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

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

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.

Outline Overview Pathogenesis Clinical Presentation Differential Diagnosis Diagnostic evaluation Treatment

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

The Anatomy of the Disease

Normal Mid Esophagus

Normal GEJ

Mild Reflux Esophagitis

Severe GERD Ulceration

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

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

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

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

Schatzki Ring

Severe GERD Stricture

Barrett’s Esophagus

Esophageal Cancer

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

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

Infectious Esophagitis

Scleroderma

Radiation Injury

Peptic Ulcer Disease

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

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

Upper GI

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

Normal EGD

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

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

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

Treatment Lifestyle Modifications Drug Therapy Surgery New Therapies

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

Drug Therapies Antacids H2 Receptor Antagonists Proton Pump Inhibitors Prokinetic Drugs

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

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

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

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

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

Nissen Fundoplication

New Therapies Endoscopic therapies Endocynch Stretta Enteryx Photodynamic therapy

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

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

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

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