Update in GERD
New Techniques and Perspectives
Presented on: May 17th 2014
John E. Pandolfino, MD, MSCI
Professor of Medicine
Feinberg School of Medicine,
Northwestern University
Chief, Division of Gastroenterology and Hepatology
Northwestern Medicine
Northwestern Memorial Hospital
GERD is a condition which develops when
the reflux of stomach content causes troublesome
symptoms and / or complications
Esophageal
Syndromes
Symptomatic
Syndromes
• Typical reflux
syndrome
• Reflux chest
pain syndrome
Extra-esophageal
Syndromes
Syndromes with
Esophageal Injury
Established
Association
• Reflux esophagitis
• Reflux stricture
• Barrett's
esophagus
• Reflux cough
• Adenocarcinoma
• Reflux laryngitis
• Reflux asthma
• Reflux dental
erosions
Proposed
Association
• Sinusitis
• Pulmonary
fibrosis
• Pharyngitis
• Recurrent otitis
media
Vakil N et al. Am J Gastroenterol 2006;101:1900
Functional
Heartburn/Chest Pain
Patient with retrosternal discomfort
(heartburn/chest pain) or regurgitation
Alarm
features?
no
Heartburn
resolved?
PPI Trial
yes
yes
Reflux disease: titrate
PPI therapy
no
EGD ± biopsy
no
Abnormal?
no
pH or impedance-pH monitoring (off of PPIs)
yes
Esophagitis
EoE
>5% esophageal
acid exposure?
yes
yes
MII-pH monitoring
(on PPIs)
NERD
no
Esophageal
manometry
Positive
symptom
association?
no
Meets esophageal
motor disorder
criteria?
yes
Achalasia
DES
Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747
Functional
Heartburn/Chest Pain
Patient with retrosternal discomfort
(heartburn/chest pain) or regurgitation
Alarm
features?
no
Heartburn yes
resolved?
PPI Trial
yes
Reflux disease:
titrate PPI therapy
no
EGD ± biopsy
Abnormal?
no
pH or impedance-pH monitoring (off of PPIs)
yes
Esophagitis
EoE
>5%
esophageal
acid exposure?
yes
yes
NERD
no
Positive
symptom
association?
Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747
Phenotyping PPI Non-responders:
Low pre-test probability of refractory GERD
Bravo capsule placed
6cm above SCJ
Pandolfino et al. Am J Gastroenterol. 2003 Apr;98(4):740-9
Phenotyping PPI Non-responders:
High pre-test probability of refractory GERD
10000
ohms
17 cm
15 cm
Bravo capsule placed
6cm above SCJ
9 cm
7 cm
5 cm
3 cm
0
ohms
0
15
30
45
60
Time (Seconds)
Pandolfino JE, Vela, MF. Gastrointest Endosc. 2009 Apr;69(4):917-30,
PPI Non-responders are Heterogeneousg EGD n
• Acid Reflux Symptoms
– Abnormal acid exposure
– Hypersensitive [(+) S-R correlation]
• Non-acid Reflux Symptoms
– Volume refluxers
– Hypersensitive [(+) S-R correlation]
• Overlap between well-controlled GERD and
Functional Esophageal Disorder
• Do Not Have Reflux at ALL
– Functional heartburn….or just functional
– Unrelated disease (EoE, EMD, Cardiopulm etc..)
Pandolfino JE, Vela, MF .Gastrointest Endosc. 2009 Apr;69(4):917-30,
Evolution of the Hydrostat: EndoFlip™
Kwiatek et al. J Gastrointest Surg. 2010 Feb;14(2):268-76
Gastroesophageal Reflux Disease
True Refractory Symptoms
•Targets for therapy based on our
observations
 Alter EGJ mechanical properties
• Surgery
• Endoscopic procedures
 Medications
• Promotility agents
• Reflux inhibitors
Pandolfino JE, Krishnan, K. . Clin Gastro Hepatol. 2013 Jun 28. : S1542-3565
Functional
Heartburn/Chest Pain
Patient with retrosternal discomfort
(heartburn/chest pain) or regurgitation
Alarm
features?
no
Heartburn
resolved?
PPI Trial
yes
yes
Reflux disease: titrate
PPI therapy
no
EGD ± biopsy
no
Abnormal?
no
pH or impedance-pH monitoring (off of PPIs)
yes
Esophagitis
EoE
>5% esophageal
acid exposure?
yes
yes
MII-pH monitoring
(on PPIs)
NERD
no
Esophageal
manometry
Positive
symptom
association?
no
Meets esophageal
motor disorder
criteria?
yes
Achalasia
DES
Gastroesophageal Reflux Disease
Symptom perception
 Visceral Sensitivity
 Hypervigilance
 Psychosocial factors
MF
HV
PD
VS
Abnormal Motor Function
Case : Functional Heartburn
Case : Visceral Hypersensitivity
MF
PD
HV
HV
VS
Gut-directed Hypnotherapy
Are you getting sleepy?
• Deep physical relaxation and deep
mental concentration
• Alters focus of attention, changes
meaning about sensations arising from
the gut and encourages body to restore
itself to a healthier state
• Shown to produce cognitive change and
improve pain tolerance
• Modifies physiological arousal and
hypersensitivity over long-term
• Initially performed in a doctors office but
can eventually be self-guided
• The most scientifically supported nondrug treatment for Functional GI
disorders
GERD: Pitfalls
• Patients may have a good response to PPI and not
have GERD.
• Patients may have a positive pH study and not
have GERD.
• Patients may have a good symptom correlation on
pH-impedance testing and not have GERD.
• Be careful with belching, regurgitation and
nausea/vomiting.
tLESR
Liquid reflux
LES relaxation
and
crural inhibition
NU IRB
Rumination # 1 HRM only
Liquid reflux
Increased IGP pressure
NU IRB
Rumination #2 HRIM
Regurgitation with swallowing
Liquid reflux
Increased IGP pressure
NU IRB
Supragastric Belching
Air reflux
No LES relaxation
NU IRB
GERD: Pitfalls
Gastroesophageal Reflux Disease
Conclusions
•Reflux testing is essential to phenotype the
patient based on mechanism.
Refractory reflux
Reflux sensitivity
Functional heartburn
Alternative diagnosis- HRIM is extremely
helpful
Gastroesophageal Reflux Disease
Conclusions
• Phenotype will dictate therapies
 Refractory reflux
• Endoscopic/surgery
 Reflux sensitivity
• Motility agents, TCA, HYPNOSIS
 Functional heartburn
• TCA, CBT, Hypnosis
 Rumination syndrome/supragastric belching
• Biofeedback, CBT, hypnosis
Thank You