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Gastroesophageal Reflux Disease: Beyond Heartburn

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Gastroesophageal Reflux Disease: Beyond Heartburn Annette Y. Kwon, M.D. Edward W. Holt, M.D. October 1, 2011 * * * * * * * * * * * Several factors may predispose ... – PowerPoint PPT presentation

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Title: Gastroesophageal Reflux Disease: Beyond Heartburn


1
Gastroesophageal Reflux Disease Beyond Heartburn
  • Annette Y. Kwon, M.D.
  • Edward W. Holt, M.D.
  • October 1, 2011

2
Gastroesophageal Reflux Disease
  • The scope of the problem
  • What is the working definition?
  • What is the pathophysiology?
  • What is laryngopharyngeal reflux?
  • What is the current diagnostic strategy?
  • What is a rational treatment strategy?

3
Gastroesophageal Reflux Disease
  • Most common GI diagnosis for outpatient visits
  • 14-20 of adults affected in US
  • Rising incidence of esophageal adenocarcinoma
    with 8000 incidence in 2004 (2-6 fold increase in
    20 yrs)

4
GERD Montreal Definition
  • A condition which develops when the reflux of
    stomach contents causes troublesome symptoms
    and/or complications
  • gt 2 heartburn episodes/week
  • Adversely affect an individuals well being

From Vakil N et al. Am J Gastroenterol
20061011900-20.
5
GERD Complications
Kahrilas P. N Engl J Med 20083591700-1707
6
Montreal Classification of GERD
From Vakil N et al. Am J Gastroenterol
20061011900-20.
7
Montreal Classification of GERD
8
Pathogenesis of GERD
Decreased Salivation
Impaired Tissue Resistance
LES
Impaired Esophageal Clearance
Hiatal Hernia
Decreased LES Resting Tone
Duodenum
Delayed Gastric Emptying
Bile Reflux
9
Paradox in GERD Imperfect correlation between
symptoms and endoscopic features
From Ronikainen J et al. Gastroenterology
20051291825-31.
10
Paradox in GERD Imperfect correlation between
symptoms and esophageal adenocarcinoma
  • Typical GERD symptoms in only 60 of patients
    with cancer
  • 453/589 patients with cancer had Barretts on
    pathology
  • 23/63 with prior EGD had prior Barretts
    diagnosis
  • Laryngopharyngeal reflux (LPR) symptoms more
    common than GERD symptoms in patients with cancer

11
Diagnosis
12
GERD Diagnostic Approach ACG Guidelines
  • If history typical for uncomplicated GERD,
    initial trial of empiric therapy (including
    lifestyle modification) is appropriate

DeVault KD et al. Am J Gastroenterol
2005100190-200.
13
Role of Endoscopy in Management of GERD ASGE
Guidelines
  • GERD despite therapy
  • Dysphagia
  • Odynophagia
  • GI bleeding/anemia
  • Mass, stricture or ulcer on imaging study
  • Recurrent symptoms after antireflux surgery

From Gastrointest Endosc 200766219-24.
14
Role of Endoscopy in Management of GERD ASGE
Guidelines
  • Screening for Barretts
  • controversial with no clinically proven decrease
    in mortality with screening and surveillance
    programs
  • Persistent vomiting
  • Suspected extraesophageal GERD

From Gastrointest Endosc 200766219-24.
15
Alternative Diagnosis in GERD
  • Coronary artery disease
  • Gallstones
  • Gastric /esophageal cancer
  • Peptic ulcer disease
  • Esophageal motility disorders
  • Pill induced esophagitis
  • Eosinophilic esophagitis

From Kahrilas PJ. N Engl J Med 20083591700-7.
16
Physiological Testing Helpful in Selected Patients
  • Identify subtle motility disorders (esophageal
    manometry)
  • Demonstrate abnormal exposure to esophageal acid
    in absence of esophagitis (ambulatory pH
    monitoring)
  • Quantifying exposure to acid and reflux events
    regardless of acidic content to assess
    correlations with symptoms (combined impedance-pH
    monitoring)

17
Laryngopharyngeal Reflux (LPR)
  • LPR results when stomach contents reflux into the
    posterior pharynx and cause symptoms
  • 4-10 of ENT visits are GERD related
  • Significant association with hoarseness
  • Difference with GERD
  • Injury threshold lower
  • Weak acids, weak bases or neutral substances can
    cause significant injury
  • Rarely have erosive esophagitis

18
LPR Reflux Symptoms Index
  • Within the last month, how did the following
    probems affect you?
  • Hoarseness or problem with your voice
  • Clearing your throat
  • Excess throat mucus or postnasal drip
  • Difficulty swallowing food, liquids, or pills
  • Coughing after you ate or after lying down
  • Hammer. Dig Dis 20092714-17

19
LPR Reflux Symptoms Index
  • Breathing difficulties or choking episodes
  • Troublesome or annoying cough
  • Sensation of something sticking in your throat or
    a lump in your throat
  • Heartburn, chest pain, indigestion or stomach
    acid coming up
  • Rate of 0 to 5 by patients for each question
  • Score of gt13 suggestive of LPR

20
Treatment
21
AGA GERD Practice Guidelines Lifestyle
Modifications
  • Weight loss should be recommended in all patients
  • Lifestyle modifications should be tailored to
    individual circumstances
  • Elevate HOB if nocturnal symptoms
  • Avoid precipitating foods
  • Broad lifestyle changes for all (vs. selected)
    not recommended

From Kahrilas PJ et al. Gastroenterology
20081351383-91.
22
Weight Loss GERD
Our current treatment goals should move away
from allowing our patients to eat through their
PPI therapy.
From Pandolfino J. Am J Gastroenterol
20081031355-7.
23
AGA GERD Practice Guidelines Medication
No major differences in efficacy among various
PPIs Twice standard dose modestly effective but
significant (NNT 25) Khan M et al. Cochrane
Database Sys Rev 20072CD003244
24
GERD Is a Chronic Condition Likely to Relapse
100
No mucosal breaks
LA Grade A
80
LA Grade B
LA Grade C
60
Patients in symptomatic remission ()
40
20
0
0
1
2
3
4
5
6
Time after cessation of therapy (months)
From Lundell LR, et al. Gut. 199945172-180.
25
Adverse Events With Up to 1 Year of Esomeprazole
Treatment
From Maton PN et al. Drug Safety 200124625-35
26
Safety Profile of PPIs
  • Recent epidemiologic associations
  • C. difficile 2x
  • Bacterial gastroenteritis 1.5x
  • Hip fracture 1.4x in age gt50
  • Plavix interactionresolved
  • Pregnancy
  • Omeprazole category C but rest of PPI and H2RA
    are category B

27
GERD Treatment Algorithm Initial Work Up
  • LPR requires higher doses for 3 months

28
GERD Treatment Algorithm Initial Work Up
  • High recurrence rate when therapy discontinued

29
GERD Treatment Algorithm
30
Summary
  • GERD currently classified by Montreal system
  • Esophageal
  • Extraesophageal (LPR)
  • Diagnostic testing
  • Empiric treatment in uncomplicated cases with
    typical symptoms
  • Endoscopy

31
Summary
  • Diagnostic sequence
  • Endoscopy
  • Manometry
  • pH studies
  • Role of screening for Barretts esophagus remains
    controversial

32
Summary
  • PPIs are cornerstone of therapy
  • Goal of therapy lowest dose to control symptoms
  • Lifestyle changes should be used selectively
  • Antireflux surgery reserved for nocturnal
    regurgitation PPI intolerance

33
Thank you!
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