Case Illustration Seminar Gastroesophageal reflux disease Justin Wu Professor, Department of Medicine & Therapeutics Assistant Dean (Clinical), Faculty of Medicine The Chinese University of Hong Kong Case 1 • A 35 y.o. man presents with frequent heartburn and acid regurgitation for several years. The symptoms respond to proton pump inhibitor but they relapse after cessation of PPI. Endoscopy is normal and H. pylori testing is negative. What is your diagnosis? 1. Gastroesophageal reflux disease 2. Functional dyspepsia 3. No diagnosis Esophagus Stomach Lower esophageal sphincter What is GERD? Gastric acid Troublesome symptoms Complications Typical reflux symptoms • Acid regurgitation • Heartburn • Mostly occur after 1-3 hours after meal • Occasionally aggravated by lying down, bending forward and straining • Belching is NOT a reflux symptom
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2014-10-17 - Prof. Justin Wu - GERD Case Illustration
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Case Illustration Seminar
Gastroesophageal reflux disease
Justin Wu
Professor, Department of Medicine & Therapeutics
Assistant Dean (Clinical), Faculty of Medicine
The Chinese University of Hong Kong
Case 1• A 35 y.o. man presents with frequent heartburn
and acid regurgitation for several years. The
symptoms respond to proton pump inhibitor but
they relapse after cessation of PPI. Endoscopy is
normal and H. pylori testing is negative. What is
your diagnosis?
1. Gastroesophageal reflux disease
2. Functional dyspepsia
3. No diagnosis
Esophagus
Stomach
Lower esophageal sphincter
What is GERD?
Gastric acid
Troublesome symptoms
Complications
Typical reflux symptoms
• Acid regurgitation
• Heartburn
• Mostly occur after 1-3 hours after meal
• Occasionally aggravated by lying down,
bending forward and straining
• Belching is NOT a reflux symptom
Spectrum of GERD
Esophageal acid exposure
Reflux esophagitis
Barrett’s esophagus / Adenocarcinoma
Peptic stricture
Endoscopy negative GERD
GERD: An emerging disease in HK
18
15.4
10.4 10.1
8.59.7
7.1
2.3
3.84.9 5.2 5.4 5.6 5.8
0
2
4
6
8
10
12
14
16
18
20
1996 1997 1998 1999 2000 2001 2002
All H. pylori peptic ulcer
All GERD
Annual incidence
/10,000 persons 36,759 endoscopy records
32,807 records analyzable
Wu et al. DDW 2006
GERD: Symptom based diagnosis
Reflux symptom
Alarm symptom
Empirical PPI (PPI Test)
No
Endoscopy
Yes
Dent et al. Genval Report. Gut 1999
Good response
GERD
No response
Symptom relapse
Lower pretest probability of PPI test in Asia
At least weekly reflux symptoms based
on questionnaire / telephone survey
3%
17%
6%
3%2% 2%
4%
7%
5%
18%
8%
15%
8%
10%
18%
15%17%
13%
28%
20%20%
0%
5%
10%
15%
20%
25%
30%
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Chi
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Hon
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eaKor
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pan
Japa
n
Iran
Iran
Isra
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UK
Finla
ndSw
eden
USAU
SAU
SAU
SA
Prevalence
460 patients with frequent heartburn/ acid regurgitation as dominant
complaint recruited for OGD (NSAID use and alarm symptoms excluded)
Is symptom based diagnosis reliable?
218 (48%)
148 (32%)
82 (18%)
OGD neg, no response to PPI
OGD neg, clinical response to PPI
Reflux esophagitis
Peptic ulcer (95% H. pylori
positive)
Predictors of PU
Male, H. pylori, age>60
Wu et al. Gastrointest Endosc 2002
Empirical PPI based on reflux symptom may not be
appropriate in population with high prevalence of H. pylori
Case 1• A 35 y.o. man presents with frequent heartburn
and acid regurgitation for several years. The
symptoms respond to proton pump inhibitor but
they relapse after cessation of PPI. Endoscopy is
normal and H. pylori testing is negative. What is
your diagnosis?
1. Gastroesophageal reflux disease
2. Functional dyspepsia
3. No diagnosis
Case 2
• A 35 y.o. male presents with daily reflux
symptoms for years. OGD shows no esophagitis.
The symptoms persist despite successful H.
pylori eradication but they subside after a course
of Lansoprazole. What is your recommendation?
1.Off all medication
2.Step down to famotidine for long-term treatment
3.Continue Lansoprazole
H. pylori eradication cannot cure GERD
X
121086420
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
0.0
Probability of treatment failure
Months
Duration of follow up
Eradication group, 43.2% (95% CI: 29.9-56.5%)
P=0.043, log rank testPlacebo group, 21.1%
(95% CI: 9.9-32.3%)
Wu. Gut 2004
H. pylori eradication leads to more difficult control of GERD