gerd

Current Trends and Updates on Diagnosis and Management of

GERDJeraldine S. Orlina, MD

Grand RoundsJanuary 11, 2006

Pathophysiology• Lower esophageal sphincter

• Intrinsic muscle of distal esophagus

• Sling fibers of cardia• Diaphragm• Transmitted pressure

of abdominal cavity

• Reflux occurs when the high-pressure zone in distal esophagus is too low or when sphincter with normal pressure undergoes spontaneous relaxation

Absite Question• An operation is the primary initial

management for:• A) Achalasia• B) a large sliding esophageal hiatal

hernia• C) an epiphrenic esophageal

diverticulum• D) gastroesophageal reflux• E) a paraesophageal hiatal hernia

SymptomsSymptom Predominance (%)Heartburn 80Regurgitation 54Abdominal Pain 29Cough 27Dysphagia for solids 23Hoarseness 21Belching 15Aspiration 14Wheezing 7Globus 4

Symptoms -- Heartburn• Epigastric and retrosternal• Caustic or stinging sensation• Does not radiate to the back, is not

pressurelike• Can be confused with symptoms of

PUD, bilary colic, or CAD

Symptoms -- Regurgitation• Indicates progression of disease• Distinguish between digested and

undigested food

Diagnostic Studies• Empirical Therapy• Upper Gastrointestinal Endoscopy

(EGD)• Upper Gastrointestinal Fluoroscopy

with Barium• 24-hour pH testing• Esophageal Manometry

EGD• Allows examination of the

esophageal mucosa• Identifies presence of esophagitis

and grading of severity• Can identify other pathology, such as

diverticula, hiatal hernia, webs, rings, or strictures

• Tissue biopsies to screen for Barrett’s esophagus

Absite Question• Four hours following upper

esophagogastric endoscopy for gastroesophageal reflux, a 62 year-old man returns to the emergency room with chills, chest pain, and dyspnea. Cardiac work-up is normal, but esophagography shows a distal esophageal perforation. The most appropriate management is• A) nasogastric suction and TPN• B) reinforced primary esophageal repair• C) drainage and esophageal diversion• D) esophagectomy with gastric pull-through• E) fluoroscopic esophageal stent placement

Absite Question• A 60 year-old otherwise healthy man

has symptomatic GERD that has not responded to medical therapy, including PPIs. Esophagoscopy shows moderately severe esophagitis. Multiple biopsies of the esophageal mucosa in the area of esophagitis show columnar epithelium replacing the normal squamous epithelium. As the patient’s treatment is being planned, a biopsy report shows high-grade dysplasia.

(cont)• Treatment should be

A. Continued medical treatment with yearly esophagoscopy and biopsies

B. Laparoscopic Nissen fundoplicationC. Photodynamic therapyD. EsophagectomyE. Laser ablation of normal mucosa

24-hour pH test• Gold Standard for

presence of pathologic reflux

• Parameters measured include: total # of reflux episodes, duration of longest reflux episode, percentage of time pH is less than 4

Ambulatory pH testing – Recent Advances

• Combined impedance and acid testing• Allows for the

measurement of both acid and nonacid (volume) reflux.

• Important in pt with persistent symptoms despite an adequate medical trial

Ambulatory pH testing – Recent Advances• Tubeless method–

Bravo System• Allows a radiotelemetry

capsule to be attached to the esophageal mucosa

• Decreases patient discomfort, allows for longer (48h) monitoring, and may improve accuracy by allowing the patient to carry out their usual activities

Esophageal Manometry• Lower Esophageal

Sphincter (LES)• Mean resting

pressure• Total length

• Esophageal Body• To determine

effectiveness of peristalsis

• Amplitude of esophageal wave

Esophagram• Useful when

operation is planned—shows anatomy of esophagus and proximal stomach

• Demonstrates presence and size of hiatal hernia if present

Treatment – Lifestyle Modification• May benefit many patients with

GERD, although these changes alone are unlikely to control symptoms in the majority of patients

• Elevation of the head of the bed, decreased fat intake, cessation of smoking, avoiding recumbency for 3h postprandially, avoidance of certain foods (chocolate, EtOH, peppermint)

• No data reflecting the efficacy of these maneuvers

Treatment – Patient Directed Therapy

• Antacids • H2 receptor antagonists• If symptoms persist, continuous

therapy is required, or alarm symptoms/signs develop – pt should have additional evaluation and treatment

Treatment – Acid Suppression• 6-week course of acid-suppression

therapy• Double dose of a proton pump

inhibitor• Irreversible bind the proton pump in

parietal cells of the stomach• Maximal effect 4 days after initiation of

therapy and lasts for the life of the parietal cell

• More effective than other antacid regimens

Absite Question• Proton pump inhibitors used in the

treatment of GERDA. Cause regression of Barrett’s

epitheliumB. Inhibit progression of dysplasiaC. Increase squamous islands in Barrett’s

segmentsD. Reverse intestinal metaplasiaE. Are effective only if gastric acidity is

normalized

Treatment – Promotility Therapy• May be used as an adjunct to acid

suppression therapy in patients with demonstrated defects in esophagogastric motility (LES incompetence, poor esophageal clearance, delayed gastric emptying)

Absite Question• Five years after a myocardial infarction, a 55

year-old woman with HTN and DM has symptomatic esophagogastric reflux. Medical treatment for the last year has not been successful. Her BMI is 55. Esophagoscopy shows severe esophagitis. Multiple biopsies show inflammatory changes but no columnar epithelium or cancer. The best treatment would be:

A. Nissen fundoplicationB. Gastric bypass procedureC. Gastric banding procedureD. Vertical banded gastroplastyE. Biliary-pancreatic diversion with duodenal switch

Surgical Therapy• Indications

• Pt w/ evidence of severe esophageal injury (ulcer, stricture, or Barrett’s)

• Incomplete resolution of symptoms or relapses while on medical therapy

• Long duration of symptoms• Younger patients• Ideal patient: more than 10-year life

expectancy and are in need of lifelong therapy due to a mechanically defective sphincter

Copyright ©2004 CMA Media Inc. or its licensors

Urbach, D. R. et al. CMAJ 2004;170:219-221

Trends in the use of surgery for gastroesophageal reflux disease in Ontario, 1988-2000

Laparoscopic Nissen Fundoplication

• Lafullarde T, Watson DI, Jamieson GG, Myers JC, Game PA, Devitt PG. Laparoscopic Nissen fundoplication: five-year results and beyond. Arch Surg. 2001 Feb;136(2):180-4 • 87% of the 176 patients remained free

of significant reflux. The long-term outcome was considered "good or excellent" by 90% of patients.

Laparoscopic Nissen Fundoplication

• Success rate of greater than 90%• Procedure of choice

Absite Question• A 56 year-old man is seen 2 years after

a laparoscopic Nissen fundoplication for GERD. His pre-operative work-up 2 years ago demonstrated normal esophageal motility, and pH probe testing showed that reflux was the cause of his symptoms. He now has recurrent symptoms of GE reflux.

A Barium swallow is performed.

• Which is not true about this patient?A. Redo operation is as

effective as primary antireflux operation for ameliorationg reflux symptoms

B. Transabdominal laparoscopic redo operation is contraindicated

C. Redo operation has an increased complication rate

D. The cause is related to technical performance of the initial operation

E. Manometry is helpful in planning operative therapy

Absite Question• Four years ago, a 47 year-old woman had a

laparoscopic fundoplication. It failed after three years and she had severe, recurrent gastroesophageal symptoms. Through a celiotomy incision, the surgeon performed a redo-fundoplication with a 360-degree, 2 cm wrap around a 56 Fr dilator. For the past three months she has had severe early satiety, postprandial epigastric pain, and weight loss. The most likely cause of these symptoms is:A. The wrap is too tightB. The wrap is too looseC. Vagal injuryD. Irritable bowel syndromeE. Esophageal motor disorder

Absite Question• Barrett’s esophagus

• A) will usually regress after Nissen fundoplication

• B) carries an increased risk of squamous cell carcinoma

• C) is an indication for esophagectomy• D) should be followed by endoscopic

surveillance• E) is a contraindication to laparoscopic

Nissen fundoplication

Endoscopic Therapy• Attempt to augment the LES by

1. Suturing – EndoCinch2. Radiofrequency energy – Stretta3. Plexiglass injection –

polymethylmethacrylate4. Biocompatible polymer injection --

Enteryx

Plication/Sewing Techniques• First developed in the mid ’80’s• Allow placement of sutures into the

gastric cardia, thereby augmenting the barrier effect of the GEJ

• Bard EndoCinch

EndoCinch• Filipi CJ, Lehman GA, Rothstein RI et

al. “Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial.” Gastrointestinal Endoscopy 2001; 53: 416-22.• Suggested that endoscopic gastric

plication is a safe procedure and, at a 6-month follow-up, that 2/3 of pts undergoing the procedure were successfully treated.

EndoCinch (cont)• Inclusion Criteria

• Three or more episodes of heartburn a week when off antisecretory meds

• Successful response to and reliance upon antisecretory meds for GERD

• Abnormal acid reflux on ambulatory pH monitoring

• Exclusion Criteria• Dysphagia• BMI greater than 40• GERD refractory to PPIs• Hiatal hernia greater than 2 cm in length

EndoCinch (cont)• Treatment success defined as a decrease

in the heartburn severity score by 50% in addition to a reduction in the use of antireflux medications to fewer to 4 doses per month.

• 64 patients were enrolled• 33 pts (52%) – gastroplication in a linear

configuration• 31 (48%) – gastroplication in a circumferential

plication• No difference in outcomes between the 2

groups

• Results:• Mean heartburn scores fell from a preprocedure

score of 62.7 to mean scores of 16.7 and 17 and 3 and 6 months postprocedure

• Percent total time the pH was < 4, total number of reflux episodes, and percent upright pH time was lower than 4 were all significantly improved, but none returned to normal range

• Regurgitation scores improved significantly• Quality of life scores were improved for social

functioning and bodily pain and 62% of pts at 3 and 6 month f/u were taking less than 4 doses of medication per month

• Results (cont)• No significant change found in LES

resting pressure or length• No significant effect on mucosal healing• Adverse events included pharyngitis

(31%), vomiting (14%), and abdominal pain (14%), and chest pain (16%)

• One patient experienced a suture microperforation that was treated conservatively with IV antibiotics and brief hospitalization

EndoCinch (cont) • Chen YK, Raijman I, Ben-Menachem T

et al. “Long-term outcomes of endoluminal gastroplication: a U.S. multicenter trial.” Gastrointestinal Endoscopy 2003. 61: 434-440• Prospective, multicenter trial which

enrolled 85 patients to be treated with endoluminal gastroplication followed over 2 years

• Results:• 51% of patients had no or occasional GERD

symptoms• 73% and 69% were completely off PPIs or at 12

and 24 months postprocedure• Reduction in the mean annual medication cost

from $1564 per year preprocedure to $157 one year postprocedure (cost redux of 88%)

• Shortcomings of study• Does not contain a

nonplication sham group• Trends toward increased

symptoms over time suggestive of degradation of repair over time

EndoCinch (cont)• Schiefke I et al. “Long term failure of

endoscopic gastroplication (EndoCinch)”. Gut 2005; 54: 752-758• Evaluated prospectively long term

outcome after EndoCinch• 70 patients at a single referral center• Patients interviewed with a standard

questionaire regarding symptoms, medication use, in addition to f/u with endoscopy, 24h pH monitoring, and esophageal manometry

• Results:• 18 months after EndoCinch 56/70

patients (80%) were considered treatment failures as their heartburn symptoms did not improve or PPI medication exceeded 50% of initial dose

• Endoscopy showed all sutures in situ in 12/70 (17%), while no sutures remained in 18/70 (26%)

• No significant changes in 24h pH monitoring or LES pressure

• Conclusion:• Long term outcome is disappointing

probably due to suture loss in the majority of patients

Radiofrequency Thermal Therapy -- Stretta

• Delivery of low-power, temperature-controlled radiofrequency energy to the GEJ

• Two mechanisms1. mechanically altering the GEJ2. inducing the ablation of nerves that trigger transient lower esophageal relaxation

Radiofrequency Thermal Therapy -- Stretta

Stretta• Wolfsen HC and Richards WO. “The

Stretta Procedure for the Treatment of GERD: A registry of 558 patients.” Journal of Laparoendoscopic and Advanced Surgical Techniques 2002• 558 patients, 33 institutions• 6 months of follow-up• Survey administered which assessed

GERD severity, percentage of GERD symptom control, satisfaction, and antisecretory medication use

• Results• At baseline, the median percentage of

GERD symptom control while on drugs was 50%, compared with 90% after Stretta

• Satisfaction with symptom control was 26% versus 77% after Stretta

• Median requirement at baseline was double dose of PPI versus antacids prn after Stretta

• Most subjects (90%) would recommend Stretta to a friend

Stretta• Triadafilopolous et al: reported 6- and

12- month results of an open label trial of Stretta• Prospective multicenter trial involving 118

patients who had chronic heartburn or regurgitation, abnormal esophageal acid exposure, hiatal hernia less than 2 cm, and mild esophagitis

• At 12 mo: improvement in heartburn score, GERD score, and quality of life. PPI use decreased from 88% to 30%. Esophageal acid exposure improved significantly, although no improvement in the incidence and severity of esophagitis

• randomized, double-blinded, sham controlled trial of radiofrequency energy to the gastroesophageal junction for the treatment of GERD

Patient Criteria• heartburn or acid regurgitation at least partially

responsive to and requiring daily antacid medications

• age 18 years• 24-hour pH study (off medications) showing

abnormal esophageal acid exposure (4%) or a DeMeester score of 14.7

• esophageal manometry showing normal esophageal peristalsis and sphincter relaxation

• EGD, on medications, showing no esophagitis worse than grade II (i.e., no substantial ulcerations), no hiatal hernia 2 cm long, and no Barrett’s esophagus

• no coagulation disorders, mechanical prostheses, prominent dysphagia, or unstable disorders.

Stretta

• Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett’s esophagus.

• Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett’s were offered LF.

Stretta• Conclusions – Although the incidence

of complications is decreased compared with operative intervention, success of therapy does not approach that of surgical intervention

• After Stretta 30-50% of patients still require PPI therapy

Injection/implantation techniques -- Enteryx

• Injectable biocompatible solution consisting of 8% ethylene vinyl alcohol copolymer mixed in dimethyl sulfoxide

• When injected into the LES, the solution interacts with the surrounding fluid to become an inert spongy solid mass

• Mechanism: may impart an alteration in the compliance of tissues preventing sphincter shortening and improving the barrier function of the GEJ

Enteryx

Enteryx• Cohen LB, Johnson DA, Ganz RA et al

“Enteryx implantation for GERD: expanded multicenter trial results and interim postapproval follow-up to 24 months.” Gastrointestinal Endoscopy May 2005• Open-label, international clinical trial

conducted in 144 PPI—dependent patients with GERD with f/u at 6 and 12 months

• Primary outcome: PPI use• Secondary outcome: GERD health-related

quality of life and esophageal acid exposure

• Results:• At 12 months PPI use was reduced by

greater than 50% in 84% of treated pts

• GERD health-related quality of life < 11% in 78% of patients

• Esophageal acid exposure was reduced by 31%

Enteryx

Conclusions on Endoscopic Mgmt of GERD

• Techniques need to be further studied in sham-controlled protocol

• Long term follow-up suggest a declining effect of treatment with pts returning to PPI use -- more long term f/u studies necessary

• Future studies should improve targeting of which patients benefit, further elucidate the mechanisms of action, and provide detailed comparisons to alternative treatments.

Future of Endoscopic Therapy• As a substitute for long-term medical

therapy for the pt with mildly symptomatic GERD

• As adjuncts to ongoing pharmacologic treatment

• In patients with a failed surgical fundoplication