Gastroesophageal Reflux Disease:
Beyond Heartburn
Annette Y. Kwon, M.D.
Edward W. Holt, M.D.
October 1, 2011
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?
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)
GERD: Montreal Definition
• A condition which develops when the
reflux of stomach contents causes
troublesome symptoms and/or
complications
– > 2 heartburn episodes/week
– Adversely affect an individual’s well being
From Vakil N et al. Am J Gastroenterol 2006;101:1900-20.
GERD: Complications
Kahrilas P. N Engl J Med 2008;359:1700-1707
Montreal Classification of GERD
From Vakil N et al. Am J Gastroenterol 2006;101:1900-20.
Montreal Classification of GERD
Pathogenesis of GERD
LES
Hiatal Hernia
Decreased Salivation
Impaired Tissue Resistance
Impaired Esophageal Clearance
Decreased LES Resting Tone
Duodenum
Delayed Gastric Emptying
Bile Reflux
Paradox in GERD: Imperfect
correlation between symptoms and
endoscopic features
Barrett’s
esophagus
Esophagitis
Cases
(%)
16/1000
(1.6%)
155/1000
(15.5%)
% with
GERD
symptoms
40%
33%
From Ronikainen J et al. Gastroenterology 2005;129:1825-31.
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 Barrett’s on
pathology
• 23/63 with prior EGD had prior Barrett’s
diagnosis
• Laryngopharyngeal reflux (LPR) symptoms
more common than GERD symptoms in
patients with cancer
Diagnosis
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 2005;100:190-200.
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 2007;66:219-24.
Role of Endoscopy in Management of
GERD: ASGE Guidelines
• Screening for Barrett’s:
– controversial with no clinically proven
decrease in mortality with screening and
surveillance programs
• Persistent vomiting
• Suspected extraesophageal GERD
From Gastrointest Endosc 2007;66:219-24.
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 2008;359:1700-7.
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)
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
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 2009;27:14-17
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 >13 suggestive of LPR
Treatment
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 2008;135:1383-91.
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 2008;103:1355-7.
AGA GERD Practice Guidelines:
Medication
PPI
Esophagitis 83%
Heartburn
40%
H2RA
Placebo
52%
8%
15%
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 2007;2:CD003244
Patients in symptomatic remission (%)
GERD Is a Chronic Condition
Likely to Relapse
100
No mucosal breaks
LA Grade A
80
LA Grade B
LA Grade C
60
40
20
0
0
1
2
3
4
Time after cessation of therapy (months)
From Lundell LR, et al. Gut. 1999;45:172-180.
5
6
Adverse Events With Up to 1 Year
Esomeprazole Treatment
Adverse Event
% Patients (N=807)
Headache
10.3
Diarrhea
9.4
Abdominal pain
9.3
Nausea
6.1
Back pain
5.9
From Maton PN et al. Drug Safety 2001;24:625-35
of
Safety Profile of PPIs
• Recent epidemiologic associations
– C. difficile 2x
– Bacterial gastroenteritis 1.5x
– Hip fracture 1.4x in age >50
– Plavix interaction…resolved…
• Pregnancy
– Omeprazole category C but rest of PPI and
H2RA are category B
GERD Treatment Algorithm:
Initial Work Up
Initial Assessment
Possible patient with GERD or LPR
Rule out other causes
Coronary artery disease
Consider ultrasound if biliary colic suspected
Other causes ruled out
Typical symptoms
No Alarm symptoms
Empiric treatment 8-12 weeks
Lifestyle modification
Dysphagia present
Consider barium swallow
• LPR requires higher doses for 3 months
Referral to GI
GERD Treatment Algorithm:
Initial Work Up
Empiric Treatment
Lifestyle Modification
Resolution of symptoms
Maintain lifestyle modification
Titrate to lowest effective maintenace therapy
Maintain lifestyle modification
On demand therapy
If on multiple medications, eliminate one at a time
if on twice daily PPI, decrease to once daily x 4 weeks then off
• High recurrence rate when therapy discontinued
GERD Treatment Algorithm
Initial Assessment
Patient with Possible GERD
Other causes ruled out
Typical symptoms
No alarm symptoms
Presence of alarm symptoms
Empiric Treatment for 8-12 weeks
Lifestyle modifications
Medications
Refer to GI
Resolution of symptoms
Maintain lifestyle modifications
Maintain at lowest effective dose
Maintain lifestyle modifications
On demand therapy as needed
No response to treatment
Refer to GI
EGD
(manometry)
(pH impedence)
EGD
(manometry)
(pH impedence)
Twice standard dose of PPI
No response to Treatment
Refer to GI
EGD
(manometry)
(pH impedence)
Resolution of symptoms
Summary
• GERD currently classified by
Montreal system
– Esophageal
– Extraesophageal (LPR)
• Diagnostic testing
– Empiric treatment in uncomplicated
cases with typical symptoms
– Endoscopy
Summary
• Diagnostic sequence:
–Endoscopy
–Manometry
–pH studies
• Role of screening for Barrett’s
esophagus remains
controversial
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
Thank you!