Gastroesophageal Reflux Disease: The Burn that Burns

Geoff S Williams, MD, FRCPC

Associate Professor of Medicine

Division of Gastroenterology

Dalhousie University

Disclosures

• I was paid an honoraria by pharmaceutical company Takeda to develop educational materials for family doctors

• The educational materials were accredited

Objectives

• At the end of this session the learner should:• Be able to explain the difference between physiologic and pathologic reflux

• Be able to describe the appropriate treatment strategy for GERD

• Be able to describe the ‘red flags’ that may suggest a need for endoscopy

• Appreciate the complexities in diagnosing reflux that does not respond to typical therapies.

The case of Jonathan Milsap

• 56 year old lawyer

• PMH: Dyslipidemia and hypertension

• He has been suffering retrosternal burning 3 – 4 times per week, and regurgitates food into his mouth once per week on average

• He has had these symptoms for over 10 years, but they seem to be getting worse

• His BMI is 35

• He does not smoke

• His father died of a heart attack

Questions about Jonathan Milsap’s case

• Is this GERD?

• Could this be a heart attack???????

• How would we investigate?

• If it is GERD, how do we treat him?

• Is he at risk for complications?

GERD vs Myocardial Infarction

• GERD

• Burning quality

• No shortness of breath

• Radiates up to neck

• Often occurs after eating

• Relieved with antacids

• Myocardial infarction

• Chest pressure

• Shortness of breath

• Can radiate into jaw and down left arm

• Often occurs after exertion

• Relieved with nitroglycerin

Let’s start with definitions: heartburn and regurgitation• Heartburn is the sensation of

burning in the retrosternal area, typically manifested after eating

• The burning sensation is thought to be secondary to acid exposure to esophageal mucosa

• Regurgitation is the perception of acid or food products into the mouth

Gastric acid

• Plays a role in absorption of • Proteins

• Iron

• B12

• Calcium

• Role in killing ingested microorganisms

Physiologic reflux vs GERD

• PHYSIOLOGIC

• Post prandial

• Short lived

• No symptoms

• Rarely have nocturnal symptoms

• PATHOLOGIC

• May occur anytime

• Mucosal injury

• Symptomatic

• Nocturnal symptoms common

Upper digestive tract anatomy

Causes of GERD

• Most people believe heartburn is related to foods they eat

• Pathophysiologic factors:• Reduced saliva production• Transient lower esophageal sphincter relaxations• Decreased LES tone• Decreased gastric emptying (eg. Gastroparesis)• Hiatal hernia

• Conditions that predispose:• Certain foods: Fat, caffeine, peppermint, alcohol• Smoking• Pregnancy• Obesity

Hiatal hernia

How common is GERD?

• 10 – 20 % of people in ‘western world’ suffer GERD

• Likely an underestimate, as only typical symptoms of GERD considered in most studies

• Significant impact on quality of life

• Prevalence of GERD and its complications increasing over time (despite improvements in medical therapies)

Symptom profile: typical vs atypical

• Classic symptoms

• Retrosternal burning

• Regurgitation of food

• Atypical symptoms

• Coughing

• Sore throat

• Laryngitis

• Throat clearing

• Waterbrash

Challenges with diagnosis

Diagnosing the problem

• Uncomplicated GERD is diagnosed with treatment!

• In setting of standard symptoms, Canadian Association of Gastroenterology recommends 8 week trial of once daily proton pump inhibitor once daily, 30 minutes before breakfast

• Resolution of symptoms ‘confirms’ diagnosis and treatment is then tapered to minimal treatment required to control symptoms

Other diagnostic tests

• Barium swallow

• Upper endoscopy

• 24 hour pH study

• Esophageal manometry

Barium swallow

• Barium is radiopaque and easily seen with x-ray technology

• slurry swallowed by the patient and video recording obtained

• Reflux is determined if barium is seen entering stomach and then reentering the esophagus

• Limited usefulness

24 hour pH testing – the gold standard

Esophageal manometry

• Small probe inserted through the nose and advanced into the stomach

• Measures pressures within the esophagus

• Patient given water to swallow and pressure recordings are taken

Endoscopy

Endoscopy benefits and risks

• Benefits

• Direct visualization of the mucosa

• Allows for tissue sampling

• Allows for therapeutic intervention (eg. Dilating a stricture)

• Risks

• Sedation required

• Bleeding (1/1000)

• Perforation of hollow organ (1/1000)

• Infection (1/1000000)

• Expensive

• Long wait lists

Who needs endoscopy?

• Weight loss

• Difficulty swallowing (dysphagia)

• Painful swallowing (odynophagia_

• Upper GI bleeding

• Iron deficiency anemia

• Vomiting

• First degree relative with esophageal cancer

What do we find at endoscopy for heartburn?

Complications of GERD

• Esophagitis

• Esophageal strictures

• Barrett’s esophagus

• Esophageal adenocarcinoma

The LA Classification

LA Class A

LA Class B

LA Class C

LA Class D

Esophageal strictures

Hurst

Maloney

Savary

Endoscopic Dilation

Balloon dilators

Barrett’s esophagus

• Longstanding exposure of the esophageal mucosa to acid results in a compensatory change in the cells (termed metaplasia)

• They esophageal mucosa which is normally ‘squamous’ cells becomes specialized intestinal cells

• Barrett’s esophagus increases risk of esophageal adenocarcinoma 30 fold

• Risk is up to 3 % per year

Endscopic findings in Barrett’s esophagus

Risk factors for Barrett’s esophagus

• Age 50 years or older

• ●Male sex

• ●White race

• ●Chronic GERD

• ●Hiatal hernia

• ●Elevated body mass index

• ●Intra-abdominal distribution of body fat

Concern with Barrett’s esophagus

Esophageal adenocarcinoma

Esophageal adenocarcinoma

• Most patients develop difficulty swallowing (dysphagia)

• Can also have weight loss, GI bleeding

• Prognosis depends on stage of the disease

Treating GERD

• Lifestyle

• Medications

• Endoscopic therapies

• Surgery

Treatment begins with lifestyle

• Evidence supports these recommendations:• Weight loss in those with GERD who are overweight or recently gained weight

• Raising the head of bed 6 – 8 inches with wooden blocks under head of bed or foam insert (for nocturnal symptoms)

• Avoid eating 4 hours before bedtime, and lying down after eating

• Evidence lacking, but physiologically makes sense:• Avoid foods that weaken the lower esophageal sphincter pressure (caffeine,

peppermint, fatty food, carbonated beverages, smoking and alcohol)

• Abdominal breathing exercises to strengthen the anti-reflux barrier

• Avoid tight fitting garments

Antacids: the cornerstone of therapy

• Calcium antacids

• Alginates

• Pepto bismol

• Histamine receptor blockers

• Proton pump inhibitors

The proton pump inhibitor: mechanism of action

The PPIs you know

Drug name Marketing name Dose Duration of action

Omeprazole Losec 20 mg , 40 mg Less than 24 h

Esomeprazole Nexium 40 mg Less than 24 h

Pantoprazole Pantoloc 20 mg , 40 mg Less than 24 h

Rabeprazole Pariet 10 mg, 20 mg Less than 24 h

Lansoprazole Prevacid 15 mg, 30 mg Less than 24 h

Pantoprazole sodium Tecta 40 mg 24 hours

Dexlansoprazole Dexilant 30 mg, 60 mg 24 hours

Are PPIs safe?

• Microscopic colitis

• Clostridium difficile colitis

• Osteoporosis

• Malabsorption of magnesium, iron, B12, calcium

• Kidney disease

• Dementia

• Pneumonia

• Drug induced lupus

• Mortality

Risk taken in context

• Most studies defining risk are Retrospective Cohort studies

• Suggest possible association but cannot conclude cause-effect relationship

• Risks may be real, therefore, PPIs should be prescribed:• 1. For appropriate indication

• 2. For appropriate period of time

• 3. Use lowest dose that controls symptoms

• 4. Can monitor calcium, Magnesium, B12, iron, renal function, etc.

PPIs and refractory GERD

• Term ‘refractory GERD’ refers to patients who do not have an adequate response to 8 week therapy with PPI medication

• Patient driven diagnosis

• 25% of patients will require twice daily PPI to control symptoms

• 90% of patients who do not respond to twice daily PPI have normal endoscopy

Putative mechanisms for failure of proton pump inhibitor (PPI) treatment• Compliance

• Improper dosing time

• Weak acidic reflux

• Duodenogastroesophageal/bile reflux

• Esophageal hypersensitivity

• Delayed gastric emptying

• Psychological comorbidity

• Concomitant functional bowel

disorder

• Reduced PPI bioavailability

• Rapid PPI metabolism

• PPI resistance

• Nocturnal reflux

• Helicobacter pylori infection status

• Eosinophilic esophagitis

• Functional heartburn

Fass R. Am J Gastroenterol 2009; 104:S33 -S38.

Algorithm for refractory GERD

Katz P et al. Am J Gastroenterol. 2013;108(3):308-328

Endoscopic therapies

Endoscopic therapies

Surgical options

Surgical options: Nissen fundoplication

Summary

• Gastroesophageal reflux disease is a common clinical modality and most patients can be diagnosed and managed by trial of proton pump inhibitor medication

• Complications are uncommon but can be serious (GI bleeding, stricture formation, Barrett’s esophagus and esophageal adenocarcinoma

• Important to recognize the ‘red flags’ which suggest need for endoscopy

• Endoscopic and surgical treatments are available but rarely required to manage GERD