Gastroesophageal Reflux Disease

(GERD)
Any symptoms or esophageal mucosal damage
that results from reflux of gastric acid into the
esophagus
Classic GERD symptoms
Heartburn (pyrosis): substernal burning discomfort
Regurgitation: bitter, acidic fluid in the mouth
when lying down or bending over
Locke et al. Gastroenterology 1997;112:1148.
High Prevalence of Gastroesophageal
Reflux Symptoms
19.8%
59%
0%
10%
20%
30%
40%
50%
60%
Weekly Monthly
Frequency of heartburn and/or
regurgitation
Important Reasons to Diagnose and Treat
GERD
Negative impact on health-related quality of life
1
Risk factor for esophageal adenocarcinoma
2


1. Revicki et al. Am J Med 1998;104:252.
2. Lagergren et al. N Engl J Med 1999;340:825.
Clinical Presentations of GERD
Classic GERD
Extraesophageal/Atypical GERD
Complicated GERD
Extraesophageal Manifestations
of GERD
Pulmonary
Asthma
Aspiration pneumonia
Chronic bronchitis
Pulmonary fibrosis


Other
Chest pain
Dental erosion
ENT
Hoarseness
Laryngitis
Pharyngitis
Chronic cough
Globus sensation
Dysphonia
Sinusitis
Subglottic stenosis
Laryngeal cancer

Potential Oral and Laryngopharyngeal Signs
Associated with GERD
Edema and hyperemia of
larynx
Vocal cord erythema,
polyps, granulomas,
ulcers
Hyperemia and lymphoid
hyperplasia of posterior
pharynx
Interarytenyoid changes
Dental erosion
Subglottic stenosis
Laryngeal cancer
Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.
Pathophysiology of Extraesophageal
GERD
Symptoms of Complicated GERD
Dysphagia
Difficulty swallowing: food sticks or hangs up
Odynophagia
Retrosternal pain with swallowing
Bleeding
When to Perform Diagnostic Tests
Uncertain diagnosis
Atypical symptoms
Symptoms associated with complications
Inadequate response to therapy
Recurrent symptoms
Prior to anti-reflux surgery
Diagnostic Tests for GERD
Barium swallow
Endoscopy
Ambulatory pH monitoring
Esophageal manometry
Barium Swallow
Useful first diagnostic test for
patients with dysphagia
Stricture (location, length)
Mass (location, length)
Birds beak
Hiatal hernia (size, type)
Limitations
Detailed mucosal exam for erosive
esophagitis, Barretts esophagus
Endoscopy
Indications for endoscopy
Alarm symptoms
Empiric therapy failure
Preoperative evaluation
Detection of Barretts
esophagus
Ambulatory 24 hr. pH Monitoring
Physiologic study
Quantify reflux in
proximal/distal
esophagus
% time pH < 4
DeMeester score
Symptom correlation

Ambulatory 24 hr. pH Monitoring
Normal
GERD
Wireless, Catheter-Free Esophageal pH Monitoring

Improved patient
comfort and acceptance
Continued normal work,
activities and diet study
Longer reporting periods
possible (48 hours)
Maintain constant probe
position relative to SCJ

Potential Advantages
Esophageal Manometry
Assess LES pressure,
location and relaxation
Assist placement of 24 hr.
pH catheter
Assess peristalsis
Prior to antireflux surgery
Limited role in GERD

Treatment Goals for GERD
Eliminate symptoms
Heal esophagitis
Manage or prevent complications
Maintain remission
Lifestyle Modifications are
Cornerstone of GERD Therapy
Elevate head of bed 4-6 inches
Avoid eating within 2-3 hours of bedtime
Lose weight if overweight
Stop smoking
Modify diet
Eat more frequent but smaller meals
Avoid fatty/fried food, peppermint, chocolate,
alcohol, carbonated beverages, coffee and tea
OTC medications prn

Acid Suppression Therapy for GERD
H
2
-Receptor Antagonists
(H
2
RAs)

Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Nizatidine (Axid)
Proton Pump Inhibitors
(PPIs)

Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex)
Pantoprazole (Protonix)
Esomeprazole (Nexium )

Effectiveness of Medical Therapies for
GERD
Treatment Response

Lifestyle modifications/antacids 20 %

H
2
-receptor antagonists 50 %

Single-dose PPI 80 %

Increased-dose PPI up to 100 %
Treatment Modifications for
Persistent Symptoms
Improve compliance
Optimize pharmacokinetics
Adjust timing of medication to 15 30 minutes
before meals (as opposed to bedtime)
Allows for high blood level to interact with
parietal cell proton pump activated by the meal
Consider switching to a different PPI
GERD is a Chronic Relapsing Condition
Esophagitis relapses quickly after cessation
of therapy
> 50 % relapse within 2 months
> 80 % relapse within 6 months
Effective maintenance therapy is imperative
Complications of GERD
Erosive/ulcerative esophagitis
Esophageal (peptic) stricture
Barretts esophagus
Adenocarcinoma
Erosive Esophagitis
Peptic Stricture
Barium Swallow
Endoscopy
Esophageal Stricture: Dilating Devices
TTS Balloon Dilation of a Peptic Stricture
Barretts Esophagus
Esophageal Cancer
Barium Swallow Endoscopy
When to Discuss Anti-Reflux
Surgery with Patients
Intractable GERD rare
Difficult to manage strictures
Severe bleeding from esophagitis
Non-healing ulcers
GERD requiring long-term PPI-BID in a
healthy young patient
Persistent regurgitation/aspiration symptoms
Not Barretts esophagus alone

Endoscopic GERD Therapy
Endoscopic antireflux therapies
Radiofrequency energy delivered to the LES
Stretta procedure
Suture ligation of the cardia
Endoscopic plication
Submucosal implantation of inert material in
the region of the lower esophageal sphincter
Enteryx