Gastroesophageal Reflux Disease
(GERD)
• Any symptoms or esophageal mucosal damage
that results from reflux of gastric acid into the
esophagus
• Classic GERD symptoms
– Heartburn (pyrosis): substernal burning discomfort
– Regurgitation: bitter, acidic fluid in the mouth
when lying down or bending over
High Prevalence of Gastroesophageal
Reflux Symptoms
60%
50%
40%
30%
20%
10%
0%
59%
19.8%
Weekly
Monthly
Frequency of heartburn and/or
regurgitation
Locke et al. Gastroenterology 1997;112:1148.
Important Reasons to Diagnose and Treat
GERD
• Negative impact on health-related quality of life1
• Risk factor for esophageal adenocarcinoma2
1.
2.
Revicki et al. Am J Med 1998;104:252.
Lagergren et al. N Engl J Med 1999;340:825.
Clinical Presentations of GERD
• Classic GERD
• Extraesophageal/Atypical GERD
• Complicated GERD
Extraesophageal Manifestations
of GERD
Pulmonary
Asthma
Aspiration pneumonia
Chronic bronchitis
Pulmonary fibrosis
Other
Chest pain
Dental erosion
ENT
Hoarseness
Laryngitis
Pharyngitis
Chronic cough
Globus sensation
Dysphonia
Sinusitis
Subglottic stenosis
Laryngeal cancer
Potential Oral and Laryngopharyngeal Signs
Associated with GERD
• Edema and hyperemia of
larynx
• Vocal cord erythema,
polyps, granulomas,
ulcers
• Hyperemia and lymphoid
hyperplasia of posterior
pharynx
• Interarytenyoid changes
• Dental erosion
• Subglottic stenosis
• Laryngeal cancer
Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.
Pathophysiology of Extraesophageal
GERD
Symptoms of Complicated GERD
• Dysphagia
– Difficulty swallowing: food sticks or hangs up
• Odynophagia
– Retrosternal pain with swallowing
• Bleeding
When to Perform Diagnostic Tests
•
•
•
•
•
•
Uncertain diagnosis
Atypical symptoms
Symptoms associated with complications
Inadequate response to therapy
Recurrent symptoms
Prior to anti-reflux surgery
Diagnostic Tests for GERD
•
•
•
•
Barium swallow
Endoscopy
Ambulatory pH monitoring
Esophageal manometry
Barium Swallow
• Useful first diagnostic test for
patients with dysphagia
–
–
–
–
Stricture (location, length)
Mass (location, length)
Bird’s beak
Hiatal hernia (size, type)
• Limitations
– Detailed mucosal exam for erosive
esophagitis, Barrett’s esophagus
Endoscopy
• Indications for endoscopy
–
–
–
–
Alarm symptoms
Empiric therapy failure
Preoperative evaluation
Detection of Barrett’s
esophagus
Ambulatory 24 hr. pH Monitoring
• Physiologic study
• Quantify reflux in
proximal/distal
esophagus
– % time pH < 4
– DeMeester score
• Symptom correlation
Ambulatory 24 hr. pH Monitoring
Normal
GERD
Wireless, Catheter-Free Esophageal pH Monitoring
Potential Advantages
• Improved patient
comfort and acceptance
• Continued normal work,
activities and diet study
• Longer reporting periods
possible (48 hours)
• Maintain constant probe
position relative to SCJ
Esophageal Manometry
Limited role in GERD
• Assess LES pressure,
location and relaxation
– Assist placement of 24 hr.
pH catheter
• Assess peristalsis
– Prior to antireflux surgery
Treatment Goals for GERD
•
•
•
•
Eliminate symptoms
Heal esophagitis
Manage or prevent complications
Maintain remission
Lifestyle Modifications are
Cornerstone of GERD Therapy
•
•
•
•
•
Elevate head of bed 4-6 inches
Avoid eating within 2-3 hours of bedtime
Lose weight if overweight
Stop smoking
Modify diet
– Eat more frequent but smaller meals
– Avoid fatty/fried food, peppermint, chocolate,
alcohol, carbonated beverages, coffee and tea
• OTC medications prn
Acid Suppression Therapy for GERD
H2-Receptor Antagonists
(H2RAs)
Cimetidine (Tagamet®)
Ranitidine (Zantac®)
Famotidine (Pepcid®)
Nizatidine (Axid®)
Proton Pump Inhibitors
(PPIs)
Omeprazole (Prilosec®)
Lansoprazole (Prevacid®)
Rabeprazole (Aciphex®)
Pantoprazole (Protonix®)
Esomeprazole (Nexium ®)
Effectiveness of Medical Therapies for
GERD
Treatment
Response
Lifestyle modifications/antacids
20 %
H2-receptor antagonists
50 %
Single-dose PPI
80 %
Increased-dose PPI
up to 100 %
Treatment Modifications for
Persistent Symptoms
• Improve compliance
• Optimize pharmacokinetics
– Adjust timing of medication to 15 – 30 minutes
before meals (as opposed to bedtime)
– Allows for high blood level to interact with
parietal cell proton pump activated by the meal
• Consider switching to a different PPI
GERD is a Chronic Relapsing Condition
• Esophagitis relapses quickly after cessation
of therapy
– > 50 % relapse within 2 months
– > 80 % relapse within 6 months
• Effective maintenance therapy is imperative
Complications of GERD
• Erosive/ulcerative esophagitis
• Esophageal (peptic) stricture
• Barrett’s esophagus
• Adenocarcinoma
Erosive Esophagitis
Peptic Stricture
Barium Swallow
Endoscopy
Esophageal Stricture: Dilating Devices
TTS Balloon Dilation of a Peptic Stricture
Barrett’s Esophagus
Esophageal Cancer
Barium Swallow
Endoscopy
When to Discuss Anti-Reflux
Surgery with Patients
• Intractable GERD – rare
– Difficult to manage strictures
– Severe bleeding from esophagitis
– Non-healing ulcers
• GERD requiring long-term PPI-BID in a
healthy young patient
• Persistent regurgitation/aspiration symptoms
• Not Barrett’s esophagus alone
Endoscopic GERD Therapy
• Endoscopic antireflux therapies
– Radiofrequency energy delivered to the LES
• Stretta procedure
– Suture ligation of the cardia
• Endoscopic plication
– Submucosal implantation of inert material in
the region of the lower esophageal sphincter
• Enteryx