Download Gastroesophageal Reflux Disease

Gastro
Esophageal
Reflux
Disease
Presented for Sherman Hospital
By Lawrence R. Kosinski, MD, MBA, FACG
March 24th, 2004
Goals
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To understand the difference between
Heartburn and GERD
To be able to recognize the symptoms of
GERD
To know the potential serious complications
of GERD
To understand how we diagnose GERD
To understand the treatment of GERD
Definitions
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Gastroesophageal reflux disease
(GERD)
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A symptomatic clinical condition resulting from
episodes of gastroesophageal reflux.
Reflux esophagitis (RE)
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A subset of GERD patients with demonstrable
changes in the esophageal mucosa.
Outline
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Overview
Pathogenesis
Clinical Presentation
Differential Diagnosis
Diagnostic evaluation
Treatment
Overview
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One third of Americans occasionally have heartburn every
year
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Most common reason for the use of OTC antacids
7% of Americans have heartburn on a regular basis and
have GERD
Most of chronic GERD patients have Esophagitis
males = females for GERD
males predominate with RE
proportional to age
The Anatomy of the Disease
Normal Mid Esophagus
Normal GEJ
Mild Reflux Esophagitis
Severe GERD
Ulceration
Pathogenesis of GERD
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Abnormal LES
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Hypotensive LES
Transient LES relaxation
Hiatal Hernia
Decreased
Esophageal acid
clearance
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Role of stimulated
peristalsis
Role of saliva
Clinical Presentation
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Typical Symptoms
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Heartburn
Regurgitation
Dysphagia
Atypical Symptoms
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Chest Pain
Respiratory Symptoms
ENT Symptoms
Globus Syndrome
Natural History
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Most patients have symptoms for 3yrs
before they seek help
Most patients with GERD have Reflux
Esophagitis
When GERD is associated with RE, it is
usually chronic
We must identify the RE patient
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You can’t tell just from the symptoms
Complications of Reflux
Esophagitis
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Ulceration in 5%
Stricture in 8-20%
Barretts in 8-20%
Hemorrhage in less than 2%
Esophageal Cancer
Schatzki Ring
Severe GERD
Stricture
Barrett’s Esophagus
Esophageal Cancer
Risk factors
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Obesity/Eating habits
Smoking
Drugs
Hiatal Hernia
Post surgical
Differential Diagnosis
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Non-GERD esophagitis
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Infections: Candida, Herpes, CMV
Pills: Tetracycline, KCL, NSAIDS, AZT, Quinaglute
Systemic diseases: Crohn's, Behcet's, Pemphigus
Radiation therapy
Peptic ulcer disease
Functional Dyspepsia Syndrome (IBS)
Biliary /Pancreatic disease
Esophageal Motility Disorders
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Diffuse esophageal spasm -Achalasia -Nutcracker
esophagus
Infectious Esophagitis
Scleroderma
Radiation Injury
Peptic Ulcer Disease
Diagnostic Evaluation
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Upper GI
Esophagogastroduodenoscopy
(EGD)
Esophageal Motility Study
(EMS)
24hr Ph study
Capsule Endoscopy
Upper GI
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Diagnostic only
Inexpensive $ 300
20% sensitivity for GERD
Limited ability to detect RE
No ability to detect Barrett's
No ability to biopsy
Upper GI
EGD
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Diagnostic and therapeutic
Expensive > $ 1000
60-70% sensitivity for GERD
Near 100% sensitivity for RE -Detects
Barrett's
Ability to obtain a biopsy
Normal EGD
Esophageal Motility Study
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Measures esophageal
pressure during
swallowing
Most patients with
GERD have normal
studies
Useful for the
preoperative
evaluation before
GERD surgery
24hr Ph Study
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Diagnostic only
Moderately expensive $ 500
88% sensitive for GERD
Limited indications
Useful in the evaluation of chest pain
Uncomfortable for the patient
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New Bravo System
Capsule Endoscopy
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Currently only
approved for
visualizing the small
intestine
Capable of visualizing
the esophagus
Needs to have some
adjustments
Video
Treatment
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Lifestyle Modifications
Drug Therapy
Surgery
New Therapies
Lifestyle Modifications
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Cigarette smoking
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Eating habits
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decreases LES pressure
delays esophageal acid clearance
decreases saliva output
discourage overeating at one meal
discourage eating before reclining or exercising
encourage weight control
Elimination of certain foods
Medication adjustments
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Theophyline
Progesterone
Ca channel blockers
Fosamax
Drug Therapies
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Antacids
H2 Receptor Antagonists
Proton Pump Inhibitors
Prokinetic Drugs
Antacids
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Useful for mild and infrequent symptoms
Immediate effect but short acting
Need to be taken frequently
Prescribed 1-3hrs postprandial and at HS
Gaviscon useful for upright GERD
symptoms
No good data to show ability to heal RE
H2 Receptor Antagonists
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All H2RAs equally effective in appropriate
doses
GERD vs PUD
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therapeutic differences
Dose after dinner since this is peak acid output
time
Heals RE in 60% of patients after 12 weeks of
H2RA therapy
Expense Zantac>Pepcid>Axid>Tagamet
Proton Pump Inhibitors
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Heal RE in >80% of patients after 8
weeks of therapy
Prolonged therapy heals near 100%
Superior to H2RA
Approved by FDA for chronic use
Aciphex, Prevacid, Prilosec, Protonics,
Nexium
Prokinetic Agents
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Metoclopramide (Reglan)
Cisapride
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Not available in USA
Erythromycin
Tegaserod (Zelnorm)
Surgery
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Indications
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Persistent ulceration
Persistent stricture
Persistent aspiration
Chronic Regurgitation
Dependency on PPIs in young patients
Procedure
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Laparoscopic Nissen Fundoplication
Nissen Fundoplication
New Therapies
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Endoscopic therapies
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Endocynch
Stretta
Enteryx
Photodynamic therapy
Endocynch
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Endoscopic Procedure designed to place a
stitch in the GE Junction
Cumbersome to perform
Effects only lasted 6 months
No longer done
Stretta
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Effective in Controlling
Pain from GERD in
70% of cases
Safe
Sham Study failed to
establish effect on
Reflux
May not be performed
in the future
Enteryx
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Polymer that is injected into the GE
Junction Endoscopically
Sham Study in progress
Long Term Effectiveness and Safety
need to be established
Prevention
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Nutritional Issues
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Weight Control
Eating Habits
Foods
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Chocolate
Mint
Restrictive Garments
Exercise after eating