GERD treatments, further workup and basic management

GERD

1. GERD and Hiatal Hernias in 1 hour Joshua Lyons, MD General Surgery PGY-6

2. Symptomatology Clinical symptoms are diverse -Typical and atypical presentations May direct clinical evaluation toward unrelated diseases GERD

3. Typical Symptomatology Pyrosis - most common symptom; associated with meals, position, sleep, exercise Regurgitation/vomiting Hypersalivation - reflex salivation secondary to acid reflux into esophagus Chest pain - secondary to acid reflux or esophageal motility disorders GERD

4. Atypical Symptomatology Asthma Hoarseness Hiccups Dysphagia Odynophagia Chronic anemia GERD

5. Diagnosis Contributing factor Diagnostic technique Mucosal injury Endoscopy Abnormal LES and Esophageal motility esophageal motility study, Barium swallow Reflux-induced symptoms pH monitoring (Bravo), Trial of PPI’s GERD

6. Principles of treatment Education of patient about GERD Elimination of symptoms Prevention of complications GERD

7. Education of the patient Lifestyle changes Dietary modifications Postural maneuvers Cessation of smoking and alcohol intake GERD

8. Summary of studies 1978-1992 Symptomatic (%) Endoscopic (%) Response Healing Placebo 52/562 (27%) 104/433 (24%) H2 Antagonist* 132/1887 (60%) 506/1003 (50%) Omeprazole (60mg) 695/834 (83%) 591/754 (78%) *cimetidine(800-1600mg/d), ranitidine(300-600mg/d), famotidine(40mg/d) GERD

9. GERD refractory to treatment with PPIs (ACG Guidelines) 9 The first step in management of refractory GERD is optimization of PPI therapy Upper endoscopy should be performed in refractory patients with typical or dyspeptic symptoms principally to exclude non-GERD etiologies. In patients in whom extraesophageal symptoms of GERD persist despite PPI optimization, assessment for other etiologies should be pursued through concomitant evaluation by ENT, pulmonary, and allergy specialists. Patients with refractory GERD and negative evaluation by endoscopy (typical symptoms) or evaluation by ENT, pulmonary, and allergy specialists (extraesophageal symptoms), should undergo ambulatory reflux monitoring Reflux monitoring  off  medication can be performed by any available modality (pH or impedance-pH). Testing  on  medication should be performed with impedance-pH monitoring in order to enable measurement of nonacid reflux Refractory patients with objective evidence of ongoing reflux as the cause of symptoms should be considered for additional antireflux therapies, which may include surgery. Patients with negative testing are unlikely to have GERD and PPI therapy should be discontinued

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11. Bravo ambulatory pH test 11

12. EGD 12

13. EGD 13

14. EGD 14

15. EGD 15