Update in GERDNew Techniques and Perspectives

Presented on: May 17th 2014

John E. Pandolfino, MD, MSCIProfessor of Medicine

Feinberg School of Medicine, Northwestern University

Chief, Division of Gastroenterology and Hepatology Northwestern Medicine

Northwestern Memorial Hospital

Vakil N et al. Am J Gastroenterol 2006;101:1900

GERD is a condition which develops when the reflux of stomach content causes troublesome

symptoms and / or complications

Esophageal Syndromes

Extra-esophageal Syndromes

Symptomatic Syndromes

• Typical reflux syndrome

• Reflux chest pain syndrome

Syndromes with Esophageal Injury

• Reflux esophagitis• Reflux stricture• Barrett's esophagus

• Adenocarcinoma

Established Association

• Reflux cough

• Reflux laryngitis

• Reflux asthma

• Reflux dental erosions

Proposed Association

• Sinusitis• Pulmonary

fibrosis• Pharyngitis• Recurrent otitis

media

Positive symptom

association?

yes

no

Alarm features?

PPI Trial yesno Heartburn resolved?

Reflux disease: titrate PPI therapy

yes

EsophagitisEoE

Abnormal?

EGD ± biopsyno

yes

pH or impedance-pH monitoring (off of PPIs)no

>5% esophageal acid exposure?

yes

NERD

Esophageal manometry

Meets esophagealmotor disorder

criteria?

AchalasiaDES

yesno

Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747

no

Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation

FunctionalHeartburn/Chest Pain

MII-pH monitoring (on PPIs)

Positive symptom

association?

yes

no

Alarm features?

PPI Trial yesno Heartburn resolved?

Reflux disease: titrate PPI therapy

yes

EsophagitisEoE

Abnormal?

EGD ± biopsyno

yes

pH or impedance-pH monitoring (off of PPIs)no

>5% esophageal

acid exposure?

yes

NERD

Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation

FunctionalHeartburn/Chest Pain

Kahrilas PJ & Smout AJPM. Am J Gastroenterol 2010;105:747

Phenotyping PPI Non-responders: Low pre-test probability of refractory GERD

Bravo capsule placed 6cm above SCJ

Pandolfino et al. Am J Gastroenterol. 2003 Apr;98(4):740-9

Phenotyping PPI Non-responders: High pre-test probability of refractory GERD

Bravo capsule placed 6cm above SCJ

Impe

danc

e

0 3015 45 60

Time (Seconds)

0 ohms

10000 ohms

3 cm

5 cm

7 cm

9 cm

15 cm

17 cm

Pandolfino JE, Vela, MF. Gastrointest Endosc. 2009 Apr;69(4):917-30,

• Acid Reflux Symptoms– Abnormal acid exposure– Hypersensitive [(+) S-R correlation]

• Non-acid Reflux Symptoms– Volume refluxers– Hypersensitive [(+) S-R correlation]

• Overlap between well-controlled GERD and Functional Esophageal Disorder

• Do Not Have Reflux at ALL – Functional heartburn….or just functional– Unrelated disease (EoE, EMD, Cardiopulm etc..)

PPI Non-responders are Heterogeneousg EGD n

Pandolfino JE, Vela, MF .Gastrointest Endosc. 2009 Apr;69(4):917-30,

Evolution of the Hydrostat: EndoFlip™

Kwiatek et al. J Gastrointest Surg. 2010 Feb;14(2):268-76

Gastroesophageal Reflux Disease True Refractory Symptoms

•Targets for therapy based on our observations- Alter EGJ mechanical properties• Surgery• Endoscopic procedures

- Medications• Promotility agents• Reflux inhibitors

Pandolfino JE, Krishnan, K. . Clin Gastro Hepatol. 2013 Jun 28. : S1542-3565

Positive symptom

association?

yes

no

Alarm features?

PPI Trial yesno Heartburn resolved?

Reflux disease: titrate PPI therapy

yes

EsophagitisEoE

Abnormal?

EGD ± biopsyno

yes

pH or impedance-pH monitoring (off of PPIs)no

>5% esophageal acid exposure?

yes

NERD

Esophageal manometry

Meets esophagealmotor disorder

criteria?

AchalasiaDES

yesno

no

Patient with retrosternal discomfort (heartburn/chest pain) or regurgitation

FunctionalHeartburn/Chest Pain

MII-pH monitoring (on PPIs)

Gastroesophageal Reflux DiseaseSymptom perception

MF

VS

PD HV

MF

HV

VS

HVPD

Abnormal Motor Function Case : Functional Heartburn Case : Visceral Hypersensitivity

- Visceral Sensitivity- Hypervigilance- Psychosocial factors

Gut-directed HypnotherapyAre you getting sleepy?

• Deep physical relaxation and deep mental concentration

• Alters focus of attention, changes meaning about sensations arising from the gut and encourages body to restore itself to a healthier state

• Shown to produce cognitive change and improve pain tolerance

• Modifies physiological arousal and hypersensitivity over long-term

• Initially performed in a doctors office but can eventually be self-guided

• The most scientifically supported non-drug treatment for Functional GI disorders

GERD: Pitfalls

• Patients may have a good response to PPI and not have GERD.

• Patients may have a positive pH study and not have GERD.

• Patients may have a good symptom correlation on pH-impedance testing and not have GERD.

• Be careful with belching, regurgitation and nausea/vomiting.

NU IRB

tLESR

LES relaxation and

crural inhibition

Liquid reflux

NU IRB

Rumination # 1 HRM only

Increased IGP pressure

Liquid reflux

NU IRB

Rumination #2 HRIM

Increased IGP pressure

Liquid reflux

Regurgitation with swallowing

NU IRB

Supragastric Belching

No LES relaxation

Air reflux

GERD: Pitfalls

Gastroesophageal Reflux Disease Conclusions

•Reflux testing is essential to phenotype the patient based on mechanism.- Refractory reflux- Reflux sensitivity- Functional heartburn- Alternative diagnosis- HRIM is extremely

helpful

Gastroesophageal Reflux Disease Conclusions•Phenotype will dictate therapies- Refractory reflux• Endoscopic/surgery

- Reflux sensitivity•Motility agents, TCA, HYPNOSIS

- Functional heartburn• TCA, CBT, Hypnosis

- Rumination syndrome/supragastric belching• Biofeedback, CBT, hypnosis

Thank You