New Treatments for GERD and Barrett's Esophagus

Summit Health
Summit HealthSummit Health
Gastroesophgeal Reflux
   Disease (GERD)

      Hazar Michael, M.D.
        June 14, 2012
GERD Overview
• Reflux occurs when the stomach contents reflux or
  back up into the esophagus and/or mouth.
   
       Reflux is a normal process that occurs in healthy individuals
   
       Most episodes are brief and do not cause symptoms or
       complications
   
       Mostly after meals, rarely at night
   
       Results from transient relaxation of the muscle sphincter in
       lower esophagus
• People with GERD experience symptoms or
  complications as a result of the reflux
New Treatments for GERD and Barrett's Esophagus
GERD is a Common Problem
                 80                                        Males
                                                           Females

                 60
Prevalence (%)




                                                         Any episode
                                                         of GERD symptoms
                 40

                                                         At least weekly
                 20                                      episodes of GERD
                                                         symptoms
                 0
                      25–34   35–44    45–54    55–64   65–74
                                      Age (years)         Locke et al. Gastroenterology 1997
Symptoms of GERD
• Typical symptoms
   
       Pain in the upper abdomen
   
       Burning chest pain
   
       Food getting stuck (dysphagia)
   
       Pain upon swallowing (odynophagia)
   
       Taste of acid or food in throat or food or fluid coming up
       without effort (regurgitation)
• Atypical symptoms
   
       Persistent sore throat
   
       Sense of a lump in the throat
   
       Waking up with a choking sensation
Symptoms of GERD
• Atypical symptoms continue
   
       Persistent laryngitis/hoarseness
   
       Chronic cough, new onset asthma, or asthma only at night
   
       Worsening dental disease
   
       Recurrent Pneumonia
   
       Chronic sinusitis
Natural History of GERD
• Majority of patients do very well and only require
  symptom control
• Minority will develop serious complications
Potential Complications of
             GERD
• Severe esophageal inflammation and esophageal
  ulcer formation
• Esophageal stricture formation (narrowing diameter)
• Barrett’s esophagus
• Esophageal cancer
• Hoarseness
• Pneumonia which if frequent may lead to permanent
  lung damage
Barrett’s Esophagus
    • Changing in the lining of the esophagus to become
      intestine like lining
    •     Exact number of effected individual is unknown
            
                 Overall 1.6%
                  • 1.4% no GERD symptoms
                  • 2.3% with GERD symptoms
            
                 Risks factors
                   •   Male
                   •   Caucasian
                   •   Smoking
                   •   Hiatal hernia
                   •   Increased visceral fat deposition

Ronkainen J, et al. Prevalence of Barrett's esophagus in the general population: an endoscopic study. Gastroenterology.
2005;129:1825-31.
Bonino JA. Barret’s esophagus. Current opinion in gastroenterology 2006,22:406-411
Barrett’s Esophagus and
          Esophageal Cancer
• The exact increase risk is unclear
    
        Increased risk by 30-125 folds
         • Esophageal cancer is uncommon
    
        Life time risk of developing esophageal cancer 0.4-0.5 per
        100 patients per year
         • 1% per year in LGD
         • 10% per year in HGD
•   Risk to progress to HGD is 0.9 per year
•   Likely progression from Barrett’s     LGD       HGD
     Ad Ca
    
        ~18% in LGD
    
        ~ 34% HGD
Surveillance for Barrett’s
               Esophagus
• Not clear if useful but usually recommended
• At first endoscopy perform extensive biopsy
   
       No dysplasia, confirmed by second endoscopy within 1 year
       → EGD in 3-5 years
   
       LGD              EGD in 1 year vs. treatment
   
       HGD              In individual with reasonable life
       expectancy consider treatment
Treatment of Barrett’s
               Esophagus
• Control acid and inflammation usually by medication
• Eradication of Barrett’ tissue by heat or cold or other
  methods
• Removal of early cancer endoscopically
• For advanced cancer either surgery or chemotherapy
  and radiation therapy
HALO Device (Barrx Device)
• A device delivers heat to get rid of Barrett’s tissue
• Usually recommended for patients with dysplasia and
  few selected patients without dysplasia
   
     About 90% chance of eliminating dysplasia and
     Barrett’s esophagus and at least tow fold decrease
     in cancer risk
   
     Durable at 5 years but no longer term data
When Do I Need to Seek
          Medical Care?
• Symptoms are getting worse or inability to control
  them
• When you are in doubt if something wrong
• Need to seek immediate medical care
   •
       Trouble swallowing/chocking or sensation of food being
       stuck or lump in throat
   •
       Unintentional weight loss
   
       Chest pain
   
       Vomiting blood or having bowel movements that are black or
       look like tar
Diagnosing GERD
•   Clinical by history and therapeutic trial
•   Endoscopy
•   PH testing
•   Esophageal manometry
•   Radiology
Treatment of GERD
•   Life style modification
•   Medications
•   Endoscopic procedure
•   Surgery
Life Style modification
Not clear if it is effective but usually recommended

• Lose weight (if you are overweight)
• Raise the head of your bed by 6 to 8 inches
• Avoid foods that make your symptoms worse
     • Coffee, chocolate, alcohol, peppermint, and fatty foods
• Cut down on the amount of alcohol you drink
• Stop smoking
• Frequent small meal, avoid overeating
• Eat a bunch of small meals each day
• Avoid lying down for 3 hours after a meal
Dietary factors that may
   aggravate GERD symptoms

• Caffeinated    • Spicy foods
  products       • Citrus fruits and
• Peppermint       juices
• Fatty foods    • Tomato-based
• Chocolate        products
                 • Alcohol
New Treatments for GERD and Barrett's Esophagus
Medications
• Antacids work for mild infrequent episodes of GERD
  or as adjuvant to other medication in more severe
  case
• Antihistamine work in mild GERD and not very
  effective to heal severe esophageal inflammation
Medications
• PPI as class are the strongest medication
   
       Heal inflammation over 80%
   
       Most work better if taken before meals
   
       Usually once a day and occasionally twice a day
   
       For symptoms control only initial treatment is 8 weeks
        • If symptoms relapse within 3 months usually are needed for long term
   
       Goal of therapy is to use the lowest effective dose of
       medication
   
       Usually safe but can lead to decrease bone dentistry and
       nutrient absorption and increase risk of infections especially
       clostridium difficile
My Medications Are Not Working

             What Should I Do ?
•   If PPI, are you taking it before meal?
•   Change to different PPI
•   PPI twice a day
•   Additional testing
•   Consideration for surgery
Surgery for GERD
•   Goal to increase barrier to acid reflux with minimal impact on the
    ability to swallow
•   Surgery plays an important role in patients with large hiatus
    hernia and those unable or unwilling to take long term
    medications
•   Majority are done laparoscopically, result depends on surgeon
    experience
•   Potential complications
     
         Difficulty swallowing (5%)
     
         Sense of bloating and gas
     
         Breakdown of the repair (1 to 2 percent of patients per year)
     
         Diarrhea due to inadvertent injury to the nerves
New Treatments for GERD and Barrett's Esophagus
Summary
• GERD is common and in a majority of
  cases has benign course
• Use lowest effective dose of medication
• Trouble swallowing, chest pain or
  bleeding seek immediate attention
• Barrett’s esophagus in a majority of
  cases does not lead to cancer, but
  keeping an eye on it is advisable
For more information
       Call (908) 273.4300
Visit: summitmedicalgroup.com

      Connect with us on
 Facebook/SummitMedicalNJ
 Twitter: @SummitMedicalNJ
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New Treatments for GERD and Barrett's Esophagus

  • 1. Gastroesophgeal Reflux Disease (GERD) Hazar Michael, M.D. June 14, 2012
  • 2. GERD Overview • Reflux occurs when the stomach contents reflux or back up into the esophagus and/or mouth.  Reflux is a normal process that occurs in healthy individuals  Most episodes are brief and do not cause symptoms or complications  Mostly after meals, rarely at night  Results from transient relaxation of the muscle sphincter in lower esophagus • People with GERD experience symptoms or complications as a result of the reflux
  • 4. GERD is a Common Problem 80 Males Females 60 Prevalence (%) Any episode of GERD symptoms 40 At least weekly 20 episodes of GERD symptoms 0 25–34 35–44 45–54 55–64 65–74 Age (years) Locke et al. Gastroenterology 1997
  • 5. Symptoms of GERD • Typical symptoms  Pain in the upper abdomen  Burning chest pain  Food getting stuck (dysphagia)  Pain upon swallowing (odynophagia)  Taste of acid or food in throat or food or fluid coming up without effort (regurgitation) • Atypical symptoms  Persistent sore throat  Sense of a lump in the throat  Waking up with a choking sensation
  • 6. Symptoms of GERD • Atypical symptoms continue  Persistent laryngitis/hoarseness  Chronic cough, new onset asthma, or asthma only at night  Worsening dental disease  Recurrent Pneumonia  Chronic sinusitis
  • 7. Natural History of GERD • Majority of patients do very well and only require symptom control • Minority will develop serious complications
  • 8. Potential Complications of GERD • Severe esophageal inflammation and esophageal ulcer formation • Esophageal stricture formation (narrowing diameter) • Barrett’s esophagus • Esophageal cancer • Hoarseness • Pneumonia which if frequent may lead to permanent lung damage
  • 9. Barrett’s Esophagus • Changing in the lining of the esophagus to become intestine like lining • Exact number of effected individual is unknown  Overall 1.6% • 1.4% no GERD symptoms • 2.3% with GERD symptoms  Risks factors • Male • Caucasian • Smoking • Hiatal hernia • Increased visceral fat deposition Ronkainen J, et al. Prevalence of Barrett's esophagus in the general population: an endoscopic study. Gastroenterology. 2005;129:1825-31. Bonino JA. Barret’s esophagus. Current opinion in gastroenterology 2006,22:406-411
  • 10. Barrett’s Esophagus and Esophageal Cancer • The exact increase risk is unclear  Increased risk by 30-125 folds • Esophageal cancer is uncommon  Life time risk of developing esophageal cancer 0.4-0.5 per 100 patients per year • 1% per year in LGD • 10% per year in HGD • Risk to progress to HGD is 0.9 per year • Likely progression from Barrett’s LGD HGD Ad Ca  ~18% in LGD  ~ 34% HGD
  • 11. Surveillance for Barrett’s Esophagus • Not clear if useful but usually recommended • At first endoscopy perform extensive biopsy  No dysplasia, confirmed by second endoscopy within 1 year → EGD in 3-5 years  LGD EGD in 1 year vs. treatment  HGD In individual with reasonable life expectancy consider treatment
  • 12. Treatment of Barrett’s Esophagus • Control acid and inflammation usually by medication • Eradication of Barrett’ tissue by heat or cold or other methods • Removal of early cancer endoscopically • For advanced cancer either surgery or chemotherapy and radiation therapy
  • 13. HALO Device (Barrx Device) • A device delivers heat to get rid of Barrett’s tissue • Usually recommended for patients with dysplasia and few selected patients without dysplasia  About 90% chance of eliminating dysplasia and Barrett’s esophagus and at least tow fold decrease in cancer risk  Durable at 5 years but no longer term data
  • 14. When Do I Need to Seek Medical Care? • Symptoms are getting worse or inability to control them • When you are in doubt if something wrong • Need to seek immediate medical care • Trouble swallowing/chocking or sensation of food being stuck or lump in throat • Unintentional weight loss  Chest pain  Vomiting blood or having bowel movements that are black or look like tar
  • 15. Diagnosing GERD • Clinical by history and therapeutic trial • Endoscopy • PH testing • Esophageal manometry • Radiology
  • 16. Treatment of GERD • Life style modification • Medications • Endoscopic procedure • Surgery
  • 17. Life Style modification Not clear if it is effective but usually recommended • Lose weight (if you are overweight) • Raise the head of your bed by 6 to 8 inches • Avoid foods that make your symptoms worse • Coffee, chocolate, alcohol, peppermint, and fatty foods • Cut down on the amount of alcohol you drink • Stop smoking • Frequent small meal, avoid overeating • Eat a bunch of small meals each day • Avoid lying down for 3 hours after a meal
  • 18. Dietary factors that may aggravate GERD symptoms • Caffeinated • Spicy foods products • Citrus fruits and • Peppermint juices • Fatty foods • Tomato-based • Chocolate products • Alcohol
  • 20. Medications • Antacids work for mild infrequent episodes of GERD or as adjuvant to other medication in more severe case • Antihistamine work in mild GERD and not very effective to heal severe esophageal inflammation
  • 21. Medications • PPI as class are the strongest medication  Heal inflammation over 80%  Most work better if taken before meals  Usually once a day and occasionally twice a day  For symptoms control only initial treatment is 8 weeks • If symptoms relapse within 3 months usually are needed for long term  Goal of therapy is to use the lowest effective dose of medication  Usually safe but can lead to decrease bone dentistry and nutrient absorption and increase risk of infections especially clostridium difficile
  • 22. My Medications Are Not Working What Should I Do ? • If PPI, are you taking it before meal? • Change to different PPI • PPI twice a day • Additional testing • Consideration for surgery
  • 23. Surgery for GERD • Goal to increase barrier to acid reflux with minimal impact on the ability to swallow • Surgery plays an important role in patients with large hiatus hernia and those unable or unwilling to take long term medications • Majority are done laparoscopically, result depends on surgeon experience • Potential complications  Difficulty swallowing (5%)  Sense of bloating and gas  Breakdown of the repair (1 to 2 percent of patients per year)  Diarrhea due to inadvertent injury to the nerves
  • 25. Summary • GERD is common and in a majority of cases has benign course • Use lowest effective dose of medication • Trouble swallowing, chest pain or bleeding seek immediate attention • Barrett’s esophagus in a majority of cases does not lead to cancer, but keeping an eye on it is advisable
  • 26. For more information Call (908) 273.4300 Visit: summitmedicalgroup.com Connect with us on Facebook/SummitMedicalNJ Twitter: @SummitMedicalNJ

Editor's Notes

  1. Prevalence western country 10-20%, less in Asia, 7% of population may need long tern medication Mild one episode per week Severe >3 per week
  2. Heal 50 % of mild cases of erosive esophagitis