Optimize gerd management

1. OPTIMIZE GERD MANAGEMENT

2. 2013 ACG GUIDELINE FOR THE DIAGNOSIS AND
MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE
• Philip O. Katz MD1, Lauren B. Gerson MD, MSc2 and Marcelo F. Vela MD, MSCR3
• 1Division of Gastroenterology, Einstein Medical Center, Philadelphia,
Pennsylvania, USA; 2Division of Gastroenterology and Hepatology, Stanford
University School of Medicine, Stanford, California, USA; 3Division of
Gastroenterology, Baylor College of Medicine & Michael E. DeBakey VA Medical
Center, Houston, Texas, USA
• Am J Gastroenterol 2013; 108:308–328
54 recommendations

3. TOP TEN GERD GUIDELINE
1. PPIs can be used in patients with bone density loss (strong rec).
2. The relationship between infectious diseases and PPIs.
- C diff infection
- Community acquired pneumonia in short term PPI user
3. Screening for Barrett’s esophagus should not be routinely done in the absence of
high-risk epidemiologic evidence.
- Severity and duration of GERD symptoms, age, and abdominal obesity
4. pH testing is okay whether the patient is on or off therapy.
5. Surgery for extraesophageal manifestations of reflux disease will not work unless
the patient responded to PPIs.

4. TOP TEN GERD GUIDELINE
6. The diagnosis of laryngopharyngeal reflux cannot be made solely using
laryngoscopic findings.
7. The use of transoral fundoplication is not warranted by current clinical data
supporting it in clinical practice as an alternative to surgery.
8. Weight reduction matters.
- HUNT study: 100,000 patients, A body mass index (BMI) reduction of 3.5
units resulted in less likelihood of reporting GERD symptoms or using
GERD-related medications.
9. Helicobacter pylori testing should not be done in patients with GERD.
10. Endoscopy is not required to establish the diagnosis of GERD
- It is a clinic diagnosis

5. MORE FROM THE GUIDELINE IN DAILY
PRACTICE:
• Routine global elimination of food that can trigger reflux (including chocolate,
caffeine, alcohol, acidic and/or spicy foods) is not recommended in the
treatment of GERD, but head of bed elevation and avoidance of meals 2–3 h
before bedtime should be recommended for patients with nocturnal GERD.
- ? Large portion, high fat food
• There are no major differences in efficacy between the different PPIs.
• PPI therapy does not need to be altered in concomitant clopidogrel users as
there does not appear to be an increased risk for adverse cardiovascular events.

6. LONG-TERM PPI USE – SAFETY CONCERNS
• C Diff – relative risk 1.3
• Microscopic colitis – Odds ratio 4.5
• Mg malabsorption – RR 1.43
• Calcium – may affect water insoluble calcium
• Dementia – conflicting data, confounding factors
• Kidney disease – can cause acute intestinal nephritis (AIN)

7. GERD GUIDELINE: WHO NEEDS MANOMETRY
AND PH TESTING (7 RECOMMENDATIONS)
1. Esophageal manometry is recommended for preoperative evaluation, but has no
role in the diagnosis of GERD.
2. Ambulatory esophageal reflux monitoring is indicated before consideration of
endoscopic or surgical therapy in patients with non-erosive disease, as part of
the evaluation of patients refractory to PPI therapy, and in situations when the
diagnosis of GERD is in question.
3. Ambulatory reflux monitoring is the only test that can assess reflux symptom
association. (SI, SAP)
4. Reflux monitoring should be considered before a PPI trial in patients with
extraesophageal symptoms who do not have typical symptoms of GERD.

8. GERD GUIDELINE: WHO NEEDS MANOMETRY
AND PH TESTING (7 RECOMMENDATIONS)
5. Non-responders to a PPI trial should be considered for further diagnostic testing
and are addressed in the refractory GERD.
6. Patients with refractory GERD and negative evaluation by endoscopy (typical
symptoms) or evaluation by ENT, pulmonary, and allergy specialists
(extraesophageal symptoms), should undergo ambulatory reflux monitoring.
7. Reflux monitoring off medication can be performed by any available modality
(pH or impedance-pH). Testing on medication should be performed with
impedance-pH monitoring in order to enable measurement of nonacid reflux.
- If pH testing is going to be done on therapy, you should do it with pH
impedance, because you want to assess some of the nonacidic reflux in
correlation with symptoms.
- If you are using it for a diagnosis to send somebody to surgery, do it off
therapy.
- If you are going to assess symptoms in response to a medication
intervention, do it on therapy with impedance.

9. HIGH RESOLUTIONA ESOPHAGEAL MANOMETRY:
CHICAGO CLASSIFICATION
Swallow
UES
LES IBP
Bredenoord, Fox et al. Neurogastro and Motility, Vol 24; (Suppl 1) March 2012.
• LES relaxation
pressure/opening
pressure ≤15mmHg
• Coordinated pressure
wave front >20mmHg
• Delayed latency >4.5s
• Distal contractile index
(DCI) <5000 mmHg-cm-s
• Coordinated vigrous
contraction increases
intrabolus driving
pressure

10. RISK FACTORS THAT INCREASES REFLUX BASED ON
MANOMETRIC PRESENTATIONS
Absence of LES resting pressure Increased intragastric pressure
Hiatus hernia Transient LES relaxations (tLESRs)

11. 73% 97% 78%
Mechanisms of Reflux Observed in GERD Patients with and
without Hiatus Hernia during Ambulatory Manometry
GERD
without
hernia
Daytime
Between meals
Night-timeAfter meals
Van Herwaarden MA, et al. Gastroenterology 2000;119:1439-1446
tLESR
5%
8%
14%
2% 1%
7%
8%
8%
Strain
Low LESP
Swallow
46%
36% 38%
GERD
with
hernia
18%
18%
31%
31%
39% 22%
5%
7% 10%

12. AMBULATORY PH MONITORING
• Wireless – Bravo pH study
- Better tolerance, but chest pain common
- Allow 48-96hr recording. Prolonged recording can evaluate off/on PPI in
a single test.
- Unable to assess non-acid reflux
• Catheter based – single pH, dual pH, pH/impedance
- Better designed catheters increase tolerance
- Intragastric pH monitoring allow to assess effectiveness of PPI/H2RA
- Impedance recording to assess non-acid reflux
- Impedance recording to exclude “acid reflux event” due to drinking
acidic fluid

13. Attachment
device positioned
(6cm above EGJ)
Suction
applied
Attachment pin
fired
Probe released
from attachment
device
Recording begins
Attachment
device removed
PLACEMENT OF BRAVO PH CAPSULE

14. http://www.youtube.com/watch?v=th6nR2PrWjE
PLACEMENT OF BRAVO PH CAPSULE

15. WIRELESS BRAVO PH MONITORING
Abnormal Bravo pH testing: 85 episodes of acid reflux, 6.9% fraction time of pH<4,
positive symptom association (5/10 heartburn)

16. CATHETER BASED 24 HOUR AMBULATORY PH
AND PH/IMPEDANCE MONITORING
..
pH sensor
pH sensors
.
pH sensors
.
pH sensors
Impedance

17. Impedance
Time
Impedance Technology Fundamentals
Bolus Entry Bolus Exit
Bolus Present
Impedance contacts

18. AN EVENT OF ACID REFLUX ON PH/IMPEDANCE
RECORDING
Acid reflux
Bolus cleared by a swallow, but acid was not cleared
Acid cleared by 2nd swallow
1:18 minutes

19. NON-ACID REFLUX ASSOCIATED WITH
SYMPTOMS
Reflux
Swallow Swallow
1 minutes

20. WHY PH/IMPEDANCE MONITORING PREFERRED?
AN EXAMPLE OF A FALSE POSITIVE STUDY
• Number of acid reflux: 94 (Normal <55)
• Total acid exposure time: 7.8% (Normal <5%)
• Upright acid exposure time 12.3% (Normal <5%)

21. WHY PH/IMPEDANCE MONITORING PREFERRED?
AN EXAMPLE OF A FALSE POSITIVE STUDY
• After eliminate the episodes of drinking acidic fluid:
• Number of acid reflux: 20 (was 94)
• Total acid exposure time: 0.9% (was 7.8%)
• Upright acid exposure time 1.5% (was 12.3%)

22. WHY PH/IMPEDANCE MONITORING?
AN EXAMPLE OF A FALSE POSITIVE STUDY
• Post POEM procedure, increased acid exposure secondary to bacteria
fermentation

23. CASE 1: 46YO F WITH “REFRACTORY GERD”
• 46yo females referred by her local ENT and allergist for GI consultation re:
"refractory GERD" in a patient with allergic rhinitis, chronic sinusitis, and asthma.
(Extra esophageal symptoms)
• Pt sts she has had recurrent pneumonias since a child and frequent hoarseness
and laryngitis. She has had recurrent sinus infections that were treated with
frequent antibiotics.
• She denies symptoms of heartburn, regurgitation, frequent belching, nausea, or
vomiting. (No typical GERD symptoms)
• Trials of PPIs and H2RA did not improve her symptoms.
• EGD with esophageal biopsies: (-) EoE

24. CASE 1: 46YO F WITH “REFRACTORY GERD”
Unremarkable esophageal manometry but frequent swallows consistent with
her hypopharyngeal symptoms

25. CASE 1: 46YO F WITH “REFRACTORY GERD”
24hr esophageal pH/impedance monitoring results:
Fraction Time pH < 4 Total: 1.1% (NL< 5%)
Fraction Time pH < 4 Upright :1.9% (NL< 5%)
Fraction Time pH < 4 Recumbent: 0% (NL< 5%)
Fraction Time pH < 4 Post prandial: 2.3% (< 5%)
No. Acid Reflux: 40 (NL<55)
No. Weakly Acidic: 3 (NL<26)
Gastric pH < 4 % Total time 98.6%
Patient reported 5 episodes of heartburn, only 1/5
episodes associated with acid reflux.

26. CASE 1: 46YO F WITH “REFRACTORY GERD”
• Recommendations:
- Nasopharyngeal symptoms are not related to GERD
- No PPIs needed
ACG guideline: Reflux monitoring should be considered before a PPI trial in patients
with extra esophageal symptoms who do not have typical symptoms of GERD.

27. CASE 2: 28YO M, S/P FUNDOPLICATION WITH
RECURRENT SYMPTOMS
• 28yo male referred by a surgeon of the Gainesville VAMC. Pt is s/p
fundoplication June 2012 with recurrent symptoms post-operatively.
• Pt sts has had reflux symptoms since a child.
• Pre-operative treatment with Nexium 40 mg qd with best response of reducing
heartburn, frequent belching, hiccups, and lower retrosternal chest discomfort.
It was taken off VA formulary and pt did not have as good a response to
omeprazole or Prevacid.
• He underwent fundoplication 6/21/2012 but did not have improvement in any
symptom except belching.
• Patient requests a repeat fundoplication, because he thinks the fundoplication is
too loose.

28. CASE 2: 28YO M, S/P FUNDOPLICATION WITH
RECURRENT SYMPTOMS
• EGD 3/8/13: Normal appearing esophagus; evidence of fundoplication
• EGD 11/21/12: Irregular z-line at 35 cm. A prior Nissen fundoplication at g-e
junction and appeared loose.
• EGD 6/16/2011: report not available of procedure. Biopsy report: "Distal
esophagus biopsy: columnar metaplasia with goblet cells with pancreatic
metaplasia. Negative for dysplasia. Changes consistent with reflux esophagitis."
• Esophagram 11/6/12: No esophageal stricture, mass, or ulceration; evidence of
Nissen fundoplication; (+) spontaneous reflux to the mid-upper esophagus when
supine.

29. CASE 2: 28YO M, S/P FUNDOPLICATION WITH
RECURRENT SYMPTOMS
High resolution esophageal
impedance manometry restults:
Resting LES pressure: 22mmHg (NL
4.8-32)
LES relaxation pressure: 11.8 mmHg
(NL<15)
Mean DCI (Distal contractile integral)
(mmHg-cm-s): 1546 (NL 500-5000)

30. CASE 2: 28YO M, S/P FUNDOPLICATION WITH
RECURRENT SYMPTOMS
24hr esophageal pH/impedance monitoring
results (off PPI):
Fraction Time pH < 4 Total: 0% (NL< 5%)
Fraction Time pH < 4 Upright: 0% (NL< 5%)
Fraction Time pH < 4 Recumbent: 0% (NL< 5%)
Fraction Time pH < 4 Post prandial: 0% (< 5%)
No. Acid Reflux: 0 (NL<55)
No. Weakly Acidic: 4 (NL<26)
Gastric pH < 4 % Total time: 80%
Patient reported 54 episodes of reflux
symptoms with negative association to reflux.

31. CASE 2: 28YO M, S/P FUNDOPLICATION WITH
RECURRENT SYMPTOMS
• Recommendations:
- No repeat fundoplication needed
- No PPIs
ACG guideline: Ambulatory esophageal reflux monitoring is indicated before
consideration of endoscopic or surgical therapy in patients with non-erosive disease,
as part of the evaluation of patients refractory to PPI therapy, and in situations when
the diagnosis of GERD is in question.

32. CASE 3: 38YO F WITH UNCONTROLLED GERD
• 38 y.o. female who was referred by her PCP for evaluation of GERD, and possible
surgical management.
• This has been a problem for her for several years and has tried several different
PPI regimens which has controlled her symptoms of pain however she continues
to have AM coughing and sour taste in her mouth. (Partial response to PPI)
• She has had 3 EGDs which were biopsy negative for dysplasia and H pylori.
• On omeprazole 20mg in the AM prior to breakfast and 40mg at night before bed.
She notes that she has very frequent belching after meals.
• She denies chest pain, abdominal pain, nausea, vomiting, hematochezia, melena,
diarrhea, constipation, bloating.

33. CASE 3: 38YO F WITH UNCONTROLLED GERD
High resolution esophageal
impedance manometry restults:
Resting LES pressure: 7.3mmHg
(NL 4.8-32)
LES relaxation pressure: 3.9
(NL<15)
Mean DCI (Distal contractile
integral) (mmHg-cm-s): 697 (NL
500-5000)

34. CASE 3: 38YO F WITH UNCONTROLLED GERD
24hr esophageal pH/impedance monitoring
results (off PPI):
Fraction Time pH < 4 Total: 4.4% (NL< 5%)
Fraction Time pH < 4 Upright: 6.9% (NL< 5%)
Fraction Time pH < 4 Recumbent: 0% (NL< 5%)
Fraction Time pH < 4 Post prandial: 10.1% (<
5%)
No. Acid Reflux: 44 (NL<55)
No. Weakly Acidic: 24 (NL<26)
Gastric pH < 4 % Total time: 91%
Patient reported 44 episodes of belching, all of
them are associated with reflux events.

35. CASE 3: 38YO F WITH UNCONTROLLED GERD
• Adjustment to her treatment based on manometry and pH/impedance results:
- Change omeprazole to 20mg bid 30min before breakfast and
dinner
- Add Baclofen 5mg tid with meals
- No fundoplication
• RTN in 3 months: doing well on baclofen and omeprazole. She will occasionally
have belching, but denies any chest pain, or regurgitation.
• ACG guideline: Therapy for GERD other than acid suppression, including
prokinetic therapy and/or baclofen, should not be used in GERD patients without
diagnostic evaluation.

36. CASE 4: 47YO F WITH CHRONIC COUGH
• 47 y.o. female with psoriasis who is referred for evaluation of chronic cough.
• She has episodic coughing which significantly affects the qualities of her life as
well as her job. She was evaluated by an ENT, an allergist and a pulmologist. She
was told that GERD was the cause of her refractory cough.
• She has been taking Dexilant and Zantac for past 6 months without much effect.
• She also reports regurgitation, especially at night. She sleeps on eight pillows.
She notice dysphagia with solid, and drinking liquids helped to relieve the
symptoms.
• EGD with biopsy (-) H pylori

37. CASE 4: 47YO F WITH CHRONIC COUGH
High resolution esophageal
impedance manometry restults:
Resting LES pressure:
13.5mmHg (NL 4.8-32)
LES relaxation pressure: 6.4
(NL<15)
Mean DCI (Distal contractile
integral) (mmHg-cm-s): 1753
(NL 500-5000)
Weakness of proximal
esophageal muscles

38. CASE 4: 47YO F WITH CHRONIC COUGH
24hr esophageal pH/impedance monitoring
results (off PPI):
Fraction Time pH < 4 Total: 0.1% (NL< 5%)
Fraction Time pH < 4 Upright: 0.2% (NL< 5%)
Fraction Time pH < 4 Recumbent: 0% (NL< 5%)
Fraction Time pH < 4 Post prandial: 0.2% (< 5%)
No. Acid Reflux: 2 (NL<55)
No. Weakly Acidic reflux: 88 (NL<26)
Gastric pH < 4 % Total time: 0.7%
Patient reported 67 episodes of belching, 16/67
were associated with weakly reflux events.

39. CASE 4: 47YO F WITH CHRONIC COUGH
Numerous non-acid reflux episodes recorded by pH/impedance monitoring

40. CASE 4: 47YO F WITH CHRONIC COUGH
• Achlorhydria, further evaluation found anti-parietal cell antibody (+)
• Autoimmune diseases: psoriasis, hypothyroidism
• Stop PPI
• Nutrition evaluation
• Trial of Baclofen
• ? Anti-reflux surgery

41. CASE 5: 48YO F WITH UNCONTROLLED GERD
• 48 yof w/ severe heartburn and reflux x 20 + years referred by her local
gastroenterologist. She has had lifelong issues with heartburn, reflux and
epigastric pain but it has been worse over the past year or two.
• She struggles with issues with aspiration particularly when recumbent. She
sleeps in an incliner.
• She takes the zantac at night PRN waking up with regurgitation. At baseline, she
is taking 1 gm of Carafate TID, in addition to dexilant 60 mg BID.
• She notes hoarseness and a sore throat, no dysphagia or odynophagia.

42. CASE 5: 48YO F WITH UNCONTROLLED GERD
• EGD 4/2012, linear erosions, mild non-erosive gastritis, normal duodenum; path-
mild to moderate gastritis, -ive H.pylori, esophagus is inflamed and ulcerated
along with reactive changes
• GES 2012, rapid gastric emptying, 13 min (normal 16 to 83 min)
• Upper GI 3/2013 , mucosal irregularity in the lower esophagus, large hiatal
hernia, friable gastric fundus/body, severe esophageal reflux during the exam.
• Labs: 2/13, normal BMP, CBC, TSH; normal LFT's 2012. Abnormal- ammonia 48.6
(9-33), ferritin 10, vitamin D 17.6

43. CASE 5: 48YO F WITH UNCONTROLLED GERD
High resolution esophageal
impedance manometry restults:
Resting LES pressure: 7.6mmHg
(NL 4.8-32)
LES relaxation pressure: 5.1
(NL<15)
Mean DCI (Distal contractile
integral) (mmHg-cm-s): 594 (NL
500-5000)
Large paraesophageal hernia.
The manomatric catheter was
unable to transverse EGJ.

44. CASE 5: 48YO F WITH UNCONTROLLED GERD
24hr esophageal pH/impedance monitoring
results (on Dexilant 60mg bid, Zantac 150 HS):
Fraction Time pH < 4 Total: 23.1% (NL< 5%)
Fraction Time pH < 4 Upright: 342% (NL< 5%)
Fraction Time pH < 4 Recumbent: 17% (NL< 5%)
Fraction Time pH < 4 Post prandial: 22.4% (<
5%)
No. Acid Reflux: 134 (NL<55)
No. Weakly Acidic reflux: 109 (NL<26)
Gastric pH < 4 % Total time: 15.4%
Patient reported 36 episodes of chest pain and
heartburn, 22/36 were associated with weakly
reflux events.
9pm
Dexilant
9am
Dexilant
11pm
Zantac

45. CASE 5: 48YO F WITH UNCONTROLLED GERD

46. CASE 5: 48YO F WITH UNCONTROLLED GERD
• Patient underwent laparoscopic Nissen fundoplication and repair
paraesophageal hernia
• Six weeks post-op visit, PPI decreased to Lansoprazole 30mg daily with no GERD
sx, advised to stop PPI in 2 month