2Objectives:Examine general GERD overview, pathophysiology and disease progressionGERD symptoms-typical versus atypicalComprehensive Diagnosis of GERDOur current medical options for treatmentCurrent surgical options for treatmentSurgical interventions-what to expect
4GERD It is a chronic, often progressive disease Caused by a weak Lower Esophageal Sphincter (LES)LES is the body’s natural barrier to refluxEsophagusLower EsophagealSphincterDuodenumStomach
5Weak Sphincter (LES)? Unknown Weakens over time Family history Association with hiatal hernias
6Hiatal 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 GERDPicture obtained from Medicine Net, Inc.
12Complications of GERD (cont’d) Barrett’s esophagusCartoon 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).
14Esophageal CancerIncidence of adenocarcinoma arising out of Barrett’s esophagus is rising dramatically (Uptodate, 2015).Risk factors:Long standing GERD (>20 years)Severe symptomsSmokingObesityDaily sx increased odds of adenocarcinoma 7foldAmong patients who have Barrett’s esophagus, the risk of developing esophageal cancer is increased at least 30-fold above that of the general populationEndoscopic screening to detect dysplasia is recommended for patients with Barrett’s esophagus
15Comprehensive evaluation of GERD Patient visitArrange for endoscopic evaluationAdditional testing if neededEsophageal manometryBarium esophogram
16Upper endoscopy -VISUAL Evalution -Rule out significant lesion -Obtain biopsies (microscopic evaluation)-Rule out Barrett’s esophagus, EoE,candida, adenocarcinoma-Placement of pH monitor
17Breakthrough symptoms on PPIs Long-standing GERD (>5 years) Indications for EGDBreakthrough symptoms on PPIsLong-standing GERD (>5 years)Rule out other pathologyDysphagiaBarrett’s surveillanceScreeningMale, smoker, obese, >50 yrs80% of pts will have normal EGD
18Ambulatory pH testing -PHYSIOLOGIC evaluation -Most accurate test to establish diagnosis of GERD-Study can be programmed for hoursWireless receiver
26Dietary Modification Avoid trigger foods Fatty, spicy or fried foods Tomato based productsCaffeineChocolateAlcoholCarbonated beveragesSpecific trigger foods vary from person to personOmit the foods that cause problems
27Lifestyle Modifications Bed blocksAvoid overeatingLose excess weightAvoid postprandial recumbency
29Medical therapy BENEFITS Reduces the amount of acid in the stomach May reduce inflammation of esophageal liningProvides symptom relief for many patients, but relief can be temporaryLIMITATIONSDOES NOT affect the cause of reflux (LES)DOES NOT prevent refluxMay require life-long use and dose escalation
30Decreased calcium absorption Increased pneumonia risk PPI side effectsCommon side effects:Diarrhea or constipationNauseaHeadacheDecreased calcium absorptionIncreased pneumonia riskDecreased Plavix efficacyDecreased magnesium absorption
31Potential Risks of Long term PPI use FDA alertsFDA: Possible Fracture Risk with High Dose, Long-term Use of Proton Pump InhibitorsMay 25, 2010Labeling changes will include new safety informationThe 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 AnnouncementThe 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, 2012Safety AnnouncementThe 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.
32Antisecretory 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 enoughThey have symptoms that do not respond well to medication ie: regurgitation, chronic cough, hoarseness or asthmaReflux is not the primary cause of their symptoms – need to see Reflux Specialist for testing62%NOBreakthrough Symptoms38%Breakthrough Symptoms
33Patient profile with Progressive disease Family history of GERDTakes PPIs with complusive regularityHas increased symptom severity after 1 year of PPI therapyRequires dose escalation of PPIs to control symptomsEsophagitis on baseline endoscopyEsophagitis remaining unhealed after PPI therapyBarrett’s esophagus
34Surgical Options for GERD Medically refractory GERDEsophagitis despite medsHistory of Barrett’sConcerned with PPI side effectsIntolerant of meds/side effectsInterest in alternative optionsConcern/awareness of Barrett’s esophagus or esophageal cancerQOLHiatal hernia