Transcript GERD - University of California, Irvine

GERD
Ambulatory Mini-Lecture
Gastro-Esophageal Reflux Disease
• The condition of chronic, pathologic reflux of
acidic stomach contents
– Esophagus
– Oropharynx
– Larynx, even lungs
• Leads to symptoms and/or mucosal damage
– NERD = symptoms without damage
– Symptoms may be typical or atypical
Typical Symptoms
• Heartburn
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Retrosternal burning sensation
Most commonly post-prandial, nocturnal
Fatty foods, spicy foods, acidic foods
Relived with antacids, water, milk
Worsened with recumbency
• Acid Regurgitation
– Perception of gastric content reflux in the mouth or
hypopharynx
– AKA water brash: bitter, acidic
Atypical Symptoms
• Atypical
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Dysphagia, odynophagia
Nausea
Chest pain
Dyspepsia = non-severe upper abdominal discomfort
• Epigastric fullness, bloating
• Frequent belching
• Heartburn
• Extraesophageal
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Chronic cough
Hoarseness, laryngitis
Vocal Cord Dysfunction, Bronchospasm
Globus sensation
Complications of GERD
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Peptic stricture
Metaplastic disease (Barrett’s)
Dysplastic disease (adenocarcinoma)
Laryngitis
Pulmonary disease
Red Flags…think endoscopy
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Dysphagia/odynophagia
Nausea/vomiting
Melena, anemia*
Weight loss, anorexia
Extended duration of symptoms
No response to PPI
Family history of PUD
• Caucasian Male, 50+ years old, sx > 10 yrs
– Concern for Barrett esophagitis
Diagnosis
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History
Trial of PPI
Upper Endoscopy
Esophageal pH monitoring
• Presumptive GERD diagnosis can be based on
clinical symptoms alone and can start with
empiric therapy
Diagnostic Considerations
• Esophagitis
– Infectious: Fungal vs viral
– Pill
– Eosinophilic (Allergic)
• H. pylori testing prior to PPI
• CAD
– Women
– Elderly
– Diabetics
Work up
• History + Empiric treatment
– Although a response to PPIs is not a definitive
diagnosis of GERD, in clinical practice it is more
appropriate to start empiric treatment than to
pursue reflux pH monitoring
– Symptoms that do not improve warrant further
evaluation to demonstrate the existence of GERD
and evaluate for an alternate diagnosis
Endoscopy with biopsy
• Upper endoscopy is not required for diagnosis
• Indicated for suspected GERD plus
– Red flags, or
– Symptoms resistant to twice daily PPI therapy
• Esophagitis or Barrett’s esophagus =
diagnostic
• Remember NERD
– 62% of patients with typical symptoms of GERD
will have a normal EGD
Other diagnostic work up
• Ambulatory pH monitoring
– Persistent symptoms despite medical therapy
– Confirmatory testing in patients with normal EGD
• No Barium
• Esophageal manometry for dysmotility
Articles
• Badillo R, Francis D. Diagnosis and treatment of gastroesophageal
reflux disease. World Journal of Gastrointestinal Pharmacology and
Therapeutics 2014; 5(3):105-112. doi: 10.4292/wjgpt.v5.i3.105.
• Achem SR, DeVault KR. Gastroesophageal reflux disease and the
elderly. Gastroenterol Clin North Am. 2014 Mar; 43(1):147-60. doi:
10.1016/j.gtc.2013.11.004. Review. PubMed PMID: 24503365
• Vela MF. Medical treatments of GERD: the old and new.
Gastroenterol Clin North Am. 2014 Mar; 43(1):121-33. doi:
10.1016/j.gtc.2013.12.001. Epub 2013 Dec 31. Review. PubMed
PMID: 24503363
• Overland MK. Dyspepsia. Med Clin North Am. 2014 May; 98(3):54964. doi: 10.1016/j.mcna.2014.01.007. Epub 2014 Mar 18. Review.
PubMed PMID: 24758960
MKSAP QUESTIONS
Question 1
A 35 yo woman is evaluated for a 6 month history of an
upset stomach that usually occurs after meals. She also
has heartburn symptoms after meals at least 4 times per
week. She reports no difficulty of pain with swallowing
an no vomiting, weight loss, altered stool habits or blood
in the stool. There is no family history of malignancy.
On physical examination, the vital signs are normal.
Abdominal examination discloses a non-tender
epigastrium and no masses or lymphadenopathy. CBC is
normal.
Question 1
Which of the following is the most appropriate
management?
A. Proton pump inhibitor
B. Sucralfate
C. Test for Helicobacter pylori and treat if positive
D. Upper endoscopy
Question 1 Explanation
Educational Objective
Manage dyspepsia and heartburn with proton pump inhibitor therapy.
The best first line treatment for this patient is acid suppression with a proton pump
inhibitor (PPI). This patient is considered to have GERD with dyspeptic features. Studies
have shown that patients with dyspepsia who undergo endoscopy commonly have normal
findings. However, the most common finding in patients with abnormalities is esophagitis.
PPI is thought to be superior to H2 blockers for both dyspepsia and heartburn.
Sucralfate does not have a role in the treatment of GERD and has no advantage when
compared with placebo for treatment of functional dyspepsia.
A test-and-treat strategy for H. pylori would be appropriate for patients with dyspeptic
symptoms without heartburn or alarm symptoms and who are fun an area with high
prevalence of H. pylori infection (>20%). Because this patient also has heartburn, this
approach is incorrect. There has been some controversy as to whether eradication of H.
pylori in patients with dyspepsia may increase the risk of post-eradication GERD, but a
recent meta analysis has shown this to be true.
An upper endoscopy is incorrect because this patient does not have alarm symptoms such as
onset after the age of 50, anemia, dysphagia, odynophagia, vomiting, weight loss, family
history of upper GI malignancy, personal history of peptic ulcer disease, gastric surgery or
GI malignancy, and abdominal mass or lymphadenopathy on examination.
Question 2
A 40 year old woman is evaluated for a 1 year history of
reflux symptoms. She has heartburn and regurgitation
of gastric contents several times a week. She was placed
on lifestyle modifications and an empiric trial of a once
daily proton pump inhibitor (PPI) 12 weeks ago with
minimal relief of symptoms. For the past 6 weeks, se has
taken the PPI twice daily, with minimal relief. She has
had intermittent solid food dysphagia. She appears to be
adherent to her lifestyle and medical therapy.
Physical examination discloses normal vital signs and a
BMI of 35.
Question 2
Which of the following is the most appropriate next step
in management?
A. Add an H2 blocker at night
B. Ambulatory esophageal pH study
C. Endoscopy
D. Fundoplication
Question 2 Explanation
Educational Objective
Manage GERD that does not respond to an empiric trial of PPI therapy
This patient should undergo endoscopy. Her symptoms suggest GERD and there has been
no response to empiric trials of high dose PPI for an adequate period of time (8-12 weeks).
Further evaluation with endoscopy is required for patients with symptoms of weight loss,
dysphagia, odynophagia, bleeding or anemia and in men with long standing symptoms (>5
years) or symptoms that are refractory to acid suppression therapy. This patient has had
intermittent dysphagia to solid food and her symptoms appear to be refractory to PPI
therapy; she should therefore undergo endoscopy to explore complications and alternative
diagnoses such as eosinophilic esophagitis, stricture, malignancy or achalasia.
PPIs are much more effective in healing esophagitis compared to H2 blockers. Adding H2
blockers to maximal PPI therapy does not result in a meaningful increase in acid blockade.
Therefore, an additional dose of an H2 blocker is unlikely to produce relief for patients who
continue to have heartburn after 6 weeks of treatment with a PPI.
Ambulatory esophageal pH monitoring is most commonly used to confirm GERD in
patients with persistent symptoms despite maximal medical therapy and an unrevealing
endoscopy. In this patient with persistent symptoms and intermittent dysphagia, endoscopy
is the most appropriate next diagnostic test to assess for evidence of reflux induced
complications. If endoscopy is unrevealing, ambulatory pH monitoring should be
considered.
Persistent or recurrent symptoms despite maximal medical therapy for GERD are
indications for anti-reflux surgery such as fundoplication. However, before consideration of
anti-reflux surgery, this patient should undergo endoscopy to confirm the presence of
esophagitis and to eliminate the possibility of another diagnosis and possibly ambulation
pH recording.
Question 3
A 75 year old man is evaluated in follow up after recent
surveillance endoscopy for Barrett esophagus. Biopsy from
one of the salmon colored columnar segment shows high
grade dysplasia. His GERD symptoms are well controlled
with proton pump inhibitor therapy. His medical history is
significant for New York Heart Association functional class
III heart failure (Ejection fracture of 30%). His medications
are pantoprazole, furosemide, digoxin, metoprolol, enalapril
and spironolactone.
On physical examination, he is afebrile, blood pressure is
100/50 mmHg, pulse rate is 62/min, and respiratory rate is
12/min. BMI is 35. There is no evidence of jugular venous
distention. Cardiac rhythm is regular with a soft S3 at the
cardiac apex. The lungs are clear. No peripheral edema is
present.
Question 3
Which of the following is the most appropriate
management?
A. Endoscopic ablation
B. Esophagectomy
C. Fundoplication
D. Repeat endoscopic surveillance in 3 years
Question 3 Explanation
Educational Objective
Manage high grade dysplasia in a patient with Barrett esophagus.
This patient should receive endoscopic ablation. Options for the management of
high grade dysplasia in patients with Barrett esophagus include esophagectomy,
and endoscopic therapy (combined mucosal resection and ablation of residual
BE). However, esophagectomy is associated with a mortality rate of 2-8% and a
morbidity rate of 30-40% in the immediate postoperative period. This patient has
a significant medical comorbid condition and is a suboptimal candidate for
esophagectomy. Endoscopic therapy is a reasonable alternative because of its
lower morbidity rates, especially in patients with high surgical risk. Results of
endoscopic therapy have been shown in cohort studies to be comparable with
those of esophagectomy.
Fundoplication is recommended when uncontrolled GERD symptoms persist
despite maximal medical therapy; however, this patients symptoms are well
controlled with PPI. Fundoplication has not been shown to reduce the risk of BE
progression to dysplasia or cancer compared with medical therapy.
Repeat endoscopic evaluation would be recommended at intervals of no longer
than 3 months because of ht4e substantial risk of progression of high grade
dysplasia to adenocarcinoma (6% per year) and risk of coexisting neoplasia (1012%). If subsequent surveillance detects progression to adenocarcinoma,
endoscopic therapy can be utilized at that time.
Question 4
A 44 year old woman is evaluated for a 1 year history of
vague upper abdominal discomfort that occurs after
eating. She is from a rural area in a developing country.
She has not had nausea, vomiting, dysphagia,
odynophagia, weight loss or black or bloody stools. She
is otherwise healthy. She has no personal history of
peptic ulcer disease and no family history of
gastrointestinal malignancy. Her only medication is a
multivitamin.
On physical examination, temperature of 36.8C/98.2F,
blood pressure is 127/82 mmHg, pulse rate is 72/min,
and respiration rate is 16/min. BMI is 27. There is
epigastric tenderness with moderate palpitation but no
masses or lymphadenopathy. Complete blood count is
normal.
Question 4
Which of the following is the most appropriate
management?
A. Helicobacter pylori stool antigen testing
B. Initiate an H2 blocker
C. Initiate empiric treatment for H. pylori infection
D. Perform endoscopy
Question 4 Explanation
Educational Objective – Manage dyspepsia without alarm feature in a patient from a developing
country
The most appropriate management for this patient is stool antigen testing for Helicobacter pylori.
Dyspepsia is chronic or recurrent discomfort in the upper mid-abdomen. The prevalence of dyspepsia is
not well known because of the vagueness of its description by both patients and physicians. In addition
to discomfort, affected patients may have mild nausea or bloating. The recommended approach for a
patient younger than 50 years without alarm features (anemia, dysphagia, odynophagia, vomiting, weight
loss, family history of upper GI malignancy, personal history of peptic ulcer disease, gastric surgery or
gastrointestinal malignancy and abdominal mass or lymphadenopathy on examination) is a test an treat
strategy for H. pylori or empiric treatment with a proton pump inhibitor. The test and treat strategy for
H. pylori is an appropriate first line a strategy when the patient is from an area where prevalence of H.
pylori is high (such as developing countries); however, PPI is the most appropriate first line strategy if the
patient is from an area where prevalence of H. pylori is low. Pats such as this one from developing
countries have a high prevalence of H. pylori owing to likely fecal oral transmission. Therefore, for this
patient, a test and treat approach is preferred. If testing is positive, eradication of H. pylori may relieve
symptoms, but it is important to note that randomized controlled trials provide conflicting results as to
the efficacy of H. pylori eradication in improving symptoms of functional dyspepsia. If the patient does
not test positive for H. pylori, a trial of PPI is warranted.
PPIs are superior to H2 blockers, so initiating an H2 blocker would not be appropriate in this patient.
Empiric treatment for H. pylori is incorrect because the diagnosis of H. pylori should be determined
before initiating treatment.
Endoscopy would be appropriate for patients who symptoms do not respond to H. pylori treatment or
PPI therapy. Patients older than 50 years or with alarm feats should always be evaluated with upper
endoscopy. In patients without alarm features , endoscopy as an initial management intervention would
be unlikely to find gastritis, peptic ulcer disease, or esophagitis.