Treatment Options for Patients with GERDGERD-Facts Approximately 1/3 of patients have endoscopic abnormalities such as erosive esophagitis, Barrett’s esophagus, peptic stricture

Treatment Options for Patients with GERD

Kristina F. Skarbinski, MSN, FNP-BC

MGH Gastroenterology

Neurointestinal Health Center

November 4, 2017

Disclosures

I do not have any disclosures.

Objectives

Identify GERD in the clinical setting by understanding the many different presentations commonly seen in this diagnosis

Explain basic pathophysiology in how GERD manifests in patients

Understand different medication and dietary/lifestyle treatment approaches in GERD

Identify some of the commonly associated risks seen with poorly treated GERD

Become associated with different testing methods for GERD and when to use them

Understand and describe two common surgical options available for patients with refractory GERD and common risks seen post-op

GERD- Symptoms

Typical

• Heartburn

• Acid/food regurgitation

• Intermittent dysphagia

Atypical

• Cough

• Hoarseness

• Throat clearing

• Post-nasal drip

• Sore throat

• Non-cardiac chest pain

GERD-Facts

Most reflux episodes occur during transient relaxations of the LES that are triggered by gastric distention.

Some patients with GERD have an incompetent LES (< 10 mmHg) that results in acid reflux, especially when supine or when intra-abdominal pressures are increased by lifting or bending, exercise, pregnancy.

Most uncomplicated cases do not require further testing.

Reference: McPhee Papadakis, 2011. Current Medical

Diagnosis and Treatment

GERD-Facts

Approximately 1/3 of patients have endoscopic abnormalities such as erosive esophagitis, Barrett’s esophagus, peptic stricture or Schatzki ring.

Hiatal hernias: most are asymptomatic (usually < 3cm-small). Can be a risk factor for GERD.

Abnormal acid reflux is defined as a pH of LESS than 4 in the esophagus. Total acid exposure time is also important!

McPhee S. J., Papadakis M.A. & Rabow M.W. (2011). Current Medical Diagnosis and Treatment.

5th edition , McGraw Hill.

Case 1: 32 year old female

• CC: Heartburn and acid regurgitation in the setting of 15 lb weight gain over the last 3 months, increased stress at work and limited physical activity.

• Symptoms worsen at night when lying supine or after eating spicy meals. She takes an OTC antacid prn with minimal benefit.

• No dysphagia, nausea or vomiting

• PMH: Generalized Anxiety Disorder, Tension Headaches, Eczema

• PSH: few suspicious but benign mole removals in her 20s.

• Medications: Celexa 30 mg daily, OTC antacid prn, hydrocortisone 2.5% prn, Excedrin

prn headaches

• Wt: 185 lbs Ht: 5’5” BMI: 30.8 BP: 130/86 HR 75 O2 sat: 99% RA

• Physical Exam: Normal.


What is your next step?

• Switch to OTC liquid Gaviscon TID prn

• Start ranitidine 150 mg bid prn

• Start omeprazole 20 mg bid, ½ hour before meals for 6-8 weeks.

• Counsel on dietary and lifestyle changes.

• Do nothing, recommend living with her symptoms

Medication Therapy

• Antacid

• H2RA

• PPI

Antacids

• Speed of relief vs length of effect

• Gaviscon vs antacids

• PRN use vs chronic use

H2 Blockers

• Medium reaction; medium effect

• Less dependent on food

Proton Pump Inhibitors

• How it works H K ATPase

• Administration with food

• Strength of response versus speed of response

• Acid rebound The importance of tapering

• Placebo relief: I feel great immediately after my PPI!

Dietary and Lifestyle Changes

• Low fat diet

• Limit carbonated drinks

• Small frequent meals

• Limit alcohol or remove completely

Dietary and Lifestyle Changes

• Limit foods high in acidity (such as citrus fruits, tomatoes, apple juice, orange juice, tomato sauce, coffee)

• Eat no later than 4 hours before bedtime

• Elevate entire head of bed with cinderblocks vs wedge or pillow


• Patient returns for follow up 3 months after being initiated on omeprazole 20 mg bid and following dietary and lifestyle changes. She has lost 8 lbs and while her symptoms have improved dramatically, she is concerned about long term effects related to omeprazole use.

PPIs in the News

Osteoporosis Risk!- vit D, prophylaxis,

Dementia!- debunked

Interstitial nephritis!- rare

C. Difficile!

Infections with acid decrease

Cytochrome P450 interactions: Anti-coagulants

TAKE HOME MESSAGE: risk benefit ratio: quality of life vs life

threatening issues


• Despite your efforts to re-assure the patient, you decide to taper off the PPI.

• Taper schedule: 20 mg daily for 1-2 weeks, then 20 mg every other day for a week and then stop.

Case 2: 55 year old male

History of longstanding GERD well controlled on omeprazole 20 mg bid for 18 years. Initial symptoms prior to therapy: heartburn and acid regurgitation

Presents to local GI provider for consult. Symptoms include increased acid regurgitation and new dysphagia to solids and intermittent non-exertional chest pain. Stress test: NEGATIVE.


PMH: HTN, hyperlipidemia, Type II DM A1C 7.5, GERD PSH: appendectomy as a child, cholecystectomy age 40 Allergies: none Meds: ASA 81 mg, Atorvastatin 40 mg QD, Metformin 500 mg bid


You decide to do the following interventions:

Increase pantoprazole to 40 mg bid, 30 minutes before breakfast and dinner

Counsel on dietary and lifestyle restrictions for GERD management

Schedule an upper endoscopy Age and length of symptoms >10 years

Upper Endoscopy

Assess type and extent of tissue damage in reflux patients. Detecting other lesions that may mimic GERD. Detect GERD-related complications such as: esophageal stricture, esophageal

adenocarcinoma, Barrett's metaplasia

Barrett's esophagus

Squamous epithelium of the esophagus changes--> metaplastic columnar epithelium containing goblet and columnar cells. (ie. Intestinal metaplasia)

Short segment vs Long segment

Due to chronic injury of esophageal mucosa from frequent untreated exposure to acid reflux.

PPIs indicated to reduce acid exposure risk ---> decrease chances of esophageal cancer developmentNo evidence of regression of disease!

Reference: McPhee S. J., Papadakis M.A. & Rabow M.W. (2011). Current Medical Diagnosis and

Treatment. 5th edition , McGraw Hill.

Barrett's esophagus

Treatment goal: reduce changes to esophageal mucosa. Complications of chronic untreated Barrett's esophagus include adenocarcinoma of the esophagus thought to be related to dysplastic epithelium in Barrett's esophagus.

Screening: Women over age 60 and Men over age 50 who have GERD symptoms for several years.

Known Barrett's esophagus: surveillance endoscopy every 3 years to assess for low or high grade dysplasia

Known low grade dysplasia: repeat upper endoscopy in 6 months then yearly if no high grade dysplasia found on pathology.

Treatments for dysplastic esophageal mucosa: ablation therapy, esophagectomy

Reference: McPhee S. J., Papadakis M.A. & Rabow M.W. (2011). Current Medical

Diagnosis and Treatment. 5th edition , McGraw Hill.

Peptic Stricture

→ Occurs in 5% of patients who have esophagitis

→ dysphagia to solids often gradual but progressive over several months to years

→ Often noted on upper endoscopy near the GE junction

→ Biopsies of the stricture to rule out carcinoma

→ Esophageal dilation during endoscopy is helpful but acid suppression should be initiated or increased s/p procedure

→ May require several esophageal dilations

Reference: McPhee S. J., Papadakis M.A. & Rabow M.W. (2011). Current Medical Diagnosis

and Treatment. 5th edition , McGraw Hill.

Schatzki Ring

• Hx of steakhouse syndrome, intermittent solid food dysphagia

• -Marshmallow vs tablet test

• -Role of acid suppression

• -Role of esophageal dilation

Case 3: 68 year old woman

Long standing GERD for 20 years. Treated with omeprazole 20 mg bid. Presents to the office with concerns for increasing heartburn, acid and food regurgitation as well as intermittent solid food dysphagia easily cleared by drinking water. She also has had a persistent non-productive cough worse at night. CXR with PCP negative. No fevers or wheezing.

She takes Zantac 150 mg prn bid for breakthrough symptoms.

You send her for an upper endoscopy and it shows SEVERE LA Grade D esophagitis

What next?

Esophagitis Classifications A to D


You increase her PPI to 40 mg bid, 30 minutes before breakfast and dinner as well as add in Zantac 300 mg bid. For breakthrough, she is recommended to try OTC liquid Gaviscon, especially if any nocturnal symptoms as well as elevating head of bed at night.


Repeat upper endoscopy 3 months from initiating new dose of acid suppression showed a normal appearing esophagus. Normal esophageal biopsies; negative eosinophilic esophagitis and no evidence of celiac disease on duodenal biopsies.

She returns to clinic for follow up and reports 80% improvement but still has a persistent cough that occurs nocturnally.

You decide to?

• Ensure proper medication administration

• Encourage continued acid suppression and dietary/lifestyle changes

• Schedule esophageal manometry

• Schedule ph testing

Esophageal Manometry

• Role of manometry

• Placement of ph catheter

• Ineffective Esophageal Motility from GERD

Esophageal Manometry

Low LES pressures (3 mm Hg (nl 15 to 45) and decreased LES relaxation,

56% ineffective swallows

44% weak swallows

Esophageal pH testing

ON vs OFF acid medication?

What type of pH study?

2 channel pulmonary

Impedance pH

1 channel gastric

BRAVO pH study

pH impedance testingOn acid suppression

In the pH sensor in the distal esophagus, there were 80 acid reflux episodes noted (nl<50).

Total % time pH<4 was 13.7% (nl<4.5), upright 17.9% (nl<6), supine 22.0% (nl<2).

pH-based symptom association probability (SAP) for cough: 96.5 (Probability that symptom and reflux are not associated solely by chance, >95% is

significant)

DeMeester score: 22.3 (abnl >14.72)

Some Surgical Options

• Nissen fundoplication

• Linx

• Stretta

Pre-Testing

• Barium Swallow

• Upper Endoscopy

• Esophageal manometry

• pH study – what kind?

Nissen fundoplication

Potential complications

• Post op dysphagia

• Surgical wrap failure

• Vagal nerve injury

• Abdominal bloating

LINX

Reference: Torax Medical Devices, 2017

Potential complications

• Device erosion

• Post-operative dysphagia

• Not compatible with most MRI

Clinical Pearls for Anti-Reflux Surgery

Good medical response predicts good surgical response

PPI refractory cases generally do not do well with anti-reflex surgery

BMI less than 30 is most ideal

Pre-op dysphagia is a good predictor of post-op dysphagia

Post-op diet and recommendations

Can I vomit after the surgery?

What if I have the flu?

Gas bloat syndrome?

Hiatal hernia


Patient had complete a Nissen fundoplication and did well post-operatively.

She is completely asymptomatic and has been able to wean off of all acid suppression

However, she returns a year later with recurrent heartburn. She was restarted on omeprazole 20 mg bid by her PCP and she has ZERO benefit from taking it.

What now?

Testing!

Repeat esophageal manometry and pH study

Recommend 2 channel pulmonary pH study OFF Acid suppression

pH testing is negative without any abnormal reflux and poor symptom correlation of heartburn with reflux events

Visceral Hypersensitivity

Medication Options

• gabapentin

• amitriptyline, nortriptyline, desipramine

• trazodone

• topiramate

• pregabalin

• buspirone

Role of Cognitive

Behavioral Therapy


Over the course of 6 months, she starts taking gabapentin and finds 100% relief in her heartburn with 300 mg TID which she increases slowly over time

Other References:

• Lochhead, P. et al. (2017). Association Between Proton Pump Inhibitor Use and Cognitive Function in Women. Gastroenterology, 153, 971-979.

• Khalili, H. et al. (2012). Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective study. BMJ.

• McPhee S. J., Papadakis M.A. & Rabow M.W. (2011). Current Medical Diagnosis and Treatment. 5th edition , McGraw Hill.

Special Thank You’s

• Massachusetts General Hospital Neurointestinal Center

• Braden Kuo, MD

• Barbara Nath, MD

• David Rattner, MD

• Kyle Staller, MD

• Andrea Thurler, NP

• Elizabeth Glennon, NP

Documents

Treatment Options for Patients with GERDGERD-Facts Approximately 1/3 of patients have endoscopic abnormalities such as erosive esophagitis, Barrett’s esophagus, peptic stricture