Gastroesophageal Reflux Disease

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Gastroesophageal Reflux Disease

• Susan M. Lepinski, M.D.
• University of Wisconsin Madison

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Mechanisms of GERD
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Offending Agents

• Acid
• Bile
• Food

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Result of GERD

• Frequent symptoms/No damage
• Normal EGD
• Damage/Changes on EGD
• Damage to contiguous organs

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Erosive Esophagitis
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Laryngitis
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Etiology

• Motility disorder
• TLESR
• Weak LES
• Weak Peristalsis
• Decreased gastric emptying

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Damaging Factors

• Acid
• Pepsin
• Bile
• Pancreatic juice

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Resistance Factors

• Saliva
• HCO3
• Mucosal Blood Flow

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Hiatal Hernia
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Epidemiology of GERD

• Chronic Heartburn
• Acid Regurgitation
• 40 US adults monthly
• 18 weekly
• Atypical Pain

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Management of Typical Symptoms
ACID SUPPRESSION
Increase to twice daily/change brand/compliance/em
pty stomach
Stop
Relapse
Scope
Long term PPI
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Warning Symptoms

• Dysphagia
• Anemia
• Unexplained Weight Loss
• Scope

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To scope or not to scope

• Long standing heartburn
• Barretts
• AdenoCA risk 0.5/yr
• Surveillance

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Refractory symptoms

• Visceral analgesics
• Decrease TLESR
• Promotility
• Surgery or endoscopic procedures

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Supraesophageal or Extraintestinal GERD

• Pulmonary
• ENT

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Asthma
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ENT/LPR

• Chronic cough
• Hoarseness
• Nodules on larynx
• Laryngitis
• Globus pharyngeus
• Sinusitis
• Otitis media

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Vocal Folds
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Reflux Finding Score RFSReflux Severity Index
RSI

• ENT

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24 hour pH/Impedance

• 24 hour pH alone
• Capsule
• Dual 24 hour pH/impedance

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Empiric Therapy

• BID PPI
• 3-4 months

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Results of Impedance

• Acid reflux in spite of ppi
• Nonacid reflux causing symptoms
• No reflux eventsnot reflux related

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Safety of long term ppi

• B12
• Gastrinoma
• Osteopenia

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Surgery

• Laparoscopic Nissen
• Success is less if refractory to ppi
• Best candidates
• Respiratory
• Free regurgitation
• Severe heartburn

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Worst Candidates for Nissen

• Refractory to ppi
• Hypersensitive esophagus
• Gastric dysmotility

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Endocinch
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Summary of GERD

• Common
• Largely a clinical diagnosis
• Often confirmed by empiric therapy
• Long term ppi