Current Trends and Updates on Diagnosis and Management of GERD

Jeraldine S. Orlina, MD Grand Rounds January 11, 2006

‡ Lower esophageal sphincter
‡ Intrinsic muscle of distal esophagus ‡ Sling fibers of cardia ‡ Diaphragm ‡ Transmitted pressure of abdominal cavity

‡ Reflux occurs when the high-pressure zone in distal esophagus is too low or when sphincter with normal pressure undergoes spontaneous relaxation

Absite Question ‡ An operation is the primary initial management for: ‡ A) Achalasia ‡ B) a large sliding esophageal hiatal hernia ‡ C) an epiphrenic esophageal diverticulum ‡ D) gastroesophageal reflux ‡ E) a paraesophageal hiatal hernia .

Symptoms Symptom Heartburn Regurgitation Abdominal Pain Cough Dysphagia for solids Hoarseness Belching Aspiration Wheezing Globus Predominance (%) 80 54 29 27 23 21 15 14 7 4 .

is not pressurelike ‡ Can be confused with symptoms of PUD.Heartburn ‡ Epigastric and retrosternal ‡ Caustic or stinging sensation ‡ Does not radiate to the back.Symptoms -. or CAD . bilary colic.

Symptoms -.Regurgitation ‡ Indicates progression of disease ‡ Distinguish between digested and undigested food .

Diagnostic Studies ‡ Empirical Therapy ‡ Upper Gastrointestinal Endoscopy (EGD) ‡ Upper Gastrointestinal Fluoroscopy with Barium ‡ 24-hour pH testing ‡ Esophageal Manometry .

EGD ‡ Allows examination of the esophageal mucosa ‡ Identifies presence of esophagitis and grading of severity ‡ Can identify other pathology. hiatal hernia. or strictures ‡ Tissue biopsies to screen for Barrett·s esophagus . webs. such as diverticula. rings.

but esophagography shows a distal esophageal perforation. and dyspnea. The most appropriate management is ‡ ‡ ‡ ‡ ‡ A) nasogastric suction and TPN B) reinforced primary esophageal repair C) drainage and esophageal diversion D) esophagectomy with gastric pull-through E) fluoroscopic esophageal stent placement . a 62 year-old man returns to the emergency room with chills. Cardiac work-up is normal.Absite Question ‡ Four hours following upper esophagogastric endoscopy for gastroesophageal reflux. chest pain.

Esophagoscopy shows moderately severe esophagitis.Absite Question ‡ A 60 year-old otherwise healthy man has symptomatic GERD that has not responded to medical therapy. including PPIs. a biopsy report shows highgrade dysplasia. . Multiple biopsies of the esophageal mucosa in the area of esophagitis show columnar epithelium replacing the normal squamous epithelium. As the patient·s treatment is being planned.

Continued medical treatment with yearly esophagoscopy and biopsies B. Laser ablation of normal mucosa . Photodynamic therapy D. Esophagectomy E. Laparoscopic Nissen fundoplication C.(cont) ‡ Treatment should be A.

24-hour pH test ‡ Gold Standard for presence of pathologic reflux ‡ Parameters measured include: total # of reflux episodes. duration of longest reflux episode. percentage of time pH is less than 4 .

Ambulatory pH testing ² Recent Advances ‡ Combined impedance and acid testing ‡ Allows for the measurement of both acid and nonacid (volume) reflux. ‡ Important in pt with persistent symptoms despite an adequate medical trial .

Ambulatory pH testing ² Recent Advances ‡ Tubeless method² Bravo System ‡ Allows a radiotelemetry capsule to be attached to the esophageal mucosa ‡ Decreases patient discomfort. and may improve accuracy by allowing the patient to carry out their usual activities . allows for longer (48h) monitoring.


Esophageal Manometry ‡ Lower Esophageal Sphincter (LES) ‡ Mean resting pressure ‡ Total length ‡ Esophageal Body ‡ To determine effectiveness of peristalsis ‡ Amplitude of esophageal wave .

Esophagram ‡ Useful when operation is planned³shows anatomy of esophagus and proximal stomach ‡ Demonstrates presence and size of hiatal hernia if present .

avoidance of certain foods (chocolate. peppermint) ‡ No data reflecting the efficacy of these maneuvers . although these changes alone are unlikely to control symptoms in the majority of patients ‡ Elevation of the head of the bed. decreased fat intake.Treatment ² Lifestyle Modification ‡ May benefit many patients with GERD. EtOH. cessation of smoking. avoiding recumbency for 3h postprandially.

continuous therapy is required. or alarm symptoms/signs develop ² pt should have additional evaluation and treatment .Treatment ² Patient Directed Therapy ‡ Antacids ‡ H2 receptor antagonists ‡ If symptoms persist.

Treatment ² Acid Suppression ‡ 6-week course of acid-suppression therapy ‡ Double dose of a proton pump inhibitor ‡ Irreversible bind the proton pump in parietal cells of the stomach ‡ Maximal effect 4 days after initiation of therapy and lasts for the life of the parietal cell ‡ More effective than other antacid regimens .

Cause regression of Barrett·s epithelium B.Absite Question ‡ Proton pump inhibitors used in the treatment of GERD A. Reverse intestinal metaplasia E. Inhibit progression of dysplasia C. Increase squamous islands in Barrett·s segments D. Are effective only if gastric acidity is normalized .

Treatment ² Promotility Therapy
‡ May be used as an adjunct to acid suppression therapy in patients with demonstrated defects in esophagogastric motility (LES incompetence, poor esophageal clearance, delayed gastric emptying)

Absite Question
‡ Five years after a myocardial infarction, a 55 year-old woman with HTN and DM has symptomatic esophagogastric reflux. Medical treatment for the last year has not been successful. Her BMI is 55. Esophagoscopy shows severe esophagitis. Multiple biopsies show inflammatory changes but no columnar epithelium or cancer. The best treatment would be:
A. B. C. D. E. Nissen fundoplication Gastric bypass procedure Gastric banding procedure Vertical banded gastroplasty Biliary-pancreatic diversion with duodenal switch

Surgical Therapy
‡ Indications
‡ Pt w/ evidence of severe esophageal injury (ulcer, stricture, or Barrett·s) ‡ Incomplete resolution of symptoms or relapses while on medical therapy ‡ Long duration of symptoms ‡ Younger patients ‡ Ideal patient: more than 10-year life expectancy and are in need of lifelong therapy due to a mechanically defective sphincter

R. 1988-2000 Urbach. D.Trends in the use of surgery for gastroesophageal reflux disease in Ontario.170:219-221 Copyright ©2004 CMA Media Inc. CMAJ 2004. or its licensors . et al.

Myers JC. Arch Surg. Devitt PG. The long-term outcome was considered "good or excellent" by 90% of patients.Laparoscopic Nissen Fundoplication ‡ Lafullarde T. Jamieson GG. 2001 Feb.136(2):180-4 ‡ 87% of the 176 patients remained free of significant reflux. Laparoscopic Nissen fundoplication: five-year results and beyond. Watson DI. . Game PA.

Laparoscopic Nissen Fundoplication ‡ Success rate of greater than 90% ‡ Procedure of choice .








He now has recurrent symptoms of GE reflux.Absite Question ‡ A 56 year-old man is seen 2 years after a laparoscopic Nissen fundoplication for GERD. His pre-operative work-up 2 years ago demonstrated normal esophageal motility. . and pH probe testing showed that reflux was the cause of his symptoms. A Barium swallow is performed.

‡ Which is not true about this patient? A. Redo operation has an increased complication rate D. Redo operation is as effective as primary antireflux operation for ameliorationg reflux symptoms B. Manometry is helpful in planning operative therapy . Transabdominal laparoscopic redo operation is contraindicated C. The cause is related to technical performance of the initial operation E.

Esophageal motor disorder . Through a celiotomy incision. The most likely cause of these symptoms is: A.Absite Question ‡ Four years ago. The wrap is too tight B. Vagal injury D. the surgeon performed a redo-fundoplication with a 360-degree. a 47 year-old woman had a laparoscopic fundoplication. 2 cm wrap around a 56 Fr dilator. For the past three months she has had severe early satiety. and weight loss. The wrap is too loose C. Irritable bowel syndrome E. recurrent gastroesophageal symptoms. It failed after three years and she had severe. postprandial epigastric pain.

Absite Question ‡ Barrett·s esophagus ‡ A) will usually regress after Nissen fundoplication ‡ B) carries an increased risk of squamous cell carcinoma ‡ C) is an indication for esophagectomy ‡ D) should be followed by endoscopic surveillance ‡ E) is a contraindication to laparoscopic Nissen fundoplication .

Plexiglass injection ² polymethylmethacrylate 4.Endoscopic Therapy ‡ Attempt to augment the LES by 1. Biocompatible polymer injection -Enteryx . Suturing ² EndoCinch 2. Radiofrequency energy ² Stretta 3.

Plication/Sewing Techniques ‡ First developed in the mid ·80·s ‡ Allow placement of sutures into the gastric cardia. thereby augmenting the barrier effect of the GEJ ‡ Bard EndoCinch .


. flexible endoscopic suturing for treatment of GERD: a multicenter trial. 53: 416-22. ‡ Suggested that endoscopic gastric plication is a safe procedure and. Rothstein RI et al. Lehman GA. at a 6month follow-up.µ Gastrointestinal Endoscopy 2001.EndoCinch ‡ Filipi CJ. that 2/3 of pts undergoing the procedure were successfully treated. ´Transoral.

EndoCinch (cont) ‡ Inclusion Criteria ‡ Three or more episodes of heartburn a week when off antisecretory meds ‡ Successful response to and reliance upon antisecretory meds for GERD ‡ Abnormal acid reflux on ambulatory pH monitoring ‡ Exclusion Criteria ‡ ‡ ‡ ‡ Dysphagia BMI greater than 40 GERD refractory to PPIs Hiatal hernia greater than 2 cm in length .

‡ 64 patients were enrolled ‡ 33 pts (52%) ² gastroplication in a linear configuration ‡ 31 (48%) ² gastroplication in a circumferential plication ‡ No difference in outcomes between the 2 groups .EndoCinch (cont) ‡ Treatment success defined as a decrease in the heartburn severity score by 50% in addition to a reduction in the use of antireflux medications to fewer to 4 doses per month.

‡ Results: ‡ Mean heartburn scores fell from a preprocedure score of 62.7 to mean scores of 16. and percent upright pH time was lower than 4 were all significantly improved. but none returned to normal range ‡ Regurgitation scores improved significantly ‡ Quality of life scores were improved for social functioning and bodily pain and 62% of pts at 3 and 6 month f/u were taking less than 4 doses of medication per month . total number of reflux episodes.7 and 17 and 3 and 6 months postprocedure ‡ Percent total time the pH was < 4.

and abdominal pain (14%).‡ Results (cont) ‡ No significant change found in LES resting pressure or length ‡ No significant effect on mucosal healing ‡ Adverse events included pharyngitis (31%). vomiting (14%). and chest pain (16%) ‡ One patient experienced a suture microperforation that was treated conservatively with IV antibiotics and brief hospitalization .

61: 434-440 ‡ Prospective.µ Gastrointestinal Endoscopy 2003. multicenter trial. multicenter trial which enrolled 85 patients to be treated with endoluminal gastroplication followed over 2 years . ´Long-term outcomes of endoluminal gastroplication: a U.S.EndoCinch (cont) ‡ Chen YK. Ben-Menachem T et al. Raijman I.

‡ Results: ‡ 51% of patients had no or occasional GERD symptoms ‡ 73% and 69% were completely off PPIs or at 12 and 24 months postprocedure ‡ Reduction in the mean annual medication cost from $1564 per year preprocedure to $157 one year postprocedure (cost redux of 88%) ‡ Shortcomings of study ‡ Does not contain a nonplication sham group ‡ Trends toward increased symptoms over time suggestive of degradation of repair over time .

Gut 2005. 54: 752-758 ‡ Evaluated prospectively long term outcome after EndoCinch ‡ 70 patients at a single referral center ‡ Patients interviewed with a standard questionaire regarding symptoms.EndoCinch (cont) ‡ Schiefke I et al. and esophageal manometry . medication use. 24h pH monitoring. ´Long term failure of endoscopic gastroplication (EndoCinch)µ. in addition to f/u with endoscopy.

‡ Results: ‡ 18 months after EndoCinch 56/70 patients (80%) were considered treatment failures as their heartburn symptoms did not improve or PPI medication exceeded 50% of initial dose ‡ Endoscopy showed all sutures in situ in 12/70 (17%). while no sutures remained in 18/70 (26%) ‡ No significant changes in 24h pH monitoring or LES pressure .

‡ Conclusion: ‡ Long term outcome is disappointing probably due to suture loss in the majority of patients .

inducing the ablation of nerves that trigger transient lower esophageal relaxation .Radiofrequency Thermal Therapy -.Stretta ‡ Delivery of low-power. mechanically altering the GEJ 2. temperaturecontrolled radiofrequency energy to the GEJ ‡ Two mechanisms 1.

Radiofrequency Thermal Therapy -.Stretta .

and antisecretory medication use . 33 institutions ‡ 6 months of follow-up ‡ Survey administered which assessed GERD severity.Stretta ‡ Wolfsen HC and Richards WO. ´The Stretta Procedure for the Treatment of GERD: A registry of 558 patients. percentage of GERD symptom control. satisfaction.µ Journal of Laparoendoscopic and Advanced Surgical Techniques 2002 ‡ 558 patients.

‡ Results ‡ At baseline. compared with 90% after Stretta ‡ Satisfaction with symptom control was 26% versus 77% after Stretta ‡ Median requirement at baseline was double dose of PPI versus antacids prn after Stretta ‡ Most subjects (90%) would recommend Stretta to a friend . the median percentage of GERD symptom control while on drugs was 50%.

and mild esophagitis ‡ At 12 mo: improvement in heartburn score. although no improvement in the incidence and severity of esophagitis . abnormal esophageal acid exposure. PPI use decreased from 88% to 30%. hiatal hernia less than 2 cm.Stretta ‡ Triadafilopolous et al: reported 6. and quality of life. Esophageal acid exposure improved significantly.and 12month results of an open label trial of Stretta ‡ Prospective multicenter trial involving 118 patients who had chronic heartburn or regurgitation. GERD score.

sham controlled trial of radiofrequency energy to the gastroesophageal junction for the treatment of GERD . double-blinded.‡ randomized.

Patient Criteria ‡ heartburn or acid regurgitation at least partially responsive to and requiring daily antacid medications ‡ age 18 years ‡ 24-hour pH study (off medications) showing abnormal esophageal acid exposure (4%) or a DeMeester score of 14. . or unstable disorders. prominent dysphagia.e. showing no esophagitis worse than grade II (i.7 ‡ esophageal manometry showing normal esophageal peristalsis and sphincter relaxation ‡ EGD. mechanical prostheses. no substantial ulcerations). on medications. and no Barrett·s esophagus ‡ no coagulation disorders. no hiatal hernia 2 cm long..



‡ Patients with larger hiatal hernias. LES pressure less than 8 mmHg. or Barrett·s esophagus.Stretta ‡ Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm. . LES pressure less than 8 mmHg. or Barrett·s were offered LF.





success of therapy does not approach that of surgical intervention ‡ After Stretta 30-50% of patients still require PPI therapy .Stretta ‡ Conclusions ² Although the incidence of complications is decreased compared with operative intervention.


Injection/implantation techniques -. the solution interacts with the surrounding fluid to become an inert spongy solid mass ‡ Mechanism: may impart an alteration in the compliance of tissues preventing sphincter shortening and improving the barrier function of the GEJ .Enteryx ‡ Injectable biocompatible solution consisting of 8% ethylene vinyl alcohol copolymer mixed in dimethyl sulfoxide ‡ When injected into the LES.

Enteryx .

Johnson DA. Ganz RA et al ´Enteryx implantation for GERD: expanded multicenter trial results and interim postapproval follow-up to 24 months. international clinical trial conducted in 144 PPI³dependent patients with GERD with f/u at 6 and 12 months ‡ Primary outcome: PPI use ‡ Secondary outcome: GERD health-related quality of life and esophageal acid exposure .µ Gastrointestinal Endoscopy May 2005 ‡ Open-label.Enteryx ‡ Cohen LB.

‡ Results: ‡ At 12 months PPI use was reduced by greater than 50% in 84% of treated pts ‡ GERD health-related quality of life < 11% in 78% of patients ‡ Esophageal acid exposure was reduced by 31% .

Enteryx .

.Conclusions on Endoscopic Mgmt of GERD ‡ Techniques need to be further studied in shamcontrolled protocol ‡ Long term follow-up suggest a declining effect of treatment with pts returning to PPI use -more long term f/u studies necessary ‡ Future studies should improve targeting of which patients benefit. further elucidate the mechanisms of action. and provide detailed comparisons to alternative treatments.

Future of Endoscopic Therapy ‡ As a substitute for long-term medical therapy for the pt with mildly symptomatic GERD ‡ As adjuncts to ongoing pharmacologic treatment ‡ In patients with a failed surgical fundoplication .

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