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Gastroesophageal Reflux Disease

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Rajeev Jain, MD November 27, 2006 Outline Definition Epidemiology Pathophysiology Diagnosis Treatment Management Definition No gold standard Montreal Definition a ... – PowerPoint PPT presentation

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Title: Gastroesophageal Reflux Disease


1
Gastroesophageal Reflux Disease
  • Rajeev Jain, MD
  • November 27, 2006

2
Outline
  • Definition
  • Epidemiology
  • Pathophysiology
  • Diagnosis
  • Treatment
  • Management

3
Definition
  • No gold standard
  • Montreal Definition
  • a condition which develops when the reflux of
    stomach contents causes troublesome symptoms
    and/or complications

Vakil N, et al. Am J Gastroenterol
101(8)1900-20.2006.
4
Classification
  • Endoscopy
  • Erosive esophagitis
  • Los Angeles classification
  • Non-erosive reflux disease (NERD) or endoscopy
    negative reflux disease (ENRD)
  • Symptoms
  • Esophageal
  • Extra-esophageal

5
LA Classification
6
Epidemiology
  • Prevalence
  • Symptoms in western populations
  • 25 monthly
  • 12 weekly
  • 5 daily
  • Incidence
  • 1.5 3 develop weekly GERD per yr

Moayyedi P, Axon ATR. Aliment Pharmacol Ther
22(S1)11-9.2005.
7
Risk Factors
  • Demographic
  • Age gender not a major difference
  • Lifestyle Environmental
  • Obesity, EtOH, tobacco have weak associations
    (OR 1.5 2.5) 1
  • H. pylori has no impact 2
  • Genetic
  • Higher concordance in mono- than dizygotic twins 1

1. Moayyedi P Talley NJ. Lancet
3672086-100.2006. 2. Raghunath AS, et al.
Aliment Pharmacol Ther 20733-44.2004.
8
Pathophysiology
  • Primary mechanism impaired function of the
    lower esophageal sphincter (LES)
  • In most patients with GERD, exposure of the
    esophagus to refluxate is greater than normal
  • In a minority of patients, exposure is within
    normal limits in these patients, GERD may be due
    to decreased mucosal resistance to refluxate

9
Mechanisms of Acid Reflux
10
Defective Esophageal Clearance
  • Ineffective peristalsis
  • Reduced salivary secretion
  • Reduced secretion from esophageal submucosal
    glands

11
LES dysfunction
  • Inappropriate and prolonged transient relaxations
  • Reduction in basal LES pressure/tone

12
Substances that Decrease LES Pressure
  • Hormones
  • Secretin
  • Cholecystokinin
  • Glucagon
  • Somatostatin
  • Progesterone
  • Foods
  • Fat
  • Chocolate
  • Ethanol
  • Peppermint
  • Medications

13
Medications that Decrease LES Pressure
  • ?-adrenergic agonists
  • Theophylline
  • Anticholinergics
  • Tricyclic antidepressants
  • ?-adrenergic antagonists
  • Diazepam
  • Calcium channel blockers

14
Hiatal Hernia
  • May trap a reservoir of gastric contents above
    the diaphragm, increasing reflux
  • May compromise LES function

15
Increased Intra-abdominal Pressure
  • Pregnancy
  • Obesity
  • Bending
  • Straining
  • Coughing
  • Tight clothes

16
Delayed Gastric Emptying
  • May result in an increase in the volume of
    gastric contents available for reflux into the
    esophagus
  • Exact role in GERD remains to be clarified

17
Diagnostic Methods
  • History
  • Endoscopy
  • Empiric therapy
  • pH monitoring
  • Radiology

18
History
  • History taking is the primary diagnostic tool
    for GERD
  • Heartburn sensation of discomfort or burning
    behind the sternum rising up to the neck
  • Regurgitation effortless return of gastric
    contents into the pharynx
  • Accuracy of symptoms when compared to endoscopy
    as gold standard
  • Sensitivity 30-76
  • Specificity 45-68

Moayyedi P, et al. JAMA 2951566-76.2006.
19
Endoscopy
  • Allows direct visualization of the esophageal
    mucosa and biopsy if necessary
  • Presence and severity of erosive esophagitis
  • Detection of complications such as stricture or
    Barretts esophagus

DeVault et al. Am J Gastroenterol 1999
20
Advances in Endoscopy
  • Ultra-thin endoscopes
  • Transnasal or oral
  • No sedation
  • Magnification endoscopy
  • Capsule endoscopy

21
Referral for Endoscopy
  • Chronic symptoms requiring continuous
    acid-suppression therapy
  • Persistent suspected GERD symptoms that fail to
    respond to acid suppression
  • Any new GERD patient over the age of 40
  • Warning signs
  • Weight loss
  • Anemia or Bleeding
  • Dysphagia

22
Empiric Therapy PPI Test
  • Logical as GERD is an acid-related disorder
  • Normal or high-dose PPI for 1-4 wks in the
    diagnosis of GERD (gold standard was 24 hr
    ambulatory pH study)
  • Sensitivity 78 (95 CI 66-86)
  • Specificity 54 (95 CI 44-65)

Numans ME, et al. Ann Intern Med 140518-27.2006.
23
pH Monitoring
  • Allows investigation of
  • the amount and timing of reflux
  • the correlation between reflux and symptoms
  • the effect of therapy on reflux
  • In general, most useful in
  • endoscopy-negative patients
  • patients with chest pain or pulmonary/upper
    respiratory symptoms
  • patients with refractory symptoms

24
pH Monitoring
  • 24 hr pH monitoring
  • single best test
  • 50-60 will have abnormalities
  • new device
  • BRAVO probe
  • 48 hr monitoring

25
pH Monitoring
26
Barium Esophagram
  • Now considered to be of very limited practical
    value in the diagnosis of GERD1
  • May be helpful in the detection of subtle
    strictures and hiatal hernias in patients with
    dysphagia
  • May be helpful in identifying pathologies
    unrelated to GERD

1Dent et al. Gut 1999
27
The Pyramid of Diseases Associated with GERD
Yes
0
Misc
Asthma
ENT
Need to investigate role of acid
Prevalence of GERD
Chest pain
Non-erosive reflux disease
Erosive esophagitis
100
No
Richter. Am J Gastroenterol 2000
28
Complications of GERD
  • Esophageal
  • Barretts esophagus
  • adenocarcinoma
  • stricture
  • ulceration
  • bleeding
  • Extra-esophageal
  • asthma
  • reflux laryngitis
  • vocal cord ulcers
  • subglottic stenosis
  • tracheal stenosis

29
Esophageal stricture
30
Barretts Esophagus
31
Barretts Esophagus Clinical Significance
  • Premalignant lesion for esophageal adenocarcinoma
  • Patients with Barretts esophagus may be 3060
    times more likely to develop this cancer than the
    general population1
  • The reported incidence of Barretts esophagus is
    rising

1Lagergren et al. New Engl J Med 1999
32
The Risk of Esophageal Adenocarcinoma Increases
with
  • Frequency of reflux symptoms
  • OR 16.7 with gt 3/wk
  • Duration of reflux symptoms
  • OR 16.4 with greater than 20 yrs
  • Severity of reflux symptoms
  • OR 20 with most severe score

Lagergren et al. N Engl J Med 1999
33
Treatment
34
Treatment Options
  • Lifestyle measures
  • Pharmacological therapy
  • Initial therapy
  • Maintenance therapy
  • Antireflux surgery
  • Endoscopic techniques

35
Lifestyle Measures
  • Raise the head of the bed, or lie on left side
  • Decrease fat intake
  • Avoid certain foods
  • Avoid lying down for 3 hours after eating
  • Stop smoking
  • Lose weight if appropriate

36
Aggravating Dietary Factors
  • Caffeinated products
  • Peppermint
  • Fatty foods
  • Chocolate
  • Spicy foods
  • Citrus fruits and juices
  • Tomato-based products
  • Alcohol

37
Pharmacological Therapy
  • Antacids
  • Prokinetics
  • Acid suppression
  • Histamine 2-receptor antagonists (H2RAs)
  • Proton pump inhibitors (PPIs)

38
Acid Suppression Erosive Esophagitis Initial
Therapy
  • H2RA v placebo (4-8 wks of therapy)
  • 18 trials, 2134 patients
  • NNT 5 (95 CI, 3-22)
  • PPI v placebo
  • 5 trials, 635 patients
  • NNT 2 (95 CI, 1.4-2.5)
  • PPI v H2RA
  • 26 trials, 4064 patients
  • NNT 3 (95 CI, 2.8-3.6)

Khan M, et al. Cochrane Database Syst Rev.2006.
39
Acid Suppression Erosive Esophagitis
Maintenance Therapy
  • 80 relapse after 6-12 months off therapy
  • PPI v H2RA
  • 10 trials, 1583 patients, 24-52 wks of therapy
  • Relapse rate
  • 22 in PPI group
  • 58 in H2RA group
  • NNT 2.5 (95 CI, 2.0-3.4)

Donnellan C, et al. Cochrane Database Syst
Rev.42004.
40
Antireflux Surgery Procedures
41
Antireflux Surgery use and efficacy
  • Antireflux surgery is an option as maintenance
    therapy for patients with well documented GERD1
  • The efficacy of antireflux surgery is similar to
    that of chronic PPI therapy2
  • The outcome of surgery is highly dependent on the
    skill and experience of the surgeon2

1DeVault et al. Am J Gastroenterol 1999 2Dent et
al. Gut 1999
42
Endoscopic Therapy
  • Three FDA approved techniques
  • Stretta radiofrequency therapy to LES
  • EndoCinch endoscopic gastroplication
  • Enteryx 8 ethylene vinyl alcohol copolymer


43
Endoscopic Gastroplication
44
Management Goals
  • Provide complete relief from heartburn and other
    symptoms
  • Heal underlying erosive esophagitis
  • Treat or prevent complications
  • Prevent recurrence

45
Management
  • Clinical diagnosis
  • Endoscopy in pts with alarm symptoms
  • PPI once daily taken 30 min before breakfast for
    4-8 weeks
  • If symptoms resolve, consider on-demand therapy
    or step down
  • Relapse is common

46
Management
  • If symptoms persist despite daily PPI
  • Nonadherence
  • Inadequate dosing or timing
  • Nocturnal acid breakthrough
  • Rare
  • Zollinger-Ellison syndrome
  • Drug resistance
  • Surgery right patient and right surgeon

47
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