Difficult To Manage GERD Hani Abdallah Zamil MD

Difficult To Manage GERD Hani Abdallah Zamil, MD Assistant Professor of Medicine Director, GI Motility and Physiology Quality Officer Ertan Digestive Disease Center Division of Gastroenterology, Hepatology & Nutrition Mc. Govern Medical School

Objectives 1. Define GERD and failure to medical therapy 2. Discuss causes of failure of medical therapy of GERD 3. Discuss other condition that mimic GERD and failed medical therapy

IS IT GERD?

What is GERD? Montreal Definition of GERD “GERD is a condition which develops when the reflux of stomach contents cause troublesome symptoms and/or complications. ”

GERD Symptoms Typical Symptoms Heartburn Regurgitation 50% Atypical Symptoms Chest pain Cough Asthma LPR 10 -20% Complications Persistent symptoms Dysphagia Strictures Barrett’s

GERD Symptoms PPI Success Confirmed diagnosis Persistent symptoms 10 -40% p. H - Impedance Acid reflux Non-acid reflux No reflux

Erosive GERD • • Erosive esophagitis by endoscopy Male, older and overweight More complications More relapse without therapy

NERD • • Endoscopy Negative GERD Female, younger and thin Usually without a hiatus hernia Higher prevalence of functional GI disorders

Difficult to manage GERD • • Failure to respond to medical therapy (PPIs) 10 -40% Partial vs. complete Once daily vs. BID

Causes of Failed Medical Therapy • • • Medicines related Compliance and timing adherence Metabolism (CYP 2 C) Reduced bioavailability Drug resistance

Non acidic or weakly acidic reflux • • Detected by p. H-impedance Hiatus hernia Volume distention of the esophagus? Hypersensitive esophagus?

Bile acid reflux • • Different from non acidic reflux Bilitec Acid rather then bile? Role of bile acids despite alkaline refluxate

Nocturnal acid reflux breakthrough • Common in patients on PPI BID (70% p. H <4 at night for more then 60 minutes) • Correlates with severity of esophagitis • Not common in our experience • H 2 blockers at bedtime

Acid Pocket Gut 2010; 59: 441 e 451.

H Pylori • Higher healing rates in HP positive patients (more acid suppression with PPIs) • Proximal migration of HP

Delayed healing • Healing of esophagitis takes up to 8 weeks • Severe esophagitis may take longer

Residual acid reflux • Abnormal p. H study despite therapy with PPIs (daily or BID)

IF IT’S NOT GERD, THEN WHAT IS IT?

Diseases of the Esophagus (2013) 26, 443– 450

Eosinophilic esophagitis • Primarily dysphagia • One third have heartburn (with dysphagia) • PPI responsive eosinophilia

Impaired gastric emptying • Gastroparesis

Achalasia

NSAIDs • Can cause esophageal symptoms (heartburn)

Other Esophagitis • • Infectious esophagitis Candida esophagitis CMV and HSV in immunocompromised Autoimmune, vasculitis. .

Evaluation • Endoscopy

Evaluation • Esophageal p. H testing

Evaluation • Esophageal manometry

Evaluation • Gastric emptying study

Management • • • Lifestyle changes and dietary precautions Optimization of medical therapy Improvement of gastric emptying Decrease TLES: baclofen Increase LESP: bethanechol Alginic acid (Scleroderma)

Surgery and endoscopic management

T. Hershcovici, R. Fass / Best Practice & Research Clinical Gastroenterology 24 (2010) 923 – 936