Gastroesophageal Reflux Disease GERD Any symptoms or

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 Locke et al. Gastroenterology 1997; 112: 1148.

Important Reasons to Diagnose and Treat GERD • Negative impact on health-related quality of life 1 • Risk factor for esophageal adenocarcinoma 2 1. Revicki et al. Am J Med 1998; 104: 252. 2. 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 p. H 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. p. H Monitoring • Physiologic study • Quantify reflux in proximal/distal esophagus – % time p. H < 4 – De. Meester score • Symptom correlation

Ambulatory 24 hr. p. H Monitoring Normal GERD

Wireless, Catheter-Free Esophageal p. H 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. p. H 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 H 2 -Receptor Antagonists (H 2 RAs) 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 % H 2 -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