A gastroenterologist’s view of GERD and its pre-

operative workup

George Triadafilopoulos, MDClinical Professor of MedicineStanford University School of

MedicineM.I.S.S. 2.22.2011 Disclosures: None

Outline

• What can happen

• How do we find out

• What can we do about it

- Erosive reflux disease (ERD): Erosions in the distal esophagus- Non-erosive reflux disease (NERD): Normal esophagus and abnormal pH- Barrett’s esophagus: Endoscopic and histologic evidence of intestinal metaplasia/dysplasia

= Heartburn/regurgitation

Not all GERD is the same…

• NERD (most common)• Erosive esophagitis (LA B, C and

D)– +/- Hiatal hernia

• Refractory GERD• Consequences of repair – Peptic stricture – Barrett's metaplasia

• Extra-esophageal manifestations – Asthma – Laryngitis– CoughHiatal hernia

Peptic stricture

PPI therapy in GERD• The most effective medical therapy available– 90%+ healing rates– 70%+ symptom control rates

• Symptoms may continue despite therapy

• Relapses may still occur despite maintenance therapy

• Subject to drug-drug interactions, long-term side effects and poor adherence

Understand

Understand PreventPrevent ManageManage

PPI drawbacks

PPI may lose efficacy over time!  Total percentage acid exposure time at baseline, at the time of normalization, and

at 2-year follow-up.

Frazzoni M, Dig Liv Dis 2007

Long term PPI safety

• Pneumonia• C.difficile infection• Other enteric infections• Hypergastrinemia• Atrophic gastritis• Vitamin B12 malabsorption• Hip fractures• Drug interactions

GERD in primary care

• Patients with heartburn, regurgitation, or chest pain, are typically treated initially with proton pump inhibitors (PPI).

• 3 possible outcomes:– Complete response (no symptoms)– Partial response (breakthrough

symptoms)–No response (no change in

symptoms)

Refractory GERD

Clinically significant impairment of health-related well-being (GERD-HRQoL) due to

episodes of gastro-esophageal reflux while on PPI therapy

“GERD” symptoms may not always reflect the acidity of the refluxate but may be due to: refluxate volume, esophageal distensibility and sensitivity to acid

Differential Diagnosis

-Achalasia & dysmotility: Defined manometrically- EoE: > 25 eosinophils / hpf- RD (Reflux-like dyspepsia): Normal endoscopy, biopsies and pH monitoring - Gastroparesis: Normal endoscopy, abnormal GES

Clinical evaluation

Endoscopy

Esophageal biopsy

Eosinophilic esophagitis Barrett’s esophagus

Esophageal Motility

• Non-invasive & quasi-physiologic

• Measures effectiveness of peristalsis and LES pressure/relaxation

• Essential in defining esophageal dysmotility (achalasia, spasm, etc)

Fox, M R et al. Gut 2008;57:405-4

HRM depicts esophageal pressure activity from the pharynx to the stomach

• Non-invasive & physiologic

• Quantifies acid reflux (off/on Rx)

• Correlates symptoms to acid reflux

• Sensitivity and specificity > 90%

• Indispensable for atypical & refractory cases

24-hr ambulatory pH monitoring

“Abnormal” intra-esophageal pH profile on PPI

56 yo man with persistent heartburn while on PPI

24-hr pH study on lansoprazole (30 mg bid)

DeMeester score (on therapy): 17.3

% time intra-gastric pH < 4.0: 57.4

On high-dose PPI, this patient has achieved an inadequate intra-gastric pH control, resulting in persistent symptomatic GERD

ie pH

ig pH

62 yo man with belching/regurgitation but no heartburn while on

PPI

24-hr pH study on rabeprazole 40mg bid.

DeMeester score (on therapy): 12.9

% time ig pH<4.0: 27.4

“Normalized” intra-esophageal & intra-gastric pH profile

Disease prevalence in PPI-refractory GERD

270 patients (143 men and 127 women), aged 16-89 years

%

Triadafilopoulos G et al. Gastroenterology 2010

Acid reflux frequently overlaps

%

Triadafilopoulos G et al. Gastroenterology 2010

Reasons to consider endoscopic therapies

for GERD

Refractory GERD

Persistent heartburn despite escalating PPIs

Residual regurgitation without heartburn on PPIs

PPI intolerance (2% of users)

Desire to stop drug therapy (concerns about long-term effects)

Concerns about LARS side effects (i.e. dysphagia, gas bloat)

Symptomatic GERD after fundoplicationTriadafilopoulos, G. Am. J. Med. 115(3A): 192S-200S, 2003.

Fundic polyps

StrettaCatheter

Module

Radiofrequency Rx

Enhances LESP

Reduces tLESRs

Transoral incisionless fundoplication (TIF)

Serosa-to-serosa Serosa-to-serosa fixationfixation

FastenersFasteners

Full thickness tissue plications are used to reconstruct & augment the ARB

Pre Pre TIFTIF

Post Post TIFTIF

Serosa-to-serosa fixation Serosa-to-serosa fixation at 2wksat 2wks

Who are not good candidates for EndoRx?

• Patients with refractory GERD who have a large, fixed, hiatal hernia (> 3 cm long) and foreshortened esophagus

Laparoscopic Nissen fundoplication

• Patients with “functional” heartburn

– Patients with 0 % response to PPIs

– “Les malades du petit papier”

–Negative pH studies + no symptom correlation with acid events

Who are not good candidates for either

endoscopic or surgical therapy?

Bravo pH monitoring

Conclusions

• Reflux symptoms may or may not reflect GERD

• PPI therapy is widely used and quite effective in ~80% of cases

• Structural and functional evaluation of the esophagus are essential in refractory cases

• Emerging role of endoscopic and newer surgical therapies

• Multidisciplinary approach is essential to successful outcomes