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
What is GastroEsophogeal Reflux Disease? (GERD)
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 Lower Esophageal Sphincter Duodenum Stomach Esophagus
Weak Sphincter (LES)? Unknown Weakens over time Family history Association with hiatal hernias
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.
Common (typical) Symptoms Heartburn Regurgitation Mild dysphagia Chest pain
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
PPI side effects Common side effects: –Diarrhea or constipation –Nausea –Headache Decreased calcium absorption Increased pneumonia risk Decreased Plavix efficacy Decreased magnesium absorption
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.
Antisecretory Medications Percentage of patients experiencing breakthrough symptoms while on a PPI (among all patients) 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 Why might medication not be effective?
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
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
Surgery options Nissen fundoplication LINX-magnetic sphincter augmentation