Gastroesophageal Reflux Disease (GERD) Any symptoms or esophageal mucosal damage that results from reflux of gastric acid into the esophagusAny symptoms or esophageal mucosal damage that results from reflux of gastric acid into the esophagus Classic GERD symptomsClassic GERD symptoms –Heartburn (pyrosis): substernal burning discomfort –Regurgitation: bitter, acidic fluid in the mouth when lying down or bending over

Locke et al. Gastroenterology 1997;112:1148. High Prevalence of Gastroesophageal Reflux Symptoms

Important Reasons to Diagnose and Treat GERD Negative impact on health-related quality of life 1Negative impact on health-related quality of life 1 Risk factor for esophageal adenocarcinoma 2Risk factor for esophageal adenocarcinoma 2 1.Revicki et al. Am J Med 1998;104: Lagergren et al. N Engl J Med 1999;340:825.

Clinical Presentations of GERD Classic GERDClassic GERD Extraesophageal/Atypical GERDExtraesophageal/Atypical GERD Complicated GERDComplicated GERD

Extraesophageal Manifestations of GERD PulmonaryAsthma Aspiration pneumonia Chronic bronchitis Pulmonary fibrosis Other Chest pain Chest pain Dental erosion Dental erosionENTHoarsenessLaryngitisPharyngitis Chronic cough Globus sensation DysphoniaSinusitis Subglottic stenosis Laryngeal cancer

Potential Oral and Laryngopharyngeal Signs Associated with GERD Edema and hyperemia of larynxEdema and hyperemia of larynx Vocal cord erythema, polyps, granulomas, ulcersVocal cord erythema, polyps, granulomas, ulcers Hyperemia and lymphoid hyperplasia of posterior pharynxHyperemia and lymphoid hyperplasia of posterior pharynx Interarytenyoid changesInterarytenyoid changes Dental erosionDental erosion Subglottic stenosisSubglottic stenosis Laryngeal cancerLaryngeal cancer Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:

Pathophysiology of Extraesophageal GERD

Symptoms of Complicated GERD DysphagiaDysphagia –Difficulty swallowing: food sticks or hangs up OdynophagiaOdynophagia –Retrosternal pain with swallowing BleedingBleeding

When to Perform Diagnostic Tests Uncertain diagnosisUncertain diagnosis Atypical symptomsAtypical symptoms Symptoms associated with complicationsSymptoms associated with complications Inadequate response to therapyInadequate response to therapy Recurrent symptomsRecurrent symptoms Prior to anti-reflux surgeryPrior to anti-reflux surgery

Diagnostic Tests for GERD Barium swallowBarium swallow EndoscopyEndoscopy Ambulatory pH monitoringAmbulatory pH monitoring Esophageal manometryEsophageal manometry

Barium Swallow Useful first diagnostic test for patients with dysphagiaUseful first diagnostic test for patients with dysphagia –Stricture (location, length) –Mass (location, length) –Bird’s beak –Hiatal hernia (size, type) Limitations Limitations –Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus

Endoscopy Indications for endoscopyIndications for endoscopy –Alarm symptoms –Empiric therapy failure –Preoperative evaluation –Detection of Barrett’s esophagus

Ambulatory 24 hr. pH Monitoring Physiologic studyPhysiologic study Quantify reflux in proximal/distal esophagusQuantify reflux in proximal/distal esophagus –% time pH < 4 –DeMeester score Symptom correlationSymptom correlation

Ambulatory 24 hr. pH Monitoring Normal GERD

Wireless, Catheter-Free Esophageal pH Monitoring Improved patient comfort and acceptance Improved patient comfort and acceptance Continued normal work, activities and diet study Continued normal work, activities and diet study Longer reporting periods possible (48 hours) Longer reporting periods possible (48 hours) Maintain constant probe position relative to SCJ Maintain constant probe position relative to SCJ Potential Advantages

Esophageal Manometry Assess LES pressure, location and relaxationAssess LES pressure, location and relaxation –Assist placement of 24 hr. pH catheter Assess peristalsisAssess peristalsis –Prior to antireflux surgery Limited role in GERD

Treatment Goals for GERD Eliminate symptomsEliminate symptoms Heal esophagitisHeal esophagitis Manage or prevent complicationsManage or prevent complications Maintain remissionMaintain remission

Lifestyle Modifications are Cornerstone of GERD Therapy Elevate head of bed 4-6 inchesElevate head of bed 4-6 inches Avoid eating within 2-3 hours of bedtimeAvoid eating within 2-3 hours of bedtime Lose weight if overweightLose weight if overweight Stop smokingStop smoking Modify dietModify diet –Eat more frequent but smaller meals –Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and tea OTC medications prnOTC medications prn

Acid Suppression Therapy for GERD H 2 -Receptor Antagonists (H 2 RAs) (H 2 RAs) Cimetidine (Tagamet®) Ranitidine (Zantac®) Famotidine (Pepcid®) Nizatidine (Axid®) Proton Pump Inhibitors Proton Pump Inhibitors (PPIs) (PPIs) Omeprazole (Prilosec®) Lansoprazole (Prevacid®) Rabeprazole (Aciphex®) Pantoprazole (Protonix®) Esomeprazole (Nexium ®)

Effectiveness of Medical Therapies for GERD TreatmentResponse Lifestyle modifications/antacids20 % H 2 -receptor antagonists50 % Single-dose PPI 80 % Increased-dose PPIup to 100 %

Treatment Modifications for Persistent Symptoms Improve complianceImprove compliance Optimize pharmacokineticsOptimize pharmacokinetics –Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime) –Allows for high blood level to interact with parietal cell proton pump activated by the meal Consider switching to a different PPIConsider switching to a different PPI

GERD is a Chronic Relapsing Condition Esophagitis relapses quickly after cessation of therapyEsophagitis relapses quickly after cessation of therapy –> 50 % relapse within 2 months –> 80 % relapse within 6 months Effective maintenance therapy is imperativeEffective maintenance therapy is imperative

Complications of GERD Erosive/ulcerative esophagitisErosive/ulcerative esophagitis Esophageal (peptic) strictureEsophageal (peptic) stricture Barrett’s esophagusBarrett’s esophagus AdenocarcinomaAdenocarcinoma

Erosive Esophagitis

Peptic Stricture Barium Swallow Endoscopy

Esophageal Stricture: Dilating Devices

TTS Balloon Dilation of a Peptic Stricture

Barrett’s Esophagus

Esophageal Cancer Barium Swallow Endoscopy

When to Discuss Anti-Reflux Surgery with Patients Intractable GERD – rareIntractable GERD – rare –Difficult to manage strictures –Severe bleeding from esophagitis –Non-healing ulcers GERD requiring long-term PPI-BID in a healthy young patientGERD requiring long-term PPI-BID in a healthy young patient Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms Not Barrett’s esophagus aloneNot Barrett’s esophagus alone

Endoscopic GERD Therapy Endoscopic antireflux therapiesEndoscopic antireflux therapies –Radiofrequency energy delivered to the LES Stretta procedureStretta procedure –Suture ligation of the cardia Endoscopic plicationEndoscopic plication –Submucosal implantation of inert material in the region of the lower esophageal sphincter EnteryxEnteryx