GERD Medical and Surgical Management Dr Daniel Sadowski

GERD: Medical and Surgical Management Dr. Daniel Sadowski GI for GPs April 13, 2019

Disclosures/COI None

Objectives At the end of this talk, you will be able to: Determine how to diagnose GERD; outline need for GI consultation Review medical therapy for GERD Identify indications and current surgical techniques

What is GERD? Montreal Definition of GERD Vakil N et al. Am J Gastroenterol 2006 101(8): 1900 -20

What causes GERD? Impaired barrier function at GE junction Weak LES TLESRs Hiatus hernia Impaired clearance of reflux from esophagus Impaired peristalsis Decreased saliva

Hypotensive LES Factors Which Lower L E S P r e s s u r e : • A l c o h o l • N i c o t i n e • D i e t a r y F a t • P e p p e r m i n t • M e d i c a t i o n s : • Narcotics, calcium • • channel blockers H o r m o n e s • Estrogen, glucagon

Hiatus hernia Sliding Paraesophageal

GERD Diagnosis - Symptoms GERD more likely: Rising sensation of painful acid in chest Regurgitation with bending, lifting Waterbrash with reflux GERD less likely Constant unrelenting chest pain Hoarseness Sore throat Globus sensation Chronic cough Dent et al Gut 2010: 59; 714 -721

GERD Primary Care Pathway

Your GI and GERD Is this really GERD? Is their an alternative diagnosis? If GERD, why is the patient not responding to adequate therapy?

Heartburn Syndromes: esophageal hypersensitivity and acid exposure Aziz, Q, Fass, R, Gyawali, CP, Miwa, H, Pandolfino, JE, Zerbib, F: Functional Esophageal Disorders. Gastroenterology 2016,

Endoscopy in evaluation of GERD Highly specific for erosive esophagitis and GERD complications i. e. if present, the patient has GERD Rule out other diagnosis: Eosinophillic esophagitis Achalasia Neoplasm PUD Negative endoscopy does not rule out GERD – Nonerosive reflux disease (NERD) ENDOSCOPY – ON OR OFF PPI?

24 p. H-Impedance Testing

Information obtained from p. H-Impedance Study Degree of esophageal Acid Exposure Time AET > 4% Quantitation of numbers of reflux events: Total (N<73) Acid Non-Acid Correlation of symptom events to reflux events Symptom Index and Symptom Association Probability

Classification of heartburn syndromes Esophagitis by EGD Abnormal 24 -hr p. H (off PPI) SI/SAP Erosive Esophagitis + + +/- NERD - +/+ - - - Reflux Hypersensitivity Functional Heartburn SI – symptom index (# of symptom associated with reflux/total # of symptom) SAP – symptom association probability Sifrim & Zerbib. Diagnosis and Management of patients with refractory to PPI. GUT 2012; 61: 1340 -1345

PPI Therapy for Erosive Esophagitis Healing rates depend on degree of severity of esophagitis. 8 weeks of PPI therapy resulted in: 91% healing in LA-A esophagitis 70% of LA-D esophagitis Castel Am J Gastro 2001 LA- B LA-C

PPI Therapy for Erosive Esophagitis Discontinuation of PPI in healed esophagitis results in relapse rates of up to 60% at 1 year Donnellan Cochrane Database Review 2004 Healing rates and symptom relief identical across PPI’s Fennerty MB Clin Gastroenterol Hepatol 2006 ? ? Dexlanzoprazole Erosive Esophagitis Patients have a better symptomatic response than NERD patients Up to 40% of all patients treated with PPI for GERD have ongoing symptoms

GERD and loss of response to PPI’s Non-compliance Improper dosing Development of obesity Lifestyle factors Delayed gastric empyting Narcotics Diabetic Development of esophageal hypersensitivity GERD overlap

The patient with known GERD and persistent symptoms BID PPI superior to Once Daily PPI H 2 RA Suppression of nocturnal acid secretion Rapid tachyphylaxis Antacids Rapid relief but short lived effect Sucralfate Binds to denuded esophageal mucosa Efficacy established for Erosive reflux disease but not NERD

The patient with known GERD and persistent symptoms Alginates Creates a physical barrier/raft in fundus NERD>GERD Reimer et al APT 2016 Baclofen Reduces transient LES relaxations Early studies suggested reduced reflux events but inconsistent compared to PPI Ren WJG 2014 Multiple side effects – fatigue, dizziness

The patient with known GERD and persistent symptoms Prokinetics Theoretically could increase LES tone Enhance gastric emptying of potential refluxate Modest/inconsistent results with metoclopramide, domperidone Prucalopride Monotherapy less effective than H 2 RA and PPI Modest symptom reduction when added to PPI therapy Shaheen APT 2015 Probably useful in patients with GERD associated with delayed gastric emptying

The patient with symptoms but no evidence for GERD Consider extraesophageal disease Cardiac, gastric, biliary Other esophageal syndromes that can present with heartburn Regurgitation Rumination Supragastric belching Achalasia

Heartburn Syndromes: esophageal hypersensitivity and acid exposure Aziz, Q, Fass, R, Gyawali, CP, Miwa, H, Pandolfino, JE, Zerbib, F: Functional Esophageal Disorders. Gastroenterology 2016,

Lifestyle Measures Diet Fat, caffeine, citrus, chocolate Provide printed instructions Weight loss Elevation of head of bed Alcohol Nicotine Cessation therapy

Hypersensitive esophagus/Function Heartburn Reassurance regarding benign nature of symptoms Neuromodulators TCA’s ( e. g. amitriptyline 10 -20 mg or imipramine 25 -50 mg at hs) SSRI’s (e. g. citalopram 20 mg od) Small short term studies – 40 -60% response rates Gabapentin (300 mg) for prominent globus sensation Cognitive behavioral therapy

PPI vs. Laparoscopic fundoplication JAMA. 2011; 305(19): 1969 -1977.

Fundoplication for GERD Predictors of Good Response: Typical Symptoms with complete response to PPI Abnormal AET >6% Increased number of reflux episodes on p. H-Impedance testing Prominent regurgitation symptoms Predictors of poor symptoms response to fundoplication: Atypical symptoms Normal AET Normal number of reflux episodes

Long term PPI use: Don’t maintain long term Proton Pump Inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop/reduce PPI at least once per year in most patients.

Objectives At the end of this talk, you will be able to: Determine how to diagnose GERD; outline need for GI consultation Review medical therapy for GERD Identify indications and current surgical techniques