A gastroenterologist’s view of GERD and its pre-operative workup

1. A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School of Medicine M.I.S.S. 2.21.2012 Disclosures: None

2. Outline • What can happen • How do we find out • What can we do about it

4. = Heartburn/regurgitation - Erosive reflux disease (ERD): Erosions in the distal esophagus - Non-erosive reflux disease (NERD): Normal esophagus and abnormal pH - Barrett’s esophagus: Endoscopic and histologic evidence of intestinal metaplasia/dysplasia

5. Not all GERD is the same… Peptic stricture • NERD (most common) • Erosive esophagitis (LA B, C and D) • +/- Hiatal hernia • Refractory GERD • Consequences of repair • Peptic stricture • Barrett's metaplasia • Extra-esophageal manifestations • Asthma • Laryngitis • Cough Hiatal hernia

6. PPI therapy in GERD • The most effective medical therapy available • 90%+ healing rates • 70%+ symptom control rates • Symptoms may continue despite therapy • Relapses may still occur despite maintenance therapy • Subject to drug-drug interactions, long-term side effects and poor adherence

7. Understand Prevent Manage

8. PPI drawbacks

9. PPI may lose efficacy over time! Total percentage acid exposure time at baseline, at the time of normalization, and at 2-year follow-up. Frazzoni M, Dig LivDis 2007

10. Long term PPI safety • Pneumonia • C.difficile infection • Other enteric infections • Hypergastrinemia • Atrophic gastritis • Vitamin B12 malabsorption • Hip fractures • Drug interactions

11. GERD in primary care • Patients with heartburn, regurgitation, or chest pain, are typically treated initially with proton pump inhibitors (PPI). • 3 possible outcomes: • Complete response (no symptoms) • Partial response (breakthrough symptoms) • No response (no change in symptoms)

12. Refractory GERD Clinically significant impairment of health-related well-being (GERD-HRQoL) due to episodes of gastro-esophageal reflux while on PPI therapy “GERD” symptoms may not always reflect the acidity of the refluxate but may be due to: refluxate volume, esophageal distensibility and sensitivity to acid

13. Differential Diagnosis

14. Achalasia & dysmotility: Defined manometrically • EoE: > 25 eosinophils / hpf • RD (Reflux-like dyspepsia): Normal endoscopy, biopsies and pH monitoring • Gastroparesis: Normal endoscopy, abnormal GES

15. Clinical evaluation

16. Endoscopy

17. Esophageal biopsy Eosinophilic esophagitis Barrett’s esophagus

18. Esophageal Motility • Non-invasive & quasi-physiologic • Measures effectiveness of peristalsis and LES pressure/relaxation • Essential in defining esophageal dysmotility (achalasia, spasm, etc)

19. HRM depicts esophageal pressure activity from the pharynx to the stomach Fox, M R et al. Gut 2008;57:405-4

20. 24-hr ambulatory pH monitoring • Non-invasive & physiologic • Quantifies acid reflux (off/on Rx) • Correlates symptoms to acid reflux • Sensitivity and specificity > 90% • Indispensable for atypical & refractory cases

21. “Abnormal” intra-esophageal pH profile on PPI 56 yo man with persistent heartburn while on PPI 24-hr pH study on lansoprazole (30 mg bid) DeMeester score (on therapy): 17.3 % time intra-gastric pH < 4.0: 57.4 ie pH ig pH On high-dose PPI, this patient has achieved an inadequate intra-gastric pH control, resulting in persistent symptomatic GERD

22. “Normalized” intra-esophageal & intra-gastric pH profile 62 yo man with belching/regurgitation but no heartburn while on PPI 24-hr pH study on rabeprazole 40mg bid. DeMeester score (on therapy): 12.9 % time ig pH<4.0: 27.4

23. Disease prevalence in PPI-refractory GERD % 270 patients (143 men and 127 women), aged 16-89 years Triadafilopoulos G et al. Gastroenterology 2010

24. Acid reflux frequently overlaps % Triadafilopoulos G et al. Gastroenterology 2010

26. Reasons to consider endoscopic therapies for GERD Fundic polyps Refractory GERD Persistent heartburn despite escalatingPPIs Residual regurgitation without heartburn on PPIs PPI intolerance (2% of users) Desire to stop drug therapy (concerns about long-term effects) Concerns about LARS side effects (i.e. dysphagia, gas bloat) Symptomatic GERD after fundoplication Triadafilopoulos, G. Am. J. Med. 115(3A): 192S-200S, 2003.

27. Stretta Catheter Radiofrequency Rx Enhances LESP Reduces tLESRs Module

28. Transoralincisionlessfundoplication (TIF) Pre TIF Post TIF Full thickness tissue plications are used to reconstruct & augment the ARB Serosa-to-serosa fixation at 2wks Fasteners Serosa-to-serosa fixation

29. Who are not good candidates for EndoRx? • Patients with refractory GERD who have a large, fixed, hiatal hernia (> 3 cm long) and foreshortened esophagus Laparoscopic Nissenfundoplication

30. Who are not good candidates for either endoscopic or surgical therapy? • Patients with “functional” heartburn • Patients with 0 % response to PPIs • “Les malades du petit papier” • Negative pH studies + no symptom correlation with acid events Bravo pH monitoring

31. Conclusions • Reflux symptoms may or may not reflect GERD • PPI therapy is widely used and quite effective in ~80% of cases • Structural and functional evaluation of the esophagus are essential in refractory cases • Emerging role of endoscopic and newer surgical therapies • Multidisciplinary approach is essential to successful outcomes