1. Sally Bowa, RN, MSN, FNP-C Dr. Hass Jassim,
GERD Seminar
Sally Bowa, RN, MSN, FNP-C
Dr. Hass Jassim,

2. Objectives:
Examine general GERD overview, pathophysiology and disease progression
GERD symptoms-typical versus atypical
Comprehensive Diagnosis of GERD
Our current medical options for treatment
Current surgical options for treatment
Surgical interventions-what to expect

3. What is GastroEsophogeal Reflux Disease? (GERD)

4. GERD It is a chronic, often progressive disease
Caused by a weak Lower Esophageal Sphincter (LES)
LES is the body’s natural barrier to reflux
Esophagus
Lower Esophageal
Sphincter
Duodenum
Stomach

5. Weak Sphincter (LES)? Unknown Weakens over time Family history
Association with hiatal hernias

6. Hiatal hernia
-Upper part of stomach can herniate into the chest cavity
-Can contribute to GERD symptoms
-If the LES is functioning normally (barrier), a hiatal hernia alone does not necessarily cause GERD
Picture obtained from Medicine Net, Inc.

7. GERD SYMPTOMS

8. Common (typical) Symptoms
Heartburn
Regurgitation
Mild dysphagia
Chest pain

9. Atypical Symptoms Chronic cough Hoarseness Chronic sore throat
Dental problems
Recurrent (aspiration) pneumonia
Worsening asthma
Sleep disturbances
Globus sensation
Bad breath

10. Complications of GERD
Esophagitis
Stricture

11. Complications of GERD (cont’d)
Pulmonary
ENT
-Poor asthma control
-Cough
-Aspiration pneumonia
-pulmonary fibrosis
-Hoarseness
-Voice changes
-Chronic ear infections
-Chronic sinusitis
-Sore throat
-Globus sensation

12. Complications of GERD (cont’d)
Barrett’s esophagus
Cartoon depicting the appearance when the squamocolumnar and gastroesophageal junctions coincide. In this situation, there is no apparent columnar-lined esophagus (ie, the entire esophagus is lined by squamous epithelium).

13. Barrett’s Esophagus cont’d

14. Esophageal Cancer
Incidence of adenocarcinoma arising out of Barrett’s esophagus is rising dramatically (Uptodate, 2015).
Risk factors:
Long standing GERD (>20 years)
Severe symptoms
Smoking
Obesity
Daily sx increased odds of adenocarcinoma 7fold
Among patients who have Barrett’s esophagus, the risk of developing esophageal cancer is increased at least 30-fold above that of the general population
Endoscopic screening to detect dysplasia is recommended for patients with Barrett’s esophagus

15. Comprehensive evaluation of GERD
Patient visit
Arrange for endoscopic evaluation
Additional testing if needed
Esophageal manometry
Barium esophogram

16. Upper endoscopy -VISUAL Evalution -Rule out significant lesion
-Obtain biopsies (microscopic evaluation)
-Rule out Barrett’s esophagus, EoE,
candida, adenocarcinoma
-Placement of pH monitor

17. Breakthrough symptoms on PPIs Long-standing GERD (>5 years)
Indications for EGD
Breakthrough symptoms on PPIs
Long-standing GERD (>5 years)
Rule out other pathology
Dysphagia
Barrett’s surveillance
Screening
Male, smoker, obese, >50 yrs
80% of pts will have normal EGD

18. Ambulatory pH testing -PHYSIOLOGIC evaluation
-Most accurate test to establish diagnosis of GERD -
Study can be programmed for hours
Wireless receiver

19. Case Study #1
Patient #1

20. Case Study #2
Patient #2

21. Esophageal Manometry
Functional evaluation of esophagus and LES

22. Case study #1 cont’d

23. Case study #2 cont’d

24. Barium Esophogram
Visualizes the swallowing mechanism, esophagus
Contrast study using barium
Radiopaque
Appears white on the film

25. Symptom Management & Treatment Options

26. Dietary Modification Avoid trigger foods Fatty, spicy or fried foods
Tomato based products
Caffeine
Chocolate
Alcohol
Carbonated beverages
Specific trigger foods vary from person to person
Omit the foods that cause problems

27. Lifestyle Modifications
Bed blocks
Avoid overeating
Lose excess weight
Avoid postprandial recumbency

28. Medical Therapy Antacids H2 Blockers Proton Pump Inhibitors Mylanta
Pepto-Bismol
Rolaids
Tums
H2 Blockers
Pepcid
Tagamet
Zantac
Proton Pump Inhibitors
Aciphex
Nexium
Prevacid
Prilosec

29. Medical therapy BENEFITS Reduces the amount of acid in the stomach
May reduce inflammation of esophageal lining
Provides symptom relief for many patients, but relief can be temporary
LIMITATIONS
DOES NOT affect the cause of reflux (LES)
DOES NOT prevent reflux
May require life-long use and dose escalation

30. Decreased calcium absorption Increased pneumonia risk
PPI side effects
Common side effects:
Diarrhea or constipation
Nausea
Headache
Decreased calcium absorption
Increased pneumonia risk
Decreased Plavix efficacy
Decreased magnesium absorption

31. Potential Risks of Long term PPI use
FDA alerts
FDA: Possible Fracture Risk with High Dose, Long-term Use of Proton Pump Inhibitors
May 25, 2010
Labeling changes will include new safety information
The U.S. Food and Drug Administration today warned consumers and health care professionals about a possible increased risk of fractures of the hip, wrist, and spine with high doses or long-term use of a class of medications called proton pump inhibitors. The product labeling will be changed to describe this possible increased risk.
FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs)
March 2, 2011 Safety Announcement
The U.S. Food and Drug Administration (FDA) is informing the public that prescription proton pump inhibitor (PPI) drugs may cause low serum magnesium levels (hypomagnesemia) if taken for prolonged periods of time (in most cases, longer than one year). In approximately one-quarter of the cases reviewed, magnesium supplementation alone did not improve low serum magnesium levels and the PPI had to be discontinued.
FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs)
February 8, 2012
Safety Announcement
The U.S. Food and Drug Administration (FDA) is informing the public that the use of stomach acid drugs known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that does not improve. Patients should immediately contact their healthcare professional and seek care if they take PPIs and develop diarrhea that does not improve.

32. Antisecretory Medications
Percentage of patients experiencing breakthrough symptoms while on a PPI
(among all patients)
Why might medication not be effective?
Disease is progressing – sphincter is getting worse and medication no longer is enough
They have symptoms that do not respond well to medication ie:  regurgitation, chronic cough, hoarseness or asthma
Reflux is not the primary cause of their symptoms – need to see Reflux Specialist for testing
62% NO
Breakthrough Symptoms
38%
Breakthrough Symptoms

33. Patient profile with Progressive disease
Family history of GERD
Takes PPIs with complusive regularity
Has increased symptom severity after 1 year of PPI therapy
Requires dose escalation of PPIs to control symptoms
Esophagitis on baseline endoscopy
Esophagitis remaining unhealed after PPI therapy
Barrett’s esophagus

34. Surgical Options for GERD
Medically refractory GERD
Esophagitis despite meds
History of Barrett’s
Concerned with PPI side effects
Intolerant of meds/side effects
Interest in alternative options
Concern/awareness of Barrett’s esophagus or esophageal cancer
QOL
Hiatal hernia

35. Surgery options Nissen fundoplication
LINX-magnetic sphincter augmentation

36. Dr. Jassim’s presentation