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GERD is one of the most frequentGI complaints

35% US population - symptoms 1x / month7% US population - symptoms daily

reflux esophagitis is the most frequent

finding in UGI endoscopy (~ 20%)

complications are present in ~ 20%of patients with esophagitis

Gastro-esophageal reflux diseaseEpidemiology

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disease of the developed worldmore frequently - US, EU

less frequently - Africa, Asia more frequently in men

more frequently in elderly

esophagitis - peak incidence ~ 60 - 70 y more frequently in obese and smokers

markedly decreased quality of life

Gastro-esophageal reflux diseaseEpidemiology

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Occurrence of typical symptomsand/or inflammatory changes

of esophageal mucosacaused by

repeated episodes

of gastro-esophageal reflux

Gastro-esophageal reflux disease (GERD)

Gastro-esophageal reflux diseaseDefinitions

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The presence of inflammatory changes(mucosal breaks erosions / ulcerations)

in the esophageal mucosa

confirmed

macroscopically (endoscopy)

Reflux esophagitis (RE)Erosive GERD (E-GERD)


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At least 2 episodes of heartburnof moderate to severe intensity

during 7 consecutive days

with no endoscopic changes(mucosal breaks or Barretts esophagus)

relieved after trial PPI therapy.

Non-erosive reflux disease (NERD)Endoscopy-negative reflux disease (ENRD)

Symptomatic GERD (S-GERD)


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most important pathogenic factor of GERD

10 - 60 s relaxation of LES (swallowing: 6 - 8 s)

neural reflex form brain stemthrough the vagal nerve

caused by:

- CCK- stomach distension- meal- stimulation of pharyngeal mucosa receptors

Gastro-esophageal reflux diseasePathology: TLESRs

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sliding hernia change of angle of His (loss of flap-valve)

loss of intra-abdominal part of the esophagus

widening of the esophageal hiatus separation of both parts of sphincter

acid reservoir in the hernial sac

- easier reflux during TLESRs decreased esophageal clearance

hernia is present in about 3/4 cases of GERD

Gastro-esophageal reflux diseasePathology: hiatal hernia

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Gastro-esophageal reflux diseaseSymptoms

esophageal

extra-esophageal

Symptoms may not correlatewith the severity of esophagitis.

Esophagitis may be totally asymptomatic.

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heartburn (burning, retrosternal pain)

is the most typical, pathognomonicsymptom of GERD

heartburn usually occurs with

decrease of lower esophageal pH < 4.0

Gastro-esophageal reflux diseaseHeartburn

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pulmonary: chronic coughdyspnea

asthma and bronchitisrecurrent infections

laryngo-pharyngeal: hoarseness

throat pain stomatological: dental erosions

hematological: anemia

Gastro-esophageal reflux diseaseExtra-esophageal symptoms of GERD

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dysphagia

bleeding

anemia

weight loss

severe chest pain

Gastro-esophageal reflux diseaseAlarm symptoms

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male sex

advanced age (> 50-60 yrs ?)

long-lasting symptoms (> 5-10 yrs ?)

obesity

smoking & alcohol

Gastro-esophageal reflux diseaseRisk factors for severe GERD

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diagnosis of esophagitis

staging

complications (Barretts esophagus, strictures)

differential diagnosis(neoplasms, other etiologies of esophagitis)

Endoscopy should be the first (basic)diagnostic test in GERD !

Gastro-esophageal reflux diseaseUpper GI endoscopy (EGD)

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A One or more mucosal breaks, < 5 mm long

B One or more mucosal breaks > 5 mm,

affecting one or more folds,non-continuous between the tops of two folds

C One or more mucosal breaks,continuous between the tops of at least

two folds, but not circumferential (< )D Circumferential (> ) mucosal break

Gastro-esophageal reflux diseaseLos-Angeles system

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Gastro-esophageal reflux diseaseLos-Angeles system

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RE Los Angeles systemGrade 0 (no esophagitis, normal)

FE Silverstein, GNJ TytgatGastrointestinal Endoscopy, Mosby-Wolfe 1997

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RE Los Angeles systemGrade A

LA: ASM: I

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RE Los Angeles systemGrade A

LA: ASM: I

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RE Los Angeles systemGrade B

LA: BSM: II

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RE Los Angeles systemGrade C

LA: CSM: II

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RE Los Angeles systemGrade C

LA: CSM: II

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RE Los Angeles systemGrade D

LA: DSM: IV a/b?

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PPI: 2 weeks, standard dose BID

may be used as a first diagnostic testsin patients with low-risk of esophagitis(young, female, short history of symptoms)

Gastro-esophageal reflux diseaseTrial therapy with PPIs

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Gastro-esophageal reflux diseaseAmbulatory 24-hour pH-monitoring

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Gastro-esophageal reflux diseaseAmbulatory 24-hour pH-monitoring

KGA AM 2001

No drug

pH < 4: 34%

DM score: 130(n: < 18)

On PPI

pH < 4: 6.6%

DM score: 29

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Multichannel intraluminal impedance

Intraluminal ions allow for electrical current flow

Current

generator

no bolus = few ions = high impedance

bolus present = many ions = low impedance

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Impedance

Time

Impedance measurement electrodes

Bolus in Bolus out

Boluspresent

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GI Motility online (May 2006) | doi:10.1038/gimo31

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Antegrade Retrograde

17 cm

15 cm

9 cm

7 cm

5 cm

3 cm

G h l fl di

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GERD symptoms

EGD

End of diagnostic process

pH / impedance

Manometry,bilitec, scintigraphy,

etc.

test positive

test negative

Trial therapy with PPI

Gastro-esophageal reflux diseaseDiagnostic scheme

G h l fl di

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lifestyle modifications pharmacotherapy

surgery / Tx endoscopy

Gastro-esophageal reflux diseaseTreatment

G t h l fl di

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diet restrictions (fat, coffee, etc)

change of number, volume and timing of meals

reduction of weight

head of the bed elevation

cessation of smoking, avoiding alcohol

avoiding / change of certain drugs (if possible)

Gastro-esophageal reflux diseaseLifestyle modifications

G t h l fl di

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antacids (alginic acid)

sucralfate prokinetics

anti-secretory agents

- H2 receptor antagonists- proton pump inhibitors

combined therapy

Gastro-esophageal reflux diseasePharmacotherapy

G t h l fl di

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Gastro-esophageal reflux diseasePharmacotherapy: H2-receptor antagonists (H2RA)

cimetidine (Altramet, Tagamet)

ranitidine (Zantac, Ranigast) famotidine (Pepcid, Ulfamid, Famogast)

nizatidine (Axid)

roxatidine (Roxit, Roxane)

G t h l fl di

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omeprazole (Losec, Antra, Prilosec, Mopral)

lansoprazole (Prevacid, Lanzul) pantoprazole (Controloc, Pantozol, Protonix)

rabeprazole (Pariet)

esomeprazole (Nexium)

tenatoprazole

Gastro-esophageal reflux diseasePharmacotherapy: proton pump inhibitors (PPI)

G t h l fl di

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omeprazole 20 mg / d

rabeprazole 20 mg / d lansoprazole 30 mg / d

pantoprazole 40 mg / d

esomeprazole 40 mg / d

Gastro-esophageal reflux diseasePharmacotherapy: standard doses of PPIs (OD)

G t h l fl di

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Double dose PPI (BID) + H2RA

Double dose PPI (BID)

Standard (full) dose PPI (OD)

Off treatment (life-style measures)

On demand treatment (antacids)

Half dose PPI (OD) Standard dose PPI (e 2nd d)

Full dose H2RA Full dose prokinetic

Step-up

Step-dow

n

Gastro-esophageal reflux diseasePharmacotherapy: step-down vs. step-up

Gastro esophageal refl disease

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Gastro-esophageal reflux diseasePharmacotherapy of an acute episode

Inadomi JM, Medscape Gastroenterology 2006

Gastro esophageal reflux disease

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on demand- relapse treatment

intermittent treatment

- week-end (Fri to Sun)- every second day

continuous treatement- prokinetics- H2RA- H2RA + prokinetics- PPI (the lowest effective dose)- PPI + prokinetics

Gastro-esophageal reflux diseaseMaintenance pharmacotherapy

G t h l fl di

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Gastro-esophageal reflux diseaseMaintenance pharmacotherapy

continuous

intermittent

on demand

recurrence ofsymptoms


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no good effect of PPI BID

no inhibition of nocturnal

basal acid secretion proposed scheme:

PPI OD + H2RA at bedtime

PPI BID+ H2RA at bedtime

Gastro-esophageal reflux diseasePharmacotherapy: nocturnal acid breakthrough


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Hill Belsey Nissen

Gastro-esophageal reflux diseaseSurgical procedures


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Gastro-esophageal reflux diseaseLaparoscopic fundoplication


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technique: laparoscopictotal fundoplication (360)or partial fundoplication (180-270)

- lower risk of dysphagia

indications: complications of GERD (local, pulmonary)

young age (< 40) failure of pharmacotherapy

(after minimum 6 months of treatment)

Gastro-esophageal reflux diseaseSurgical treatment


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complications 4 - 26% conversion ~ 10%

mortality < 1%

transient dysphagia ~ 35%

re-operation 2 - 14%

good long term result ~ 85%

late (3 yr) dysphagia < 5%

treatment cheaper than pharmacotherapy

with expected survival ~ 6 - 7 years (USA)



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only 50% improvement in extra-esophagealsymptoms of GERD

symptoms should not be the onlyindication for surgery

extensive diagnostic workup (EGD,impedance, manometry, trial PPI therapy)is mandatory before surgery

experience of surgeon extremely important



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Gastro-esophageal reflux diseaseEndoscopic treatment

injection- collagen- poly-tetrafluoroethylen (Polytef, PTFE)- polymethylmethacrylate microspheres (Artecol)

- hydrogel polyacrylonitril prostheses (Gatekeeper)- ethylene-vinyl alcohol polymer (Enteryx)

suturing- EndoCinch (BARD)- Endoscopic Suturing Device (Wilson-Cook)

endo-plication - stapler (NDO Surgical Plicator)

radio-frequency application (Stretta)

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Boston Scientific Corp., Nattick, Ma

Enteryx

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Boston Scientific Corp., Nattick, Ma

Enteryx

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Torquati, ASGE 2004; Fockens et al., Endoscopy 2004

Gatekeeper

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CR Bard. Inc., Billerica, Ma

EndoCinch

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NDO Surgical, Inc., Mansfield, Ma

Single -Use Cartridge & Implant

Instrument controls

Scope Channel

Scope Exit

Leak Test Port

Retractor handle

Single -Use Cartridge & Implant

Instrument controls

Scope Channel

Scope Exit

Leak Test Port

Retractor handle

ePTFE Pledgets &

Pre-tied Suture

Endoscopic

Tissue

Retractor

Low Profile

(

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NDO Surgical, Inc., Mansfield, Ma

Full-Thickness Plicator

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EsophyX 2

EndoGastric Solutions, Redwood City, Ca

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MediGus SRS

Medigus Ltd, Omer , Israel

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Curon Medical, Inc., Fremont, Ca

Stretta

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Curon Medical, Inc., Fremont, Ca

Stretta

Gastro-esophageal reflux disease

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Gastro esophageal reflux diseaseEndoscopic treatment

short-term results encouraging

injection dangerous withdrawn

long-term results not yet fully available efficiency decreasing over time(especially for suturing techniques)

should not be recommended asstandard treatment (as yet)

probably optional treatment forselected subgroup of patients in future


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Gastro esophageal reflux diseaseSummary

diagnosis based on symptoms

GERD and especially its complicationsmay be asymptomatic

EGD should be done before treatment,but may be not necessaryin younger patients

with short duration of symptoms multichannel impedance + pH-metry

is gold Dx standard in doubtful cases


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Gastro esophageal reflux diseaseSummary

PPIs are the mainstay of pharmacotherapy

sugrery (laparoscopic fundoplication)

when pharmacotherapy fails no indications for endoscopic tretament

at present

future:- drugs inihibitng TLESRs- full-thickness fundoplications

gerd - en - students 2010-2011

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