Gastroesophageal Reflux Disease Diagnosis and Investigations Dr Abdulmalik

Gastroesophageal Reflux Disease: Diagnosis and Investigations Dr. Abdulmalik Altaf

Epidemiology • Western populations – GERD is a very common condition – One third of population experience symptoms of GERD at least once a month, – Four to 7% experience symptoms daily • The prevalence and severity of GERD reflux are likely increasing • The diagnosis of a columnar cell-lined esophagus is also increasing at a rapid rate

Symptoms of GERD Three categories of symptoms • Typical symptoms – Regurgitation and Heartburn • Worse in a recumbent position or when bending • Frequent in tense and overweight pts • Age of onset and duration possible markers of increased risks for Barrett's esophagus* • These two symptoms were the only valid ones that indicate a difference between patients who have normal and pathologic p. H-metry when heartburn is present** • Specificity is considered adequate, but sensitivity is low

Symptoms of GERD • Symptoms related to complications of GERD – Dysphagia and odynophagia • Associated with mechanical or functional obstructions that may cause reflux damage – Hematemesis and melena • Rarer complications • Related to bleeding esophagitis, • Indicate extensive mucosal damage and suggest the possibility of columnar-lined mucosa

Symptoms of GERD • Atypical reflux symptoms • Oropharyngeal dysphagia and aspiration • Episodes of asthma • Noncardiac chest pain • Hoarseness and pharyngitis • Stress, psychologic traits, and chronic anxiety may have an effect on reflux symptoms

Symptoms of GERD • Usually, regurgitation and heartburn seen in uncomplicated GERD • In 22% of patients, typical heartburn result from stomach or duodenal abnormalities • Even in cases in which the esophagus is the source of symptoms, they are not necessarily caused by reflux • Heartburn may be absent in severe reflux esophagitis

Symptoms of GERD • 25% of patients with columnar-lined esophagus have no symptoms that suggest reflux • Overall, symptoms are not good predictors of the presence and severity of esophagitis and its complications • Because of this unspecificity and poor sensitivity, symptoms must not be used as a guide to therapy but rather to investigate and document the condition

Diagnostic Tests • • • Empiric Trial of Acid Suppression Endoscopy Esophageal Biopsy Esophageal p. H Monitoring Barium Esophagram Esophageal Manometry

Empiric Trial of Acid Suppression • The simplest and most definitive method for diagnosing GERD and assessing its relationship to symptoms • Assures a cause-and-effect relationship between GERD and symptoms • Became the “first” test used in patients with classic or atypical reflux symptoms without alarm complaints • Approach was aided by the introduction PPIs • Symptoms usually respond to a PPI trial in 7 to 14 days

Empiric Trial of Acid Suppression • GERD may be assumed if symptoms disappear with therapy and then return when the medication is stopped • Reported empiric trials with heartburn: – The initial dose of PPI was high (eg, 40– 80 mg/day omeprazole) and given for not less than 14 days. – A positive response was defined as at least 50% improvement in heartburn – Sensitivity of 68% to 83%

Empiric Trial of Acid Suppression • Fass et al, 1998 – In noncardiac chest pain, a 7 -day trial of 40 mg of omeprazole in the morning and 20 mg in the evening – Sensitivity of 78% and specificity of 86% for predicting GERD, compared with traditional tests • Ours et al, 1999 – 40 mg omeprazole twice daily for 2 weeks a very reliable method for identifying acid-related cough • Patients with suspected asthma and ENT symptoms – Two to 4 -month regimen of twice-daily PPIs

Empiric Trial of Acid Suppression • Advantages – Office-based, easily performed, relatively inexpensive, available to all physicians, and avoids many needless procedures • Disadvantages – Placebo response and uncertain symptomatic endpoint if symptoms do not totally resolve with extended treatment

Upper GI Endoscopy • The standard for documenting the type and extent of mucosal injury to the esophagus • Identifies the presence of esophagitis • Excludes other causes of the patient’s complaints • Only 40% to 60% of patients with abnormal esophageal reflux by p. H testing have endoscopic evidence of esophagitis • Sensitivity is 60% at best • Specificity 90% to 95%

Upper GI Endoscopy • Endoscopic signs of acid reflux – Edema and erythema: • Earliest signs but neither is specific for GERD • Very dependent upon the quality of endoscopic visual images – Friability, granularity, and red streaks: • More reliable – Erosions • Develop with progressive acid injury • May also be caused by NSAIDs use, heavy smoking, and infectious esophagitis

Upper GI Endoscopy – Ulcers • Reflect more severe esophageal damage • They have depth into the mucosa, tend to have either a white or yellow discolored base • May be seen either isolated along a fold or surrounding the EG junction • Other signs – Schatzki ring • A thin, pearly white tissue structure located at the squamocolumnar junction • Recent debate suggests that it is a complication of GERD

Upper GI Endoscopy – Peptic strictures • Narrowing of the distal esophagus because of long-term chronic acid-induced inflammation • Shortened, thick, noncompliant region of scarring • Like rings, peptic strictures tend to occur distally at the EG junction • Typically short and less than 1 cm in length • If they are longer, other causes, should be sought. • Further evidence of esophagitis is often seen proximal to the stricture

Upper GI Endoscopy – Barrett esophagus • Appears as a salmon- or pink-colored mucosa in the tubular esophagus • Mucosal biopsies are always necessary to confirm the presence of specialized intestinal metaplasia

Upper GI Endoscopy • Endoscopic grading of GERD – Depends upon the endoscopist’s interpretation of visual images – There is no standard classification scheme for endoscopic findings – Several grading systems are available, but none is completely satisfactory • Savary-Miller classification – Most popular scheme in Europe – Based on degree of mucosal erosions • Hetzel and Los Angeles systems – Most popular in the United States – Hetzel : the area of mucosal injury – Los Angeles system: the number, length, and location of mucosal breaks

Upper GI Endoscopy

Upper GI Endoscopy • What is the role of endoscopy? – Initially, endoscopy was used to characterize patients into mild erosive and severe erosive disease and to better direct their management. – Because PPIs treat both groups equally well, early endoscopy has less impact on the choice of therapy

Upper GI Endoscopy • When to do endoscopy? – Patients experiencing “alarm” symptoms: dysphagia, odynophagia, weight loss, and GI bleeding – To rule out other entities such as infections, ulcers, cancer, or varices – Currently, the most important reason for performing endoscopy in GERD patients is to identify reflux complications – Using this rationale, most patients with chronic GERD need only one endoscopy while on therapy

Esophageal Biopsy • Microscopic changes may occur even when the mucosa appears normal endoscopically • Biopsy helps to. . – identify reflux injury – exclude other esophageal diseases – confirm complications, especially Barrett esophagus • In classic esophagitis, biopsies are not taken unless needed to exclude other diagnoses • When Barrett esophagus is suspected – biopsies are mandatory – best done when esophagitis is healed

Esophageal Biopsy • Where to biopsy? – If lesions are present • from the base of the lesion to demonstrate the depth of injury as well as reparative process – If no lesions are noted • at least 3 cm above the EG junction (Z-line) to look for reactive changes caused by reflux – Multiple biopsies are gathered because of the sporadic nature of the histological changes – Tissue closer to the Z-line is not sampled because of the decreased specificity for diagnosing GERD • Diagnostic yield – Depends on the sample size, biopsy location, tissue orientation, and the expertise of the pathologist

Esophageal Biopsy Histopathology • The most sensitive markers are reactive epithelial changes – An increase in the basal cell layer greater than 15% of the epithelium thickness or papillae elongation into the upper third of the epithelium – Papillae height increases because of loss of surface cells from acid injury – Basal cell hyperplasia is indicative of mucosal repair – These changes are also noted in up to 50% of healthy persons – Sensitive markers for GERD but have poor specificity • Short-term inflammation characterized by the presence of neutrophils and eosinophils

Esophageal p. H Monitoring • Ambulatory intraesophageal p. H monitoring is now the standard for establishing pathologic reflux • Technique: – The test is performed with a p. H probe passed nasally and positioned 5 cm above the manometrically determined lower esophageal sphincter (LES) – The probe is connected to a battery-powered data logger capable of collecting p. H values every 4 to 6 seconds – An event marker is activated by the subject in response to symptoms, meals, and body position changes – Patients are encouraged to eat normally and have regular daily activities – Monitoring is carried out usually for 18 to 24 hours – Reflux episodes are detected by a drop in p. H to below 4

Esophageal p. H Monitoring • Commonly measured parameters – – – percentage of total time at p. H < 4 percentage of time upright and supine at p. H < 4 total number of reflux episodes duration of longest reflux episode number of episodes greater than 5 minutes • Total percentage of time at p. H < 4 – The most reproducible measurement for GERD – Reported upper limits of normal values ranging from 4% to 5. 5%

Esophageal p. H Monitoring Problems with esophageal p. H monitoring: • No absolute threshold value that reliably identifies pathologic GER • Validation studies comparing the presence of esophagitis with abnormal p. H tests – Sensitivities ranging from 77% to 100% – Specificities from 85% to 100%. • False-negative studies caused by dietary or activity limitations from poor tolerability of the nasal probe

Esophageal p. H Monitoring • Advantages of ambulatory esophageal p. H monitoring – Ability to record and correlate symptoms with reflux episodes over extended periods – Replaced the shorter acid perfusion (Bernstein) test, the standard acid reflux (Tuttle) test and radionuclide scintigraphy

Esophageal p. H Monitoring Clinical applications for ambulatory p. H monitoring • Patients with a normal endoscopy and suspected reflux symptoms • Before fundoplication, p. H testing should be performed in patients with normal endoscopy to identify the presence of pathological reflux • Persistent or recurrent symptoms after antireflux surgery • Evaluation of patients with reflux symptoms resistant to treatment with normal or equivocal endoscopic findings • p. H testing may help in defining patients with extraesophageal manifestations of GERD

Barium Esophagram • Most useful in demonstrating structural narrowing of the esophagus – Consuming a 13 -mm radiopaque pill along with the barium liquid is the most sensitive test – Sensitivity: 95 -100% • Shows subtle findings usually missed by endoscopy – Schatzki rings, webs, or minimally narrowed peptic strictures • Allows good assessment of peristalsis – By giving the patient swallows of barium in the prone oblique position – Helpful preoperatively in identifying a weak esophageal pump

Barium Esophagram • Identifies GER when contrast moves in a retrograde fashion from the stomach into the esophagus – Only has a sensitivity of about 40% for defining GERD. – Provocative maneuvers can be used to elicit stress reflux but might also decrease its specificity • Primarily used in evaluating the GERD patient with newonset dysphagia because it can define subtle strictures and rings as well as assess motility • The ability to detect esophagitis varies • Also falls short when addressing the presence of a Barrett esophagus

Esophageal Manometry • Provides information on the functional ability of the esophageal muscles • Quantifies the contractile activities of the esophageal sphincters and body during swallowing • Records: – Resting pressures of the lower and upper esophageal sphincters – The timing and completeness of the relaxation • In the esophageal body, peristalsis is evaluated – The presence, propagation, velocity, amplitude, and duration of contraction waves in response to wet swallows • Measurement of LES pressures logically should be associated with the severity of GERD because of its importance as a major barrier to reflux

Esophageal Manometry • Generally not indicated in the evaluation of the uncomplicated GERD patient – The vast majority of have a normal resting LES pressure, and transient LES relaxation is the primary mechanism by which their reflux occurs • Esophageal manometry is an essential test in the preoperative evaluation of patients before antireflux surgery – A normal LES pressure does not preclude surgery – Occasionally. an alternative diagnosis is made, which may change the clinical approach – Most importantly, the presence of ineffective peristalsis suggests a weak esophageal pump. A loose 360° fundoplication or an incomplete fundoplication will minimize the risk of postoperative dysphagia.

References • Richter, Joel E. Diagnostic tests for gastroesophageal reflux disease. Am J Med Sci. 2003 Nov; 326(5): 300 -8. • Greenfield, LA et al. Surgery scientific principles and practice, 3 rd ed. Lippincott Williams & Wilkins, Philadelphia, 2001. • Duranceau A, Ferraro P, Jamieson GG. Evidence-based investigation for reflux disease. Chest Surg Clin N Am. 2001 Aug; 11(3): 495 -506, vi.

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