GERD: The Real Other Silent KillerWhat is GERD? Classic symptoms: •Heartburn –burning sensation in retrosternal area •Regurgitation –perception of flow of gastric contents

GERD: The Real Other Silent Killer

Michael Krease, D.O.

GERD: The Real Other Silent Killer

Michael Krease, D.O.

prevalence

20%

Eusebi LH, Ratnakumaran R, Yuan Y, et al Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis Gut 2018;67:430-440.

• Heartburn - a burning pain

or discomfort behind the

breast bone in the chest

• Acid regurgitation - a bitter-

or sour-tasting fluid coming

into the throat or mouth

Locke et al. Gastroenterology. 1997;112:1448-1456

• Heartburn - a burning pain

or discomfort behind the

breast bone in the chest

• Acid regurgitation - a bitter-

or sour-tasting fluid coming

into the throat or mouth

Locke et al. Gastroenterology. 1997;112:1448-1456

What is GERD?

Classic symptoms:

• Heartburn – burning

sensation in retrosternal

area

• Regurgitation – perception

of flow of gastric contents

into mouth

1 Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101:1900.2 http://www.thefdotlife.com/a-few-signs-you-may-be-getting-old/i-think-that-we-have-discovered-the-cause-of-your-severe-heartburn/

What is GERD? – atypical symptoms

Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now? Vaezi, Michael F. et al. Clinical Gastroenterology and Hepatology, Volume 16, Issue 7, 1018 - 1029

Pathophysiology – Risk Factors

https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

BMI 25-30

BMI >30

Hampel H, et al. Ann Intern Med. 2005;143:199-211

Pathophysiology – Protection

• Saliva

• Esophageal motility

• GE junction

• Fundic relaxation

• Gastric emptying

Why does reflux happen? • Part of normal physciologic mechanism of belching

• Last >10s

• Unaccompanied by protective mechanisms

Esophageal dysmotility

Ineffective barrier:

• Hiatal hernia

• TLESR

• Obesity

• Gastroparesis

Diagnosis

• Presumptive diagnosis of GERD made based on typical sx.

of heartburn / regurgitation

• Upper endoscopy is not required in the presence of typical

GERD symptoms, unless alarm features present

Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308–328

Diagnosis – pH monitoring

Bravo pH system – 48-96 hrs.

• Pre-op

• Refractory GERD

• Diagnosis in ?

Why do we care?• Strictures

• Erosive esophagitis

• Barrett’s esophagus → esophageal adenocarcinoma

https://emedicine.medscape.com/article/175098-overview

https://www.endoscopy-campus.com/en/classifications/reflux-esophagitis-los-angeles-classification/

Eliakim R., Sharma V.K. (2014) Esophageal Capsule Endoscopy. In: Keuchel M., Hagenmüller F., Tajiri H. (eds) Video Capsule Endoscopy. Springer, Berlin, Heidelberg

Why do we care?• Strictures

• Erosive esophagitis

• Barrett’s esophagus → esophageal adenocarcinoma

Management• Lifestyle modifications:

qQ

Management• Lifestyle modifications:

qQ

Management• Lifestyle modifications:

qQ

Management• Lifestyle modifications:

qQ

Management• Lifestyle modifications:

qQ

Management• Lifestyle modifications:

qQ

Management• Lifestyle modifications:

qQ

Management• Lifestyle modifications:

qQ

Management• Medication:

• Antacids

• H2 antagonists

• PPIs

Management• Medication:

• Antacids

• H2 antagonists

• PPIs

Management• Medication:

• Antacids

• H2 antagonists

• PPIs

Management• Medication:

• Antacids

• H2 antagonists

• PPIs

Management – PPI vs. H2

Chiba N , De Gara CJ , Wilkinson JM et al. Speed of healing and symptom relief in grade II to IV gastroesophageal refl ux disease: a meta-analysis . Gastroenterology 1997 ; 112 : 1798 – 810

Management – PPI vs. H2

Chiba N , De Gara CJ , Wilkinson JM et al. Speed of healing and symptom relief in grade II to IV gastroesophageal refl ux disease: a meta-analysis . Gastroenterology 1997 ; 112 : 1798 – 810

Management – ACG Guidelines• 8 week course of PPI for symptom control and healing erosive

esophagitis

• PPI therapy initiated at qday dosing, tailor dosing based on

response or switch

• Maintenance PPI should be used for recurrent symptoms after

discontinuation – lowest effective dose

• H2 antagonist can be added at bedtime for nocturnal symptoms,

tachyphylaxis can occur after several weeks

• No role for sucralfate in non pregnant GERD patient

Management – ACG Guidelines• 8 week course of PPI for symptom control and healing erosive

esophagitis

• PPI therapy initiated at qday dosing, tailor dosing based on

response or switch

• Maintenance PPI should be used for recurrent symptoms after

discontinuation – lowest effective dose

• H2 antagonist can be added at bedtime for nocturnal symptoms,

tachyphylaxis can occur after several weeks

• No role for sucralfate in non pregnant GERD patient

Management• Omeprazole

• Omeprazole – bicarbonate

• Lansoprazole

• Pantoprazole

• Rabeprazole

• Esomeprazole

• Dexlansoprazole

• No convinving RCT data one is

superior to another

• All dosed 30-60 minutes prior to meal

except:

• Omeprazole – bicarbonate

• Dexlansoprazole