GERD Seminar
Sally Bowa, RN, MSN, FNP-C
Dr. Hass Jassim,
Objectives:
• Examine general GERD overview, pathophysiology and disease progression
• GERD symptoms-typical versus atypical• Comprehensive Diagnosis of GERD• Our current medical options for treatment• Current surgical options for treatment• Surgical interventions-what to expect
What is
GastroEsophogeal
Reflux Disease?
(GERD)
GERD
• It is a chronic, often progressive disease
• Caused by a weak Lower Esophageal Sphincter (LES)
• LES is the body’s natural barrier to reflux Lower
EsophagealSphincter
Duodenum
Stomach
Esophagus
Weak Sphincter (LES)?
• Unknown• Weakens over time• Family history• Association with hiatal hernias
Hiatal hernia
-Upper part of stomach can herniate into the chest cavity-Can contribute to GERD symptoms-If the LES is functioning normally (barrier), a hiatal hernia alone does not necessarily cause GERD
Picture obtained from Medicine Net, Inc.
GERD
SYMPTOMS
Common (typical) Symptoms
• Heartburn• Regurgitation• Mild dysphagia• Chest pain
Atypical Symptoms
• Chronic cough• Hoarseness• Chronic sore throat• Dental problems• Recurrent (aspiration) pneumonia• Worsening asthma• Sleep disturbances• Globus sensation• Bad breath
Complications of GERD
• Esophagitis • Stricture
Complications of GERD (cont’d)
• Pulmonary • ENT
-Poor asthma control-Cough-Aspiration pneumonia-pulmonary fibrosis
-Hoarseness-Voice changes-Chronic ear infections-Chronic sinusitis-Sore throat-Globus sensation
Complications of GERD (cont’d)
• Barrett’s esophagus
Barrett’s Esophagus cont’d
Esophageal Cancer
• Incidence of adenocarcinoma arising out of Barrett’s esophagus is rising dramatically (Uptodate, 2015).
• Risk factors: – Long standing GERD (>20 years)– Severe symptoms– Smoking– Obesity
Comprehensive evaluation of GERD
• Patient visit• Arrange for endoscopic
evaluation• Additional testing if needed• Esophageal manometry• Barium esophogram
Upper endoscopy
-VISUAL Evalution -Rule out significant lesion-Obtain biopsies (microscopic evaluation) -Rule out Barrett’s esophagus, EoE, candida, adenocarcinoma-Placement of pH monitor
Indications for EGD
• Breakthrough symptoms on PPIs• Long-standing GERD (>5 years)• Rule out other pathology• Dysphagia• Barrett’s surveillance• Screening
– Male, smoker, obese, >50 yrs
Ambulatory pH testing
-PHYSIOLOGIC evaluation-Most accurate test to establish diagnosis of GERD-
Case Study #1
Patient #1
Case Study #2
Patient #2
Esophageal Manometry
• Functional evaluation of esophagus and LES
Case study #1 cont’d
Case study #2 cont’d
Barium Esophogram
• Visualizes the swallowing mechanism, esophagus
• Contrast study using barium• Radiopaque• Appears white on the film
Symptom Management & Treatment Options
Dietary Modification
• Avoid trigger foods– Fatty, spicy or fried foods– Tomato based products– Caffeine – Chocolate– Alcohol– Carbonated beverages
Lifestyle Modifications
• Bed blocks• Avoid overeating• Lose excess weight• Avoid postprandial
recumbency
Medical Therapy
H2 BlockersPepcidTagametZantac
AntacidsMylantaPepto-BismolRolaidsTums
Proton Pump InhibitorsAciphexNexiumPrevacidPrilosec
Medical therapy
BENEFITS►Reduces the amount of acid in the stomach►May reduce inflammation of esophageal
lining►Provides symptom relief for many patients,
but relief can be temporary
LIMITATIONS►DOES NOT affect the cause of reflux (LES)►DOES NOT prevent reflux►May require life-long use and dose escalation
PPI side effects
• Common side effects:– Diarrhea or constipation– Nausea– Headache
• Decreased calcium absorption• Increased pneumonia risk• Decreased Plavix efficacy• Decreased magnesium absorption
Potential Risks of Long term PPI use
• FDA alerts
FDA: Possible Fracture Risk with High Dose, Long-term Use of Proton Pump Inhibitors
May 25, 2010Labeling changes will include new safety information
The U.S. Food and Drug Administration today warned consumers and health care professionals about a possible increased risk of fractures of the hip, wrist, and spine with high doses or long-term use of a class of medications called proton pump inhibitors. The product labeling will be changed to describe this possible increased risk.
FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs)
March 2, 2011Safety Announcement
The U.S. Food and Drug Administration (FDA) is informing the public that prescription proton pump inhibitor (PPI) drugs may cause low serum magnesium levels (hypomagnesemia) if taken for prolonged periods of time (in most cases, longer than one year). In approximately one-quarter of the cases reviewed, magnesium supplementation alone did not improve low serum magnesium levels and the PPI had to be discontinued.
FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs)
February 8, 2012Safety Announcement
The U.S. Food and Drug Administration (FDA) is informing the public that the use of stomach acid drugs known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that does not improve. Patients should immediately contact their healthcare professional and seek care if they take PPIs and develop diarrhea that does not improve.
Antisecretory Medications
Percentage of patients experiencing breakthrough symptoms while on a PPI
(among all patients)
• Disease is progressing – sphincter is getting worse and medication no longer is enough
• They have symptoms that do not respond well to medication ie: regurgitation, chronic cough, hoarseness or asthma
• Reflux is not the primary cause of their symptoms – need to see Reflux Specialist for testing
62% NOBreakthrough Symptoms
38% Breakthrough Symptoms
Why might medication not be effective?
Patient profile with Progressive disease
• Family history of GERD• Takes PPIs with complusive regularity• Has increased symptom severity after 1
year of PPI therapy• Requires dose escalation of PPIs to
control symptoms• Esophagitis on baseline endoscopy• Esophagitis remaining unhealed after PPI
therapy• Barrett’s esophagus
Surgical Options for GERD
• Medically refractory GERD• Esophagitis despite meds• History of Barrett’s• Concerned with PPI side effects• Intolerant of meds/side effects• Interest in alternative options• Concern/awareness of Barrett’s esophagus
or esophageal cancer• QOL• Hiatal hernia
Surgery options
Nissen fundoplication
LINX-magnetic sphincter augmentation
• Dr. Jassim’s presentation
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