Medical and Surgical Management of Gastroesophageal Reflux Disease

Disclosures • No financial disclosures • I do perform anti-reflux operations…

Objectives • • Recognize symptoms of GERD Learn the diagnostic tests to evaluate GERD

Epidemiology • 61 million Americans complain of heartburn and indigestion – 40% monthly –

Anatomy • Barriers to GERD – Esophageal peristalsis – Intra-abdominal segment of esophagus –

Pathophysiology • Primary mechanisms – Spontaneously, accompanying transient LES relaxations – Stress reflux associated

Clinical Presentation • Typical vs. Atypical

Clinical Presentation • Typical symptoms – – – Heartburn Regurgitation Water brash Acid brash

Diagnostic Studies • Anatomic – EGD (± biopsy) – RULE OUT CANCER/Barrett’s! – Contrast

Treatment - Medical • Life style modifications – Weight loss – Alteration of diet

Medication Options • Antacids (Neutralize) – Tums, Rolaids, Maalox • H 2 Blockers –

Treatment – Surgical • Complications of GERD unresponsive to medical therapy – – Esophagitis

Basic Tennets of Surgery • Restoration of an effective LES • Creation of a

Post-op Care • Hospitalization • Diet • Activity

Outcomes • Lap Nissen Fundoplication Success Rate: 90 -95% • Gas Bloat • Dysphagia

Case Scenario • 56 yo. M presents to your office with Heartburn • •

GERD and Barrett’s Disease • 60% of patients with clinical GERD will have normal-appearing

Esophagitis Grading System (Endoscopic) • Los Angeles Classification System – – Grade A (≤

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Medical and Surgical Management of Gastroesophageal Reflux Disease (GERD) Edward Auyang, MD, MS, FACS Assistant Professor of Surgery Director of Minimally Invasive Surgery Residency Program Director, General Surgery

Disclosures • No financial disclosures • I do perform anti-reflux operations…

Objectives • • Recognize symptoms of GERD Learn the diagnostic tests to evaluate GERD Learn the medical treatments for GERD Learn the surgical treatments for GERD

Epidemiology • 61 million Americans complain of heartburn and indigestion – 40% monthly – 20% weekly – 7% daily

Anatomy • Barriers to GERD – Esophageal peristalsis – Intra-abdominal segment of esophagus – Lower esophageal sphincter (LES) tone – Diaphragmatic crura – Phrenoesophageal membrane – Angle of His • Normally – Transient relaxation of LES

Pathophysiology

Pathophysiology • Primary mechanisms – Spontaneously, accompanying transient LES relaxations – Stress reflux associated with a weakened LES – Increased intra-abdominal pressure – Dysfunctional LES/Hiatal hernia • Reflux -> mucosal injury -> weakened LES and/or esophageal dysmotility

Clinical Presentation • Typical vs. Atypical

Clinical Presentation • Typical symptoms – – – Heartburn Regurgitation Water brash Acid brash Nocturnal Aspiration Dysphagia • Atypical symptoms – – – – Chronic nausea Asthma Aspiration Cough Hoarse throat Dental erosions Chest pain

Diagnostic Studies

Diagnostic Studies • Anatomic – EGD (± biopsy) – RULE OUT CANCER/Barrett’s! – Contrast radiographs (UGI Esophagram) • Physiologic – 24 -hr p. H testing (on/off medication) – Esophageal manometry – Scintigraphy (gastric emptying)

EGD

Upper GI

Manometry

24 Hr p. H Monitoring

Treatment - Medical

Treatment - Medical • Life style modifications – Weight loss – Alteration of diet • Avoid chocolate, peppermint, fat, onions, garlic, alcohol, caffeine, and nicotine • Nothing by mouth for 2 -3 hr before bedtime – Elevation of head of bed 6 -10 in. Limit potentially precipitating activities, such as bending over or strenuous exercise • Medication

Medication Options • Antacids (Neutralize) – Tums, Rolaids, Maalox • H 2 Blockers – Ranitidine, famotidine • PPI – Omeprazole, pantoprazole, esomeprazole, etc. – Beware of osteoporosis/penia, fundic polyps • Max Omeprazole 40 mg BID

Treatment – Surgical

Treatment – Surgical • Complications of GERD unresponsive to medical therapy – – Esophagitis Stricture Recurrent aspiration or pneumonia Barrett esophagus • Continued symptoms despite maximal medical treatment • Symptomatic paraesophageal hernia • Patient desire to discontinue PPI therapy – Financial burden – Lifestyle choice – Young age • Intolerance to proton pump inhibitor therapy

Basic Tennets of Surgery • Restoration of an effective LES • Creation of a gastroesophageal valve • Fundoplication requires wrapping the fundus itself, not the body of the stomach, around the esophagus, rather than around the proximal body of the stomach • The fundoplication should reside within the abdomen without tension, and the crura should be closed adequately to prevent migration of the stomach or the fundoplication into the chest • Complete Vs. Partial wrap

Operation

Post-op Care • Hospitalization • Diet • Activity

Outcomes • Lap Nissen Fundoplication Success Rate: 90 -95% • Gas Bloat • Dysphagia • Hernia/GERD Recurrence

GERD and Obesity

Case Scenario • 56 yo. M presents to your office with Heartburn • • • HPI – What do you want to know? PMHx – HTN, GERD, HL PSHx – Cholecystectomy PE – HR: 75 BP: 122/85 O 2: 97% RA BMI 30 Workup ?

Questions?

Results

GERD and Barrett’s Disease • 60% of patients with clinical GERD will have normal-appearing esophageal mucosa at endoscopy • Barrett esophagus is estimated in 10% of patients with GERD • GERD + Barrett esophagus have 0. 4% per patient-year risk of adenocarcinoma Vs. 0. 07% per patient-year risk for patients with GERD but without Barrett esophagus

Esophagitis Grading System (Endoscopic) • Los Angeles Classification System – – Grade A (≤ 5 mm in length) Grade B (>5 mm in length) Grade C (continuous between two mucosal folds) Grade D (≥ 75% of esophageal circumference)