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Gastroesophageal Reflux Disease PowerPoint Presentation

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Description : Heartburn symptoms off/on for many years but increasing in severity and frequency in last 6-12 months.

Tags : gastroesophageal reflux disease,reflux disease,heartburn symptoms,problem of GERD,pathophysiology,evaluation of GERD

Published on : Sep 06, 2022 | Views : 2044 | Downloads : 3

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GERD:An Old Problem with New Approaches Jason Phillips, MD
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Case HPI: 44 y/o M with heartburn Heartburn symptoms off/on for many years but increasing in severity and frequency in last 6-12 months Symptoms are described as: Sternal ‘burning’ with acid taste in mouth Occurs most frequently at night most days of the week Last hours Partially relieved with Mylanta
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Case Exacerbated by: Supine positions after meal Large meals Food triggers: pasta, greasy food, coffee, alcohol Denies weight loss, dysphagia, melena, hematemesis
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Case PMH: Obesity Meds: Mylanta NKDA SH: smokes 1ppd x 10+years, drinks 2-4 glasses of wine per night FH: No h/o esophageal Ca
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Case PE: BP 140/86 P 96 Afeb Wt 275 lbs (BMI 36) Gen: obese, NAD Exam essentially normal
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Case Pt was seen by his PCP and diagnosed with GERD. Prescribed a PPI to take once a day. Advised pt to lose weight and quit smoking Follow-up in 4-6 weeks
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Case At 5 weeks, he called his PCP and complained he was still having daily episodes of heartburn though ‘the medicine helped a little’ PCP’s 3 options: Increase PPI to BID Change PPI Referral to GI
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Case PPI was increased to BID and the patient continued to have reflux symptoms Therefore, the pt was referred to GI for further evaluation
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Case GI visit: Additional history Pts symptoms sounded like typical reflux-like symptoms Symptoms mostly occurred from 8-10 PM after his dinner at 7 PM Large evening meals most days Had not tried avoiding typical food triggers Had not lost weight or stopped smoking
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Case GI visit: Additional history He was taking his PPI 30 minutes after meals (during dessert) twice per day as recommended His symptoms overall improved by ~50% but as mentioned, he continued to have daily symptoms
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Case GI visit: Additional history Reflux events also increased during the day during stressful moments at work
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Case Possible diagnoses Inadequately treated GERD vs functional heartburn Malignancy Esophageal spasm Peptic ulcer disease Angina
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Case EGD while still taking medications: normal esophagus with no evidence of esophagitis or Barrett’s esophagus Normal stomach and duodenum
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Case Does he have non-erosive acid reflux that is inadequately treated with his current PPI or is this functional heartburn?
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Case To distinguish, I arranged for the patient to have a 24 pH probe while still taking his BID PPI Bravo wireless 24 hour pH probe
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Case Diagnosed with acid reflux Recommendations BID PPI – taken 30 minutes BEFORE meals Additional nocturnal H2 blocker Behavioral modifications Earlier dinner, smaller portions Avoidance of trigger foods Quit smoking Lose weight
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GERD Incidence Complaints of heartburn 40% of Americans complain of monthly heartburn 20% complain of weekly heartburn 7% complain of daily heartburn Prevalence of GERD is increasing over the 30 years
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Problem of GERD Difficult to define Physiologic vs pathologic acid reflux Physiologic  postprandial, short lived, asymptomatic, rarely during sleep Pathologic  symptoms, often include nocturnal episodes
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Symptoms Heartburn Epigastric pain Regurgitation Dysphagia Chest pain Nausea Odynophagia Globus sensation Supraesophageal symptoms
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Symptoms Patient’s descriptions can be difficult to interpret: “Its not heartburn its… “…bile coming up into my throat.” “…intense pain in my stomach.” “…its not pain, its heaviness in my chest.” “…pain in the back of my throat when I awake.”
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Pathophysiology 80% of reflux symptoms occur as a result of transient LES relaxation Other motility defects LES incompetence Gastroparesis Esophageal body dymotility Anatomic defects: Hiatal hernia
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Diagnosis Symptoms  empiric PPI Uncomplicated symptoms (no alarm signs – weight loss, GI bleeding, dysphagia) Age < 65 years No esophagotoxic medications (e.g, bisphophonates) 6 weeks trial
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Diagnosis: Empiric treatment Sensitivity ~75% Specificity ~80% Using 50% improvement as the therapeutic endpoint Schindlbeck et al…Arch Int Med 155:1808-12, 1995 Fass et al…Arch Int Med 159:2161-8, 1999
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Evaluation of GERD In patients who have ‘red flags’ or fail 6 weeks of a PPI  EGD EGD: signs of esophagitis Barrett’s esophagus Hiatal hernias Exclusion of cancer and other diagnoses (PUD)
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Evaluation of GERD
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Evaluation of GERD PillCam may offer a non-invasive method to look for evidence of esophagitis or Barrett’s esophagus
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PillCam Identified 97% (32/33) of the cases of Barrett’s esophagus when confirmed by traditional endoscopy Agreed 99% (72/73) of the time in excluding Barrett’s esophagus confirmed by traditional EGD Identified 89% (33/37) of the cases of esophagitis Agreed 99% (68/69) of the cases of ‘no evidence of esophagitis’ Eliakim et al… Preliminary results. ACG 2004.
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Evaluation 75% of community based EGD for evaluation of GERD have NO evidence of mucosal injury 50% of patients with endoscopy negative reflux disease have abnormal esophageal acid exposure In these cases, other tests are needed
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Ambulatory pH monitor Considered to be the most sensitive test for diagnosing reflux Traditional  transnasal catheter with probe situated 5 cm above LES Bravo pH system  wireless technology
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Treatment PPI are standard medical therapy Daily PPI generally has a 80% healing rate for moderate to severe esophagitis and relief of symptoms in up to 90% of patients Overall, all PPI are equally effective in treating symptoms. However, there is some variability in response from patient to patient
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Treatment Proper timing of PPI administration is critical for efficacy 30 minutes before breakfast or other large meal In select patients, a second dose can be added before the evening meal
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Surgical Treatment Indications Esophagitis Stricture Barrett’s metaplasia Medication failure Purpose of surgery  restoration the LES
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Surgical Treatment Most studies indicate that the majority of patients are symptom-free (70-95%) Recent studies suggest that after 5 years, up to 1/3 of patients required PPI to control symptoms. At 10 years, up to 50% require PPIs Side-effects: gas-bloat symptoms, diarrhea, dysphagia
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Endoscopic Treatments In development with ongoing studies Most try to improve LES function in some manner Not quite ready for prime time in community practice
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Stretta procedure
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Stretta procedure Decrease in symptom score Decreased PPI No effect on LESP No effect on acid exposure Some serious thermal injury complications
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Enteryx injection
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Enteryx injection Decreased in heartburn symptoms Decreased 24 hour acid exposure Decreased need for PPI No improvement in severity of esophagitis at EGD Long term safety issues not known
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Endoscopic suturing
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Endoscopic suturing Decreased heartburn symptoms PPI eliminated in 74% of patients at 6 months Decreased esophageal acid exposure; however, only 30% completely normalized Long term follow-up needed
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Questions?