Gastroesophageal reflux disease GERD Raika Jamali M D

Gastroesophageal reflux disease GERD Raika Jamali M. D. Gastroenterologist and hepatologist Sina Hospital Tehran University of Medical Sciences

Objectives • Appreciate the significance of GERD as a chronic disease • Identify patients with different presentations of GERD • Organize a rationale management plan for different types of GERD symptoms • Be familiar with various treatment modalities of GERD and their appropriate use

Definitions GERD: any symptomatic condition or histopathologic alteration resulting from episodes of gastroesophageal reflux ●Erosive: 35% ●Nonerosive (NERD)

Why GERD is so important? ? ● is very common & increasing Burden and Quality of life ● complications: esophagitis, peptic stricture, inflammatory polyps , Barrett's metaplasia , dysplasia , adenocarcinoma

Epidemiology ●Geographic ● M=F variation ● Barrett's metaplasia (M/F = 10 /1)

• The prevalence of GERD in Asian populations is reported to be lower than that in the west. • Population-based data on the prevalence and symptom profile of GERD in developing Caucasian countries is lacking.

Frequency of Endoscopic GERD Iranian Experience: 1994 -1999 Retrospective study of 4500 UGIE reports (5 y): 34. 3% E GERD Malekzadeh, et al 2000

Prospective evaluation of referring Dyspeptics in Tehran • 269 (135 F) participant • Symptoms recorded, UGIE + Bx from Z-line was done: • 77. 6% at least one major GERD symptom • 76. 1% EE (most A & B) • 5% Specialized intestinal metaplasia • 3 Dysplasia • None of the symptoms could predict the endoscopic or histologic findings • Nasseri-Moghaddam, Malekzadeh et al 2002

CONCLUSION GERD is a common disease among Iranian general population and its prevalence is comparable with that of the western countries.

Pathogenesis ● Transient L E S Relaxation ● Hypotensive L E S ● Anatomic Variables ●Delayed Gastric Emptying ● Esophageal Acid Clearance - Salivary Function -Impairments of Esophageal Emptying

Case 1 • A 34 y engineer with heart burn for 8 y comes to your office for evaluation of his GERD symptoms. • He asks you about the diagnosis of GERD, if additional diagnostic work up is needed and his medical management.

Diagnosis ● History is usually sufficient to confirm the diagnosis Indications for Endoscopy Extra esophageal or atypical symptoms Patients > 40 y with new onset GERD symptoms Dysphagia Weight Loss Anemia Family hx of Cancer Long(>5 y) or very severe symptoms

GERD-B

The Los Angeles Classification

GERD-A

GERD-C

GERD-D

Avoid: smoking stress Heavy meals Large quantities of liquid with meals Fatty foods Coffee Choclate Alcohol Mint Orange juice Tomato catch up Anticholinergic, calcium channel blockers, smooth muscle relaxants

Therapeutic regimens for GERD in order of increasing potency • Over-the-counter antacids and/or H 2 receptor blockers • Omeprazole (20 mg QD) or equivalent dose of the other PPIs • Omeprazole (20 mg BID or 40 mg BD) or equivalent doses of the other PPIs

• Step-up approach: with mild symptoms, no change in QOL • Step-down approach: with more severe symptoms affecting QOL or with higher grades of esophagitis / complications • Bed time H 2 B for nocturnal symptoms

Dose of the different H 2 blockers Drug • Cimetidine • Ranitidine • Famotidine • Nizatidine Daily dose 800 mg 300 mg 40 mg 300 mg

PPI versus H 2 blockers in treatment of erosive GERD symptoms (right panel) and esophageal healing (left panel)

PPI side effects • Pneumonia • Hypergastrinemia (Carcinoid tumor in animal model) • Enteric infections • Vitamin B 12 malabsorption

PROKINETIC DRUGS • Metoclopramide • Cisapride • Tegaserod

Duration of therapy Maintenance therapy : lowest dose of PPI or H 2 blockers, especially in severe esophagitis (grades C & D) and with complications (BE, stricture) Intermittent therapy : on-demand therapy in patients with mild to moderate heartburn without severe esophagitis.

Effective initial and long term mangement • Decreases amount of drugs used • Decreases doctor visits • Decreases the need for repeat UGIE (Bate et al 1992, Bloom et al 1994, Bardhan et al 1999)

Case 2 • Young woman with chronic cough who is refractory to treatment with sulbutamol is referred for evaluation of GERD. • She complains of morning hoarseness. • Sulbutamol was in effective and even aggravated her symptoms. • Laryngoscopy showed posterior vocal cord erythema. • Endoscopy showed esophagitis. • Symptoms respond to 20 mg of daily omeprazol.

CLINICAL PRESENTATION Typical Symptoms ● Heartburn ● Regurgitation ● Dysphagia

Case 3 • Middle age man is visited for evaluation of dysphagia to solids from 2 months duration. • He was a heavy smoker and used famotidine for heart burn for 14 y. • Ba swallow was performed. • Endoscopy and biopsy was done.

Proximal esophageal stricture

Peptic stricture

Hyperplasia of basal cells and infiltration of PMN with erosions in GERD.

Natural History ● Peptic stricture ( 8 to 20 %) ● Ulceration ( 5 %) ● Significant bleeding ( 2 % ) ● Perforation extremely rare

Esophageal ulcer in reflux esophagitis

Case 4 • A 45 y old man with 25 y reflux symptoms comes to your office for evaluation of recent weight loss and dysphagia. • There was a histologic report of “Intestinal metaplasia” in distal esophagus in his last endoscopy 2 y ago. • Ba swallow and endoscopy was performed.

Adenocarcinoma

Barrett´s Esophagus

Barrett´s Esophagus

Long Segment Barrett’s

Endoscopic mucosal resection

Case 5 • A 38 y old woman comes to the clinic for her severe chronic reflux symptoms and consults about antireflux surgery. • She is on long term Omeprazole 40 mg twice a day and ranitidine before bed time. • Serum Gastrin level is in upper normal limits. • Endoscopy was normal (NERD).

Refractory gastroesophageal reflux disease • Failure to control symptoms with full dose of PPI + life style modification raises the possibility that symptoms are due to another disease or refractory GERD.

• Reduced bioavailability • Effect of food • Dosing interval • Gastric acid hypersecretion • Drug resistance • Slow healing • Esophageal hypersensitivity (viseral hyperalgesia) • Eosinophilic esophagitis • Pill induced esophagitits

TREATMENT • First confirm the diagnosis then, • Increase the frequency of dosing • Increasing the dose (Omeprazole to 80 mg/day) • Add a second drug • Switch to another drug • Check for Gastrinoma • Surgery

Preoperative evaluation for gastroesophageal reflux disease • Detailed clinical history and physical examination • Endoscopy to assess degree of esophagitis • Esophageal manometry to define LES pressure and disorders of peristalsis • Upper gastrointestinal series to assess esophageal length and hiatal hernia • 24 hour esophageal p. H monitoring

Indications for esophageal p. H recording • to document abnormal esophageal acid exposure in an endoscopynegative patient being considered for surgical antireflux repair • to evaluate patients after antireflux surgery who are suspected to have ongoing abnormal reflux

• to evaluate patients with normal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy • to detect refractory reflux in patients with extraesophageal or atypical symptoms using symptom association probability calculation

INDICATIONS FOR OPERATION AND PREOPERATIVE EVALUATION • Persistent or recurrent symptoms with appropriate response to medical THX. • Severe esophagitis by endoscopy • Benign stricture • Recurrent pulmonary symptoms

Predictors of successful surgery • Response to medical therapy • Typical reflux symptoms • Erosive GERD • Abnormal p. H study

Predictors of unsuccessful surgery • Lack of response to medical therapy – (medical failure? ) – It could be something other than GERD • Non-erosive GERD (NERD)

Helicobacter pylori and GERD • Eradication of H. pylori is associated with mild worsening of GERD in patients with corpus-predominant gastritis and improvement in those with antral-predominant gastritis. • The standard of care is to eradicate H. pylori in the context of peptic ulcer disease.