New Techniques and Perspectives Presented on: May 17th 2014 Update in GERD New Techniques and Perspectives Presented on: May 17th 2014 John E. Pandolfino, MD, MSCI Professor of Medicine Feinberg School of Medicine, Northwestern University Chief, Division of Gastroenterology and Hepatology Northwestern Medicine Northwestern Memorial Hospital

GERD is a condition which develops when the reflux of stomach content causes troublesome symptoms and / or complications Esophageal Syndromes Extra-esophageal Syndromes Symptomatic Syndromes Typical reflux syndrome Reflux chest pain syndrome Syndromes with Esophageal Injury Reflux esophagitis Reflux stricture Barrett's esophagus Adenocarcinoma Established Association Reflux cough Reflux laryngitis Reflux asthma Reflux dental erosions Proposed Association Sinusitis Pulmonary fibrosis Pharyngitis Recurrent otitis media Vakil N et al. Am J Gastroenterol 2006;101:1900

Functional Heartburn/Chest Pain Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation no Alarm features? PPI Trial yes no Heartburn resolved? Reflux disease: titrate PPI therapy yes Esophagitis EoE Abnormal? EGD ± biopsy no pH or impedance-pH monitoring (off of PPIs) no >5% esophageal acid exposure? yes NERD Esophageal manometry Meets esophageal motor disorder criteria? Achalasia DES yes no Positive symptom association? yes no MII-pH monitoring (on PPIs) Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747

EGD ± biopsy Functional Heartburn/Chest Pain Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation Alarm features? PPI Trial yes no Heartburn resolved? Reflux disease: titrate PPI therapy yes Esophagitis EoE Abnormal? EGD ± biopsy no pH or impedance-pH monitoring (off of PPIs) no >5% esophageal acid exposure? yes NERD Positive symptom association? yes no Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747

Phenotyping PPI Non-responders: Low pre-test probability of refractory GERD Bravo capsule placed 6cm above SCJ The Bravo system is an FDA class I approved radioltelemtry pH monitoring system that has become extremely popular due to the fact that it is easy to perform and subjects would rather not wear a Ph catheter for 24 hours.. It entails placing a small pH capsule directly onto the esophageal wall. The pH capsule contains an antimony pH electrode on the distal tip along with the reference probe. There is an internal battery which may last 3 to 5 days and an internal transmitter. The electronics are all encapsulated in epoxy. It is 6 mm wide x 5.5 mm high and 25 mm long. It can be placed orally or transnasally using either manometric or endoscopic landmarks. We prefer to place it orally as there have been anecdotal reports of significant nasal trauma after nasal passage. Pandolfino et al. Am J Gastroenterol. 2003 Apr;98(4):740-9

Phenotyping PPI Non-responders: High pre-test probability of refractory GERD 10000 ohms 3 cm 5 cm 7 cm 9 cm 15 cm 17 cm Bravo capsule placed 6cm above SCJ Impedance The Bravo system is an FDA class I approved radioltelemtry pH monitoring system that has become extremely popular due to the fact that it is easy to perform and subjects would rather not wear a Ph catheter for 24 hours.. It entails placing a small pH capsule directly onto the esophageal wall. The pH capsule contains an antimony pH electrode on the distal tip along with the reference probe. There is an internal battery which may last 3 to 5 days and an internal transmitter. The electronics are all encapsulated in epoxy. It is 6 mm wide x 5.5 mm high and 25 mm long. It can be placed orally or transnasally using either manometric or endoscopic landmarks. We prefer to place it orally as there have been anecdotal reports of significant nasal trauma after nasal passage. ohms 15 30 45 60 Time (Seconds) Pandolfino JE, Vela, MF. Gastrointest Endosc. 2009 Apr;69(4):917-30,

PPI Non-responders are Heterogeneousg EGD n Acid Reflux Symptoms Abnormal acid exposure Hypersensitive [(+) S-R correlation] Non-acid Reflux Symptoms Volume refluxers Overlap between well-controlled GERD and Functional Esophageal Disorder Do Not Have Reflux at ALL Functional heartburn….or just functional Unrelated disease (EoE, EMD, Cardiopulm etc..) Pandolfino JE, Vela, MF .Gastrointest Endosc. 2009 Apr;69(4):917-30,

Evolution of the Hydrostat: EndoFlip™ Kwiatek et al. J Gastrointest Surg. 2010 Feb;14(2):268-76

Gastroesophageal Reflux Disease True Refractory Symptoms Targets for therapy based on our observations Alter EGJ mechanical properties Surgery Endoscopic procedures Medications Promotility agents Reflux inhibitors Pandolfino JE, Krishnan, K. . Clin Gastro Hepatol. 2013 Jun 28. : S1542-3565

Functional Heartburn/Chest Pain Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation no Alarm features? PPI Trial yes no Heartburn resolved? Reflux disease: titrate PPI therapy yes Esophagitis EoE Abnormal? EGD ± biopsy no pH or impedance-pH monitoring (off of PPIs) no >5% esophageal acid exposure? yes NERD Esophageal manometry Meets esophageal motor disorder criteria? Achalasia DES yes no Positive symptom association? yes no MII-pH monitoring (on PPIs)

Gastroesophageal Reflux Disease Symptom perception MF VS PD HV Visceral Sensitivity Hypervigilance Psychosocial factors Abnormal Motor Function Case : Functional Heartburn Case : Visceral Hypersensitivity MF PD HV HV VS

Gut-directed Hypnotherapy Are you getting sleepy? Deep physical relaxation and deep mental concentration Alters focus of attention, changes meaning about sensations arising from the gut and encourages body to restore itself to a healthier state Shown to produce cognitive change and improve pain tolerance Modifies physiological arousal and hypersensitivity over long-term Initially performed in a doctors office but can eventually be self-guided The most scientifically supported non-drug treatment for Functional GI disorders

GERD: Pitfalls Patients may have a good response to PPI and not have GERD. Patients may have a positive pH study and not have GERD. Patients may have a good symptom correlation on pH-impedance testing and not have GERD. Be careful with belching, regurgitation and nausea/vomiting.

tLESR Liquid reflux LES relaxation and crural inhibition NU IRB

Increased IGP pressure Rumination # 1 HRM only Liquid reflux Increased IGP pressure NU IRB

Rumination #2 HRIM Regurgitation with swallowing Liquid reflux Increased IGP pressure NU IRB

Supragastric Belching Air reflux No LES relaxation NU IRB

GERD: Pitfalls

Gastroesophageal Reflux Disease Conclusions Reflux testing is essential to phenotype the patient based on mechanism. Refractory reflux Reflux sensitivity Functional heartburn Alternative diagnosis- HRIM is extremely helpful

Gastroesophageal Reflux Disease Conclusions Phenotype will dictate therapies Refractory reflux Endoscopic/surgery Reflux sensitivity Motility agents, TCA, HYPNOSIS Functional heartburn TCA, CBT, Hypnosis Rumination syndrome/supragastric belching Biofeedback, CBT, hypnosis

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