GASTROESOPHAGEAL REFLUX

DISEASE (GERD)

IAGH Meeting

S Darvish Moghadam

KMU, Bahman 1393

Sources 1-Katz, et al. ACG Guidelines for the Diagnosis and

Management of GERD. Am J Gastroenterol 2013

2-Kahrilas, et al. AGA Medical Position Statement on

the Management of GERD, Gastroenterol 2008

3-Auyang, et al. Endoluminal Treatments for GERD.

Society of American Gastrointestinal and Endoscopic

Surgeons. Surgical Endoscopy. 2010, 2012

4-Vakil, et al. The Montreal definition and

classification of GERD: Am J Gastroenterol 2006

5-Richter, the management of heartburn in

pregnancy, APT 2005

Sources

6-Heidelbaugh,et al. atypical presentations of GERD.

Am Fam Physician. 2008

7-Kahrilas. GERD. N Engl J Med. 2008

Bloom.The modern investigation and management of

GERD. Clinical Medicine 2009

Kripke. Medical management vs. surgery for GERD. Am Fam Physician. 2010

UTD 2015

DDW 2014

GERD Definition:Montreal Classification

No standard criterion definition

Reflux of stomach & duodenal contents into

the esophagus with troublesome symptoms

and/or complications

Heartburn is the main symptom

occuring two or more days a week

Chronic recurrent disease

Impaired QOL

Am J Gastroenterol 2006, Gastroenterol 2008

Definitions of Reflux

Physiologic reflux

– occur postprandially, short-lived,

asymptomatic, rarely during sleep

Pathologic reflux

– symptomatic or mucosal injury, often

nocturnal episodes

Reflux esophagitis

– endoscopic or histopathologic

inflammation

GERD: prevalence

Is based on heartburn &/or regurgitation

But

objective evidence of GERD

(esophagitis or Barrett's) always have

heartburn? No

Heartburn is always indicative of

GERD? No Gut 2008; 57:1354

GERD: prevalence

Prevalence: increasing trend in last 2

decade

weekly heartburn and/or regurgitation

Western world: 10 – 20% 48%

Asia: < 5 %

2.5%-4.8% before 2005 5.2%-8.5%

from 2005 to 2010 Gut 2005; 54:710

J Neurogastroenterol Motil 2011;17:14

GERD: prevalence in Iran

Ehsani:Tehran 39.7%;D: 7%, W: 8%, M: 21% Gastroenterol 2006

Mansour-Ghanaei: D: 2.4%, W: 9.1%, M:

11.3% Int J Mol Epidemiol Genet 2013

Somi: W: 26.8%, M: 34.1%, Iranian J Publ Health

2008

Kerman: 29.3%, 2012 IAGH congress abstract

Fazel: Sepahan Systematic Review, 22 study

1.9 - 52%. Int J Prevent Med, 2012

Delavari: Systematic Review, 15 study, W:

21.2%, MEJDD 2012

Frequency of Endoscopic GERD

Iranian Experience: 1994-1999

GERD

0%

20%

40%

60%

80%

100%

94 95 96 97 98 99

Retrospective study of 4500 UGIE reports (5y): 34.3% E-GERD

Malekzadeh,et al 2000

GERD- pathphysiology

Acid reflux

Non acid reflux- weak acid

Physiologic reflux

Pathologic reflux

non-acid reflux: estimated prevalence

GERD- Risk factors

Hiatal hernia

Obesity

Pregnancy

prolonged gastric emptying

Smoking

Alcohol

Anticholinergic, calcium channel

blockers, smooth muscle relaxants

2º GERD!!

Heartburn-

retrosternal burning

pain extend up into

the neck

GERD- manifestations

GERD- manifestations

Esophageal: heartburn- poor predictor

– regurgitation, dysphagia, odynophagia,

nausea

Extraesophageal

– bronchospasm, laryngitis, chronic cough,

chest pain, water brash, hoarseness, throat

clearing, globus?

Complications

– esophagitis, ulcer, stricture, Barrett’s, Ca

GERD- diagnosis

can be based on clinical symptoms

alone

Diagnostic evaluation neither necessary

nor practical to do for every patient with

heartburn

Response to Rx is not accurate enough

GERD- additional evaluation

Double contrast barium swallow

Low accuracy

Useful for * esophagitis * stricture

EGD, Bx

pH monitoring, Pepsin in refluxate

MII + pH

Manometry

ECG, exercise stress test in chest pain

GERD- esophagoscopy

intra & inter- operator variability

– Non-erosive, vs erosive

Los Angeles classification: A – D

– Based on mucosal breaks

Savary-Miller: Includes complications

– I: reddish spots

– II: erosions

– III: exudative circumferential erosions,

– IV: ulcers, stenosis, Barrett's V: metaplasia

GERD- EGD

Endoscopy indicated if:

Prolonged duration >5- 10 y, men > 50 y/o

not responsive to empiric Rx

troublesome dysphagia, GIB

systemic symptoms: weight loss, anemia

Repeat endoscopy in severe erosive esophagitis after a course of Rx

GERD guideline, AJG 2013

No sufficient data for screening endoscopy to diminish

the risk of death from Barrett’s or Ca Gastroenterol 2008

GERD- Bx

Normal endoscopy is not equal to Nl histology

Not indicated for diagnosis of GERD

Bx for suspected metaplasia, dysplasia

normal mucosa for eosinophilic esophagitis

Findings: non specific

– basal cell layer hyperplasia

– papillae elongation

– Neutrophils, eosinophils

– Vascular dilation, "balloon" squamous cells

Gastroenterol 2008

GERD- pH monitoring

Acid reflux: reflux of gastric contents

with a pH <4.0

withhold PPI Rx for 1 week before test

Recording devices

– transnasal catheter

– wireless capsule

combined multichannel intraluminal

impedance and pH (MII-pH) monitoring

GERD- pH monitoring indications

confirming Dx with persistent symptoms

& with normal endoscopy

failed twice daily PPI Rx

Monitoring adequacy of Rx in persistent

symptoms

supra-esophageal complications such

as reflux laryngitis or cough

Considering endoscopic or surgical Rx GERD guideline, AJG 2013, Gastroenterol 2008

GERD- Manometry

minimal role in diagnosis of GERD

ensuring correct place of pH probes

before antireflux surgery for peristaltic

function

to exclude motor disorders: achalasia /

scleroderma UTD 2015

GERD- Management, lifestyle

Recommended

Weight loss

Head elevation

avoidance of late-night meals

No meals 2 – 3 h before bedtime

Beneficial for nighttime heartburn or

regurgitation

GERD guideline, AJG 2013, Gastroenterol 2008

GERD- Management, lifestyle

Avoid

coffee, chocolate, fatty foods

acidic foods: citrus, carbonated drinks

spicy foods

alcohol, tobacco

GERD guideline, AJG 2013, Gastroenterol 2008

GERD- drug Rx

H2RA: mild symptoms, NERD

Also as maintenance in NERD

Duration: 8 w, D/C if asymptomatic

PPI: severe frequent symptoms, Erosive

As maintenance Rx in severe erosive

esophagitis, Barrett's

GERD Rx- role of PPI

PPIs inhibit gastric acid secretion

do not affect structural and motility

– HH, LES pressure, tLESR

PPIs do not decrease reflux

PPI concerns

no major difference in efficacy between PPIs

“step up” or “step down”?

titrate down to the lowest effective dose

Non-responders should refer for evaluation

no evidence to support adding nocturnal

H2RA to twice-daily PPI

Gastroenterol 2008

GERD-on-demand Rx

Reasonable strategy in esophageal GERD without

esophagitis

– Practically, many subjects often use intermittently

Not recommended in:

– Extra- esophageal

– Healed erosive esophagitis

Gastroenterol 2008

GERD- Rx, other drugs

Antacids

Sodium alginate

Metoclopramide

Domperidone

Cisapride

Baclofen

Am Fam Physician.

2008

DDW 2014

GERD Rx- in pregnancy

Antacids or sucralfate: first-line drug Rx

Then: H2RA

PPI roton for intractable symptoms or

complicated GERD

All but omeprazole are FDA category B

Of systemic agents, only the H2RA, except

nizatidine, are safe during lactation

APT 2005

GERD- preoperative evaluation

Upper endoscopy

esophageal manometry

assessment of esophageal length

degree of hiatal herniation

GERD- Fundoplication

Nissen, Troupet, Hill gastropexy

GERD- Endoluminal Treatments

Radiofrequency Rx

Endoscopic Plication System (EPS)

EsophyX: Endoluminal fundoplication

(ELF)

– Transoral Incisionless Fundoplication (TIF)

– “hybrid” technique: laparoscopic posterior

cruroplasty and standard TIF

GERD- radiofrequency Rx

unsatisfactory control of GERD with PPI

do not wish to be on long-term medical

Rx

considering fundoplication

Overall response , 55 – 83% in 12 - 33

months

Stretta RF: uses low power (5 Watts) RF energy and

generates low tissue temperatures (65 -85C) in one-minute

cycles

SAGES, Surgical Endoscopy. Literature Review 2012

EsophyX: Transoral Incisionless Fundoplication

A-TIF 1 gastrogastric wrap fundoplication

B- TIF 2 esophagogastric fundoplication above Z line

Society of American Gastrointestinal and Endoscopic Surgeons

Surgical Endoscopy. 2010

GERD- challenges

Does GERD progress in Severity?

Does non-erosive progress to erosive,

metaplasia, Barrett’s?

Does it warrant endoscopic monitoring? No

Can we stop medications?

What about Hpylori?

Gastroenterol 2008

Does GERD progress?

first view: “spectrum of disease”

progressive disease: going from today’s

nonerosive to tomorrow’s erosive &, Barrett’s

contrasted view: “discreet categories”

nonerosive, erosive esophagitis, Barrett’s

conversion is unusual, subjects stay in their

initial category

Gastroenterol 2008

Does GERD progress?

Available limited data: GERD sometimes may

progress from non-erosive to erosive dis.

reported rates of progression are relatively

low over a 20-year period

Progression after a normal index endoscopy,

in 7-year follow-up:

stricture:1.9%, Barrett’s: 0.0%, adenoca:

0.1%,

GERD- endoscopy F/U

Most importantly, endoscopic

monitoring in chronic GERD without

alarm symptoms has not been shown to

diminish the risk of cancer, and this

practice is discouraged Gastroenterol 2008

GERD- stop medications?

Yes in: mild , non frequent symptoms and no

relapse after a course of Rx

No in: severe symptoms, severe esophagitis

(LA: C-D), Barrett's

UTD 2015

GERD & H. pylori

available data suggest that H. pylori,

particularly Cag A strains, may be protective

against the severe forms of GERD, Barrett's

metaplasia, esoph. adenocarcinoma

corpus-dominant or pangastritis

antrum-dominant gastritis

Long term PPI use

Screening & treatment for is not recommended

GERD guideline, AJG 2013

Jovārish-e Jālīnūs, the herbal treatment of GERD,

Shirzad, Res Hist Med 2013

GERD- overall recommendation

Don’t use many combined Dx procedures

Do not switch PPIs frequently

No routine use of calcium supplement, BDM,

H pylori screening due to PPI Rx

Give him/ her an opportunity for a simple life

I’m worried and concerned

GI symptoms bother me!

My whole life is affected

Heartburn disturbs my

sleep

I cannot eat and drink whatever

I like

I cannot bend over or exercise

Illustrator: Eric Werner