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