2016;14(5):671–7

30. Magnetic sphincter augmentation
• Contraindication: large hiatal hernia and severe
reflex esophagitis
• Complication:68 % with Dysphagia, 11% at 1
years, 4% at 3 Years
6% with severe serious adverse event( persistent
dysphagia, intermittent vomit, persistent chest pain
and reflux symptoms) and eventually device
removed
Can’t have MRI
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol

31. MSA VS Laparoscopic fundoplication
• Similar symptom control
MSA:
Advantage shorter operative times and duration of hospital stays
Less gas-bloat and greater ability to belch and vomit
Higher rate of dysphagia and reoperation
Safe and effective alternative to fundoplication
Ganz RA, Edmundowicz SA, Taiganides PA, et al. Long-term outcomes of patients receiving a magnetic s
augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol 2016;14(5):671–7

32. Roux-en-Y gastric bypass
• GERD increase 6 times in BMI> 35
• Fundoplication in obesity, increase
risk of fundoplication disruption and
herniation
RYGB: control reflux and induce
weight loss.
Ideal surgery for obesity as a primary
anti-reflex procedure and correction
of a failed fundoplication.
Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis
and Management of Gastroesophageal Reflux Disease Am J Gastroenterol

33. Roux-en-Y gastric bypass
• Technically difficult operation that major alterations in anatomy
Early complication Late complication
Leakage 0.6-4.4 Marginal ulceration 5%
Stenosis: 8-19% Bleeding 5%
Bleeding: 11% Perforation 1-2%
DVT: low but common cause of death Internal hernia 2.5%
Other: SBO, Gall stone disease
Lim R, Beekley A, Johnson DC, et al. Early and late complications of bariatric operation. Trauma Surg Acute Care Open 2018;3(1):e

34. Endoscopic anti-reflux therapies
• Excluded: hiatal hernias> 2cm, grade C
and D EE, esophageal strictures and
long-segment Barrett’s esophagus
• Radiofrequency anti-reflux
(Stretta procedure)
Control reflex by inducing swelling and
mechanical alteration at EGJ.
Improved symptoms and QOL, but may
not improved acid exposure(may just
altering the sensation)
Indicate: patient refused fundoplication
Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of
gastroesophageal reflux disease: A systematic review and meta-analysis. Clin Gastroenterol Hepatol

35. Endoscopic anti-reflux therapies
• Endogastric solutions
Transoral incisionless
fundoplication(TIF)
Create a flap valve involving 180 to
270 degree.
Effective for regurgitation
Didn’t improve acid exposure,
most need PPI during follow up
Complication(perforation and
bleeding):2.4%

36. Summary
• Classic symptoms of heartburn and regurgitation W/O alarm
symptoms, suggested 8W empiric PPI once daily.
• Endoscopy for dysphagia/alarm symptoms/ multiple risk factor for
Barrett’s esophagus
• Refractory GERD after optimization of PPI and evaluation, only 21%
truly PPI refractory
• Laparoscopic fundoplication are gold standard for anti-reflex
procedure
• For obesity, fundoplication: higher rate of dysphagia and reoperation
for, RYGB: both control reflux and induce weight loss.

37. References
• Philip O. Katz, MD, MACG1, Kerry B. Dunbar ACG Clinical Guideline for the Diagnosis and
Management of Gastroesophageal Reflux Disease Am J Gastroenterol 2022;117:27–56.
• Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review
on the management of gastroesophageal reflux disease. Gastroenterology 2008;
• An Evidence-Based Approach to the Treatment of Gastroesophageal Reflux Disease Marco G. Patti,
MD,JAMA Surg. Doi : 10.1001/jamasurg. 2015.4233
• Priya Sharma1 and Rena Yadlapati, Pathophysiology and treatment options for gastroesophageal reflux
disease: looking beyond acid doi: 10.1111/nyas.14501
• JAMA. 2017 Sep 12; 318(10): 939–946. Association Between Laparoscopic Antireflux Surgery and
Recurrence of Gastroesophageal RefluxJ, ohn Maret-Ouda, MD,1 Karl Wahlin, MSc, PhD,1 Hashem B.
El-Serag, MD, MPH,2,3 and Jesper Lagergren, MD, PhD1,4
• Ganz RA, Edmundowicz SA, Taiganides PA, et al. Long-term outcomes of patients receiving a magnetic
sphincter augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol 2016;14(5):671–7
• Lim R, Beekley A, Johnson DC, et al. Early and late complications of bariatric operation. Trauma Surg
Acute Care Open 2018;3(1):e000219
• Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of
gastroesophageal reflux disease: A systematic review and meta-analysis. Clin Gastroenterol Hepatol
2015;13(6):1058–67.e1.

38. The end
•Thank you