Diagnosis and management including medical, endoscopic and surgical management of Gastro-esophageal reflux disease

1. Moderator : Dr.Nawin Kumar
Presenter : Vamsi Alluri

2. Definition of GERD…*
• A condition that develops when the
reflux of stomach contents causes
troublesome symptoms and/or
complications
*Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group, Am J
Gastroenterol. 2006;101(8):1900.

3. • Most common symptoms are heartburn,
regurgitation, and dysphagia
• Extraesophageal manifestations :
- bronchospasm
- laryngitis and
- chronic cough
• Other symptoms of GERD include chest pain,
water brash, globus sensation, odynophagia, and
nausea.

4. Diagnosis…
• Can be based upon clinical symptoms alone
• Response to antisecretory therapy is not a
diagnostic criterion for GERD
• In a subset of patients, diagnostic testing is
required to confirm the diagnosis of GERD,
assess for complications and to rule out other
diagnoses

5. Differential diagnoses…
• Infectious esophagitis
• Pill esophagitis
• Eosinophilic esophagitis
• Peptic ulcer disease
• Non-ulcer dyspepsia
• Coronary artery disease and
• Esophageal motor disorders

6. Upper GI Endoscopy
• Upper endoscopy is not required in the
presence of typical GERD symptoms of
heartburn or regurgitation*
• Upper endoscopy provides a mechanism for
detecting, stratifying, and managing the
esophageal manifestations of GERD
*[Katz PO, Gerson LB, Vela MF, Am J Gastroenterol. 2013;108(3):308]

7. Indications for UGI endoscopy…
• To rule out complications of GERD.
Alarm features are : dysphagia
odynophagia
gastrointestinal bleeding
anemia
weight loss and
recurrent vomiting
• Severe erosive esophagitis (LA classification Grade C
and D) on initial endoscopy - follow-up endoscopy after
a two-month course of PPI therapy to assess healing
and rule out Barrett's esophagus.

8. • Men older than 50 years with chronic GERD
symptoms (>5 yrs) and additional risk factors
for Barrett's esophagus and esophageal
adenocarcinoma (nocturnal reflux symptoms,
hiatal hernia, elevated BMI, tobacco use, and
intra-abdominal distribution of fat).
• If symptoms persist despite a therapeutic trial
of four to eight weeks of twice-daily PPI
therapy.

9. Ambulatory 24 hr. pH monitoring…
• Gold standard for diagnosing and quantifying
acid reflux
• Catheter
• 2 solid state
electrodes –
sense pH
between 2 and
7.

10. • Connected to a data recorder.
• Data gained from the study :
- Total number of reflux episodes (pH<4)
- Longest episode of reflux
- No. of episodes longer than 5mins
- Extent of reflux in upright position and
supine position

11. Esophageal manometry…
• Primarily done to rule out motility disorders,
which may mimic symptoms of reflux
• Also allows the surgeon to plan for the
operative procedure
• Catheter – flexible tube with pressure sensing
devices arranged at 5cm intervals
• LES is analysed for mean resting pressure and
response to swallowing
• Body is assessed for the effectiveness od
peristalsis

13. • Normal pressures at LES range from 12 to
30mm of Hg
• Sphincter generally relaxes to the pressure of
gastric baseline for several seconds when a
swallow is initiated
• Ineffective esophageal motility is defined as
<70% peristalsis
• Distal esophageal amplitudes <30mm of Hg is
associated with significant GERD

14. Medical management

15. Initial therapy…
• Step up approach or step down approach
• Step up approach provides the advantage of
minimum usage of PPIs
• Step down approach provides faster symptom
relief.

16. • Step-up therapy for GERD in patients with
mild and intermittent symptoms (fewer than
two episodes per week) who have no
evidence of erosive esophagitis on upper
endoscopy, if performed.

17. Step-up therapy…
• Lifestyle and dietary modification
+/-
low-dose H2RAs
+/-
antacids

18. • Lifestyle and dietary modification
+/-
standard dose H2RAs
+/-
antacids

19. • Lifestyle and dietary modification
+/-
low-dose PPIs (once daily)
+/-
antacids

20. • Lifestyle and dietary modification
+/-
standard dose PPIs
+/-
antacids

21. Step-down therapy…
• Patients with erosive esophagitis
• Frequent symptoms (two or more episodes
per week)
• Severe symptoms that impair quality of life

22. • lifestyle and dietary modification
+
standard-dose PPI once daily

23. • lifestyle and dietary modification
+
low-dose PPIs

24. • lifestyle and dietary modification
+
H2RAs

25. • lifestyle and dietary modification
+
acid suppression discontinued
Exceptions : Severe esophagitis
Barrett’s esophagus
Maintenance PPI therapy

26. Lifestyle modifications…
• Weight loss
• Elevation of head end of the bed in patients
with nocturnal or laryngeal symptoms
• Refraining from assuming a supine position
after meals
• Avoidance of meals two to three hours before
bedtime.

27. • Dietary modification – elimination of dietary
triggers
• Promotion of salivation through oral lozenges
or chewing gum
• Avoidance of tobacco and alcohol
• Abdominal breathing exercise

28. Antacids…
• Combination of magnesium trisilicate,
aluminum hydroxide, or calcium carbonate
• Neutralizes gastric pH
• Relief of heartburn within five minutes
• Short duration of effect of 30 to 60 minutes

29. H2 receptor antagonists…
• Decrease the secretion of acid by inhibiting
the histamine 2 receptor on the gastric
parietal cell.
• Slower onset of action, around 2.5 hours
• Significantly longer duration of action of 4 to
10 hours
• Tachyphylaxis within 2 – 6 weeks of initiation

30. Proton pump inhibitors…
• Irreversibly binds and inhibits the H-K ATPase
pump
• Should be administered daily rather than on-
demand
• Standard doses for eight weeks relieve
symptoms of GERD and heal esophagitis in up
to 86% of patients with erosive esophagitis

31. Medication Low dose (adult, oral) Standard dose (adult, oral)
Histamine 2 receptor antagonists
Famotidine 10 mg twice daily• 20 mg twice dailyΔ
Ranitidine 75 mg twice daily• 150 mg twice dailyΔ
Nizatidine 75 mg twice daily• 150 mg twice daily
Cimetidine 200 mg twice daily• 400 mg twice dailyΔ
Proton pump inhibitors
Omeprazole 20 mg daily• 40 mg daily
Lansoprazole 15 mg daily• 30 mg daily
Esomeprazole 20 mg daily 40 mg daily
Pantoprazole 20 mg daily• 40 mg daily
Dexlansoprazole Not available 30 mg daily, 60 mg daily
Rabeprazole 10 mg daily◊ 20 mg daily

32. Recurrent symptoms
• 2/3rd of patients with non erosive reflux disease
and all patients with erosive esophagitis replase
when acid suppression is discontinued
• Recurrence after 3 months of discontinuation :
Repeat 8 weeks course of acid suppressive
therapy
• Recurrence < 3 months of discontinuation : Upper
GI endoscopy to rule out complications and long
term acid suppressive therapy

33. Refractory GERD
• Partial or lack of response to PPI twice daily
should be considered as refractory GERD

34. Endoluminal therapies

35. Techniques
• Radiofrequency energy
- Stretta System
• Endoscopic plication suturing
- Bard EndoCinch Endoscopic Suturing System
- EsophyX™ System with SerosaFuse™ Fastener
(transoral incisionless fundoplication procedure)
• Injection or implantation techniques
- Gatekeeper Reflux Repair System
- Plexiglas (polymethylmethacrylate [PMMA])
procedure
- Enteryx procedure

36. Stretta…
• Principle : Radiofrequency energy delivery
• Equipment : RF control module and
Flexible Stretta catheter
• Catheter : 20Fr soft bougie tip and a balloon,
which opens into a sorrounding basket.
• 4 electrodes deliver 60 to 300 J of RF energy
to each needle, heating the surrounding
muscle tissue to the target temperature
between 650C to 850C

38. • Continuous irrigation of the esophageal
mucosa and surface temperature monitoring
is utilized to prevent thermal mucosal injury
RF energy delivery
Shrinkage of esophageal
collagen fibres
Tightening of LES
Prevents acid reflux
Remodelling of stretch fibres
in the cardia
Interruption of vagal afferent signals
to brainstem
Reduces transient LES relaxations

39. Endocinch technique…
• Effective in short-term follow-up period and
the complication rate was relatively low
• Sutures were significantly lost within the 6-
month follow-up period, thus necessitating
reprocedure in about 25% of the patients.

40. BARD Endocinch…

41. Transoral Incisionless Fundoplication…
• EsophyX™ System with SerosaFuse™ Fastener
• The device retracts the gastric cardia, and
creates full-thickness serosa to serosa
plication and valve
• Less invasive alternative to laparoscopy

43. Gatekeeper reflux repair system
• utilizes a poly-acrylonitrile based hydrogel
(HYPAN) rod
• Procedure
• Over the next 24 hours, the prosthesis swells,
narrowing the luminal diameter of the lower
esophagus.

45. Plexiglas technique
• Suspension of polymethylmethacrylate
microspheres in gelatin solution
• Gelatin is phagocytosed by macrohages within
3 months and is replaced by fibroblasts and
collagen fibres

46. EnteryX system
• 6-8ml of 8% ethylene vinyl alcohol(EVOH)
polymer infused at a rate of 1ml/min to the
muscle or deep submucosal layer 1-2mm
caudal to the Z-line
• Although Enteryx does not affect LES pressure,
the distensibility and shape of GE junction is
changed

48. Surgical management

49. Inidications for surgery…
• Failed optimal medical management
• Noncompliance
• High volume reflux
• Severe esophagitis by endoscopy
• Benign stricture
• Barrett's columnar-lined epithelium (without
severe dysplasia or carcinoma)

50. Principles of surgery…
• Restoration of intra-abdominal portion of
esophagus to maintain a pressure differential
between thoracic and abdominal esophagus
• Creation of a loose wrap around the G-E junction
to restore the mechanical effect of it
• Reduction of any hiatus hernia and
approximation of the crural fibres to narrow the
hiatus
• Identification and management of any associated
anatomical abnormalities

51. Specific anti-reflux surgeries…

52. Belsey Mark IV
• Gold standard before the advent of
laparoscopy
• Partial anterior wrap, through left 5th
intercostal space posterolateral thoracotomy
• Procedure

54. Collis gastroplasty
• Isolating the upper part of lesser curve in the
form of a tube in continuity with the
esophagus
• Procedure
• Drawbacks :
- Distal neo esophagus will not co ordinate
with the esophageal peristaltic wave
- Continues to secrete acid

56. Nissen fundoplication
• Full 3600 posterior wrap around the lower 4cm of
esophagus
• Standard laparoscopic technique
• Lithotomy position
• Port placement
• Chief surgeon – between patient’s legs
• 1st assistant – Right side
- right hand : camera
- left hand : liver retraction
• 2nd assistant – Left side : stomach retraction

57. Port placement

58. Step 1 : Division of the gastrohepatic ligament

59. 2. Retraction of the fat pad, blunt dissection, and
creation of a window posterior to the esophagus

60. 3. Division of the short gastric vessels to the base of the
left crus to allow complete fundic mobilization

61. 4. The “Shoe-shine” manoeuvre

62. 5. Closure of the crural opening posterior to the
esophagus with interrupted, nonabsorbable suture

63. 6. Fundopilcation : Creation of a 2 cm wrap

64. Types of fundoplication failure

65. Partial fundoplications

66. Toupet fundoplication
• Partial posterior wrap
• Procedure

68. Toupet fundoplication

69. Dor fundoplication

70. Completed Dor fundoplication

72. Complications of laparoscopic
fundoplication
• Intra operative
• Early post operative
• Delayed post operative

73. Intra operative
• Access injuries
- Vascular
- Hollow viscus or solid organ
• Dissection injuries
- Stomach & Esophagus
- Vagus nerve
• Bleeding
- Aberrant arteries
- Aorta, vena cava
- Short gastric arteries

74. Early post operative
• Delayed perforation
- Stomach
- Esophagus
• Deep vein thrombosis
• Pulmonary complications
• Dysphagia
• Early wrap herniation

75. Delayed post operative
• Dysphagia
- Poor motility
- Tight wrap
- Twisted wrap
• Gas bloat syndrome
• Recurrence of reflux
- Wrap herniation
- Wrap disruption
- Incompetent wrap
• Diarrhea
- Vagal injury

76. Choice of surgery…
• Factors influencing :
- degree of esophageal shortening
- disturbances of esophageal motility
- prior operations and
- local expertise with laparoscopic techniques

77. • Early uncomplicated disease : Trans-abdominal
Nissen (laparoscopic if possible) fundoplication
• Decreased motility : Although surgery cannot
directly influence esophageal motility in patients
with GERD, Nissen fundoplication can lead to
improvement in esophageal contraction
amplitude. Benefit limited to patients with
preoperative amplitudes above the 5th percentile

78. • Normal length but decreased motility :
Complete fundoplication is discouraged; (lap
or open) Toupet or Hill or transthoracic Belsey
procedure could be performed
• Shortened esophagus : Collis (esophageal
lengthening) gastroplasty combined with an
intra-abdominal or intra-thoracic
fundoplication

79. Laparoscopy vs. Open
• Laparoscopic approach had a faster
convalescent rate (3 fewer days in hospital), a
faster return to work (8 days sooner), and a
similar treatment outcome*.
• But patients undergoing laparoscopic surgery
also had a higher rate of reoperation
*Peters MJ, Mukhtar A, Yunus RM, Khan S, Pappalardo J, Memon B, Memon MA,
Am J Gastroenterol. 2009;104(6):1548.