1. Gastro Esophageal Reflux Disease Presented for Sherman Hospital By Lawrence R. Kosinski, MD, MBA, FACG March 24 th, 2004

2. Goals To understand the difference between Heartburn and GERD To be able to recognize the symptoms of GERD To know the potential serious complications of GERD To understand how we diagnose GERD To understand the treatment of GERD

3. Definitions Gastroesophageal reflux disease (GERD) A symptomatic clinical condition resulting from episodes of gastroesophageal reflux. Reflux esophagitis (RE) A subset of GERD patients with demonstrable changes in the esophageal mucosa.

4. Outline Overview Pathogenesis Clinical Presentation Differential Diagnosis Diagnostic evaluation Treatment

5. Overview One third of Americans occasionally have heartburn every year Most common reason for the use of OTC antacids 7% of Americans have heartburn on a regular basis and have GERD Most of chronic GERD patients have Esophagitis males = females for GERD males predominate with RE proportional to age

6. The Anatomy of the Disease

7. Normal Mid Esophagus

8. Normal GEJ

9. Mild Reflux Esophagitis

10. Severe GERD Ulceration

11. Pathogenesis of GERD Abnormal LES Hypotensive LES Transient LES relaxation Hiatal Hernia Decreased Esophageal acid clearance Role of stimulated peristalsis Role of saliva

12. Clinical Presentation Typical Symptoms Heartburn Regurgitation Dysphagia Atypical Symptoms Chest Pain Respiratory Symptoms ENT Symptoms Globus Syndrome

13. Natural History Most patients have symptoms for 3yrs before they seek help Most patients with GERD have Reflux Esophagitis When GERD is associated with RE, it is usually chronic We must identify the RE patient You can’t tell just from the symptoms

14. Complications of Reflux Esophagitis Ulceration in 5% Stricture in 8 ‑ 20% Barretts in 8 ‑ 20% Hemorrhage in less than 2% Esophageal Cancer

15. Schatzki Ring

16. Severe GERD Stricture

17. Barrett’s Esophagus

18. Esophageal Cancer

19. Risk factors Obesity/Eating habits Smoking Drugs Hiatal Hernia Post surgical

20. Differential Diagnosis Non ‑ GERD esophagitis Infections: Candida, Herpes, CMV Pills: Tetracycline, KCL, NSAIDS, AZT, Quinaglute Systemic diseases: Crohn's, Behcet's, Pemphigus Radiation therapy Peptic ulcer disease Functional Dyspepsia Syndrome (IBS) Biliary /Pancreatic disease Esophageal Motility Disorders Diffuse esophageal spasm ‑ Achalasia ‑ Nutcracker esophagus

21. Infectious Esophagitis

22. Scleroderma

23. Radiation Injury

24. Peptic Ulcer Disease

25. Diagnostic Evaluation Upper GI Esophagogastroduodenoscopy (EGD) Esophageal Motility Study (EMS) 24hr Ph study Capsule Endoscopy

26. Upper GI Diagnostic only Inexpensive $ 300 20% sensitivity for GERD Limited ability to detect RE No ability to detect Barrett's No ability to biopsy

27. Upper GI

28. EGD Diagnostic and therapeutic Expensive > $ 1000 60 ‑ 70% sensitivity for GERD Near 100% sensitivity for RE ‑ Detects Barrett's Ability to obtain a biopsy

29. Normal EGD

30. Esophageal Motility Study Measures esophageal pressure during swallowing Most patients with GERD have normal studies Useful for the preoperative evaluation before GERD surgery

31. 24hr Ph Study Diagnostic only Moderately expensive $ 500 88% sensitive for GERD Limited indications Useful in the evaluation of chest pain Uncomfortable for the patient New Bravo System

32. Capsule Endoscopy Currently only approved for visualizing the small intestine Capable of visualizing the esophagus Needs to have some adjustments Video

33. Treatment Lifestyle Modifications Drug Therapy Surgery New Therapies

34. Lifestyle Modifications Cigarette smoking decreases LES pressure delays esophageal acid clearance decreases saliva output Eating habits discourage overeating at one meal discourage eating before reclining or exercising encourage weight control Elimination of certain foods Medication adjustments Theophyline Progesterone Ca channel blockers Fosamax

35. Drug Therapies Antacids H2 Receptor Antagonists Proton Pump Inhibitors Prokinetic Drugs

36. Antacids Useful for mild and infrequent symptoms Immediate effect but short acting Need to be taken frequently Prescribed 1 ‑ 3hrs postprandial and at HS Gaviscon useful for upright GERD symptoms No good data to show ability to heal RE

37. H2 Receptor Antagonists All H2RAs equally effective in appropriate doses GERD vs PUD therapeutic differences Dose after dinner since this is peak acid output time Heals RE in 60% of patients after 12 weeks of H2RA therapy Expense Zantac>Pepcid>Axid>Tagamet

38. Proton Pump Inhibitors Heal RE in >80% of patients after 8 weeks of therapy Prolonged therapy heals near 100% Superior to H2RA Approved by FDA for chronic use Aciphex, Prevacid, Prilosec, Protonics, Nexium

39. Prokinetic Agents Metoclopramide (Reglan) Cisapride Not available in USA Erythromycin Tegaserod (Zelnorm)

40. Surgery Indications Persistent ulceration Persistent stricture Persistent aspiration Chronic Regurgitation Dependency on PPIs in young patients Procedure Laparoscopic Nissen Fundoplication

41. Nissen Fundoplication

42. New Therapies Endoscopic therapies Endocynch Stretta Enteryx Photodynamic therapy

43. Endocynch Endoscopic Procedure designed to place a stitch in the GE Junction Cumbersome to perform Effects only lasted 6 months No longer done

44. Stretta Effective in Controlling Pain from GERD in 70% of cases Safe Sham Study failed to establish effect on Reflux May not be performed in the future

45. Enteryx Polymer that is injected into the GE Junction Endoscopically Sham Study in progress Long Term Effectiveness and Safety need to be established

46. Prevention Nutritional Issues Weight Control Eating Habits Foods Chocolate Mint Restrictive Garments Exercise after eating