Gastroesophageal

Reflux Disease
Arthur Harris, M.D.
GI Division, Jacobi Medical Center/NCBH
Assistant Professor of Medicine, AECOM
 Objectives
 Definition of GERD
 Epidemiology of GERD
 Pathophysiology of GERD
 Clinical Manifestations
 Diagnostic Evaluation
 Treatment
 Complications
 Definition
 American College of
Gastroenterology (ACG)
• Symptoms OR mucosal
damage produced by the
abnormal reflux of gastric
contents into the esophagus
• Often chronic and relapsing
• May see complications of
GERD in patients who lack
typical symptoms
 Physiologic vs Pathologic
 Physiologic GERD  Pathologic GERD
• Post-prandial • Symptoms
• Short-lived • Mucosal injury
• Often asymptomatic • Nocturnal sx
• TLSER’s
• No nocturnal sx
 Epidemiology
 About 44% of the US adult
population have heartburn at least
once a month
 14% of Americans have symptoms
weekly
 7% have symptoms daily
 Pathophysiology
 Primary barrier to
gastroesophageal
reflux is the lower
esophageal sphincter
 LES normally works in
conjunction with the
diaphragm
 If barrier disrupted,
acid goes from
stomach to esophagus
 Clinical Manifestations

 Most common symptoms

• Heartburn—retrosternal burning
discomfort
• Regurgitation—effortless return of
gastric contents into the pharynx
without nausea, retching, or
abdominal contractions
 Clinical Manifestations
• Dysphagia—difficulty swallowing
• Other symptoms include:
 Chest pain, water brash, globus sensation,
odynophagia, nausea
• Extraesophageal manifestations
 Asthma, laryngitis, chronic cough
 Diagnostic Evaluation

• If classic symptoms of heartburn and

regurgitation exist in the absence of
“alarm symptoms” the diagnosis of
GERD can be made clinically and
treatment can be initiated
Potential Oral and Laryngopharyngeal Signs
Associated with GERD
 Edema and hyperemia
of larynx
• Vocal cord erythema,
polyps, granulomas,
ulcers
 Hyperemia and
lymphoid hyperplasia
of posterior pharynx
 Interarytenyoid
changes
 Dental erosion
 Subglottic stenosis
 Laryngeal cancer
 Alarms
• Alarm Signs/Symptoms
 Dysphagia
 Early satiety
 GI bleeding
 Odynophagia
 Vomiting
 Weight loss
 Iron deficiency anemia
 Trial of Medications
 H2RA or PPI
• Expect response in 2-4 weeks
• If no response
 Change from H2RA to PPI
 Maximize dose of PPI
 Trial of Medications
 If PPI response inadequate despite
maximal dosage
• Confirm diagnosis
 EGD
 24 hour pH monitoring
 Esophagogastrodudenoscopy
 Endoscopy (with biopsy if
needed)
• In patients with alarm
signs/symptoms
• Those who fail medication trial
• Those who require long-term Rx
 Lacks sensitivity for
identifying pathologic reflux
 Absence of endoscopic
features does not exclude a
GERD diagnosis
 Allows for detection,
stratification, and
management of esophageal
manifestations or
complications of GERD
 Ambulatory pH Testing
 24-hour pH monitoring
• Accepted standard for establishing or
excluding presence of GERD for those
patients who do not have mucosal
changes
• Trans-nasal catheter or a wireless,
capsule shaped device
Ambulatory 24 hour pH Monitoring -1
 Physiologic study
 Quantify reflux in
proximal/distal
esophagus
• % time pH < 4
• DeMeester score
 Symptom
correlation
Ambulatory 24 hour pH Monitoring -2

Normal

GERD
Wireless, Catheter-Free Esophageal pH Monitoring

Potential Advantages

●Improved patient
comfort and acceptance
●Continued normal
work, activities and diet
during study
●Longer reporting
periods possible (up to
48 hours)
●Maintain constant
probe position relative to
SCJ
Esophageal Manometry
Limited role in GERD

 Assess LES
pressure, location
and relaxation
• Assist placement of
24 hour pH catheter
 Assess peristalsis
• Prior to anti-reflux
surgery
 Patient with heartburn

Initiate Rx with H2RA or PPI

H2RA taken PPI taken QD

BID
No
Good response
No
Good response Yes Yes
Yes
Maintenance therapy Increase to
Frequent relapses max dose QD
with lowest effective dose
or BID
No
Yes
On demand Rx
Symptoms persist Good response
No

Consider EGD if
Confirm diagnosis
risk factors present
EGD, ph monitor
(> 45, white, male
and > 5 yrs of sx)
 GERD vs Dyspepsia
 Distinguish from Dyspepsia
• Ulcer-like symptoms-burning, epigastric
pain
• Dysmotility like symptoms-nausea,
bloating, early satiety, anorexia
 Distinct clinical entity
 In addition to anti-secretory meds
and an EGD, need to consider testing
for Helicobacter pylori
 Treatment
 Goals of therapy
• Symptomatic relief
• Heal esophagitis
• Avoid complications
 Better Living
 Lifestyle modifications
• Avoid large meals
• Avoid acidic foods (citrus/tomato), alcohol, caffeine,
chocolate, onions, garlic, peppermint
• Decrease fat intake
• Avoid lying down within 3-4 hours after a meal
• Elevate head of bed 4-8 inches
• Avoid meds that may potentiate GERD (CCB, alpha
agonists, theophylline, nitrates, sedatives, NSAID’s)
• Avoid clothing that is tight around the waist
• Lose weight
• Stop smoking
Treatment
 Antacids
• O-T-C acid
suppressants and
antacids may be
appropriate initial
therapy
• Approx 1/3 of patients
with heartburn-related
symptoms use at least
twice weekly
• More effective than
placebo in relieving
GERD symptoms
 Treatment
 Histamine H2-Receptor Antagonists
• More effective than placebo and
antacids for relieving heartburn in
patients with GERD
• Faster healing of erosive esophagitis
when compared with placebo
• Can use regularly or on-demand
 Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Cimetadine 400mg twice daily 400-800mg twice daily
Tagamet

Famotidine 20mg twice daily 20-40mg twice daily

Pepcid

Nizatidine 150mg twice daily 150mg twice daily

Axid

Ranitidine 150mg twice daily 150mg twice daily

Zantac
 Treatment
 Proton Pump Inhibitors
• Better control of symptoms with PPI’s vs
H2RAs and better remission rates
• Faster healing of erosive esophagitis
with PPIs vs H2RAs
 Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Esomeprazole 40mg daily 20-40mg daily
Nexium

Omeprazole 20mg daily 20mg daily

Prilosec

Lansoprazole 30mg daily 15-30mg daily

Prevacid

Pantoprazole 40mg daily 40mg daily

Protonix

Rabeprazole 20mg daily 20mg daily

Aciphex
 Treatment
 H2RAs vs PPI’s
• 12 week freedom from symptoms
 48% vs 77%
• 12 week esophagitis healing rate
 52% vs 84%
• Speed of healing
 6%/wk vs 12%/wk
Treatment Modifications for Persistent Symptoms

 Improve compliance
 Optimize 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 PPI

 Treatment
 Anti-reflux surgery - Indications
• Failed medical management
• Patient preference
• GERD complications
• Medical complications attributable to a
large hiatal hernia
• Atypical symptoms with pathologic reflux
documented on 24-hour pH monitoring
 Treatment
 Anti-reflux surgery candidates
• EGD proven esophagitis
• ?Normal esophageal motility
• Incomplete response to acid suppression
 Treatment
 Anti-reflux surgery (laparoscopic)
• Tenets of surgery
 Reduce hiatal hernia
 Repair diaphragm
 Strengthen GE junction
 Strengthen anti-reflux barrier via gastric wrap
 75-90% effective at alleviating symptoms of
heartburn and regurgitation
 Treatment
 Post-surgery
• 10% have solid food dysphagia
• 2-3% have permanent symptoms
• 7-10% have gas, bloating, diarrhea,
nausea, early satiety
• Within 3-5 years, up to 52% of patients
back on anti-reflux medications
 Treatment
 Endoscopic treatment
• Relatively new
• No clearly established indications
• Well-informed patients with well-documented
GERD responsive to PPI therapy may benefit
 Three categories
• Radiofrequency application to increase LES
reflux barrier
• Endoscopic sewing devices
• Injection of a non-resorbable polymer into LES
region
 Complications
 Erosive esophagitis
 Stricture
 Barrett’s esophagus
 Complications
 Erosive esophagitis
• Responsible for 40-60% of GERD
symptoms
• Severity of symptoms often fail to
match severity of erosive esophagitis
 Complications
 Esophageal
stricture
• Occurs as a
result of healing
of erosive
esophagitis
• May need
dilation
 Peptic Stricture

Barium swallow Endoscopy

Complications

 Barrett’s Esophagus
• Columnar metaplasia
of the esophagus
• Associated with the
development of
adenocarcinoma
 Complications
 Barrett’s Esophagus
• Acid damages lining of
esophagus and causes
chronic esophagitis
• Damaged area heals in
a metaplastic process
with abnormal columnar
cells replacing
squamous cells
• This specialized
intestinal metaplasia
can progress to
dysplasia and
adenocarcinoma
 Complications
• Patient’s who need EGD
 Alarm symptoms
 Poor therapeutic response
 Long symptom duration
• “Once in a lifetime” EGD for patient’s
with chronic GERD becoming accepted
practice
• Many patients with Barrett’s are
asymptomatic
 Complications
 Barrett’s Esophagus
• Manage in same manner as GERD
• EGD every 3 years in patient’s without
dysplasia
• In patients with dysplasia, annual to
even shorter interval surveillance is
recommended
 Summary
 Definition of GERD
 Epidemiology of GERD
 Pathophysiology of GERD
 Clinical Manifestations
 Diagnostic Evaluation
 Treatment
 Complications
?QUESTIONS?