GERD:NEW CONCEPT AND MANAGMENTS

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Dr\ Mohamed Emam Prof : gastroentrology Zagazig university Gord: guidelines and new concepts-2008-

GERD;GUIDELINES AND NEW CONCEPTS : 

GERD;GUIDELINES AND NEW CONCEPTS BY DR - MOHAMMED EMAM PROF.GASTRO.&HEPATOLOGY-ZAGAZIG UNIVERSITY - EGYPT

Introduction : 

Introduction *In the last decade the PUD was markedly decreasing all over the world while GORD is markedly increased ( Non-ulcer dyspepsia still the commonest ) *Gastro-oesophageal reflux disease (GORD) is present when the passage of gastric and duodenal contents into the oesophagus causes symptoms or damages the mucosa.

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Who gets reflux disease? : 

Who gets reflux disease? *Inherited and acquired factors both contribute to the development of GORD. *The prevalence of reflux symptoms is high in the parents of affected people, and in identical twin pairs than it is in non-identical twin pairs. *Genetic factors contribute 18-31% to the cause of GORD. *lifestyle factors. Smokers are more likely to have reflux symptoms. *Obesity is also associated with GORD; Moreover obese people tend to eat larger meals and choose rich, energy dense foods , dietary factors that increase the risk of reflux.

In contrast, although patients often think that coffee, chocolate, and alcohol can trigger symptoms, firm evidence linking specific foods with GORD is lacking. : 

In contrast, although patients often think that coffee, chocolate, and alcohol can trigger symptoms, firm evidence linking specific foods with GORD is lacking. *Advice on lifestyle, such as stopping smoking, losing weight, and avoiding large, late meals can reduce the frequency and severity of reflux symptoms, although it is rare for these measures to remove the need for acid suppression.

Helicobacter pylori and GORD : 

Helicobacter pylori and GORD *Helicobacter pylori, may inhibit or exacerbate acid reflux depending on how the infection affects the stomach. Distal (antral) gastritis increases the production of gastric acid. In this condition the eradication of H pylori not only reduces the risk of peptic ulceration but also the risk of acid reflux. *Conversely, generalised atrophic gastritis decreases the production of gastric acid; as a result H pylori eradication may increase the severity of reflux.

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*However, in clinical practice this information is rarely available, and well designed studies have found little or no overall effect of H pylori eradication on GORD. *Of more concern is that chronic H pylori infection is associated with an increased risk of peptic ulceration and gastric cancer. For this reason current guidelines recommend H pylori eradication irrespective of potential effects on GORD

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Why does reflux occur?

Why does reflux occur? : 

Why does reflux occur? *Everybody experiences gastro-oesophageal reflux at some time. *In health, reflux of air (belching) occurs during transient relaxations of the lower oesophageal sphincter triggered by gastric distension (bloating). Small volumes of ingested food and gastric acid may pass into the oesophagus during such episodes. *But GORD is present only when the reflux of gastric contents causes frequent, severe symptoms or mucosal damage

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*Although the underlying causes of GORD remain uncertain, the structure and function of the gastroesophageal junction are of key importance in this condition. Compared with healthy people.

Endoscopic findings in Gord : 

Endoscopic findings in Gord NERD. 65% Barrett's Esoph. 10% ERD 25%

GORD: a spectrum of disease or a family of diseases? : 

GORD: a spectrum of disease or a family of diseases? *Traditionally, GORD has been approached as a continuous spectrum of disease. *Endoscopy negative reflux disease was thought to represent mild disease, increasing grades of reflux oesophagitis indicating increasing severity of disease, whereas Barrett's columnar lined oesophagus was considered a very severe form of GORD.

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*Recent evidence has called this concept into question. *Firstly, progression from endoscopy negative reflux disease through erosive oesophagitis to Barrett's columnar lined oesophagus is rarely observed (and regression almost never occurs). *Secondly, oesophageal physiology and mucosal biology is not shared across the spectrum. *Thirdly, the response to therapy, clinical course, and risk of complications (including malignancy) does not change in a continuous manner as expected in a spectrum of disease but is categorically different in the three groups.

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*The traditional concept focuses on injury to the oesophageal mucosa. *The new model shifts attention to oesophageal symptoms. *On this basis patients with endoscopy negative reflux disease would not be considered to have mild disease because such patients often have severe and atypical symptoms. *Moreover their response to acid suppression is often incomplete. *In contrast, patients with erosive oesophagitis usually have typical reflux symptoms that respond to acid suppression and show healing of the erosions.

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*In patients with Barrett's columnar lined oesophagus the mucosa is often exposed to acid for prolonged periods; many do not have severe symptoms, however, because the metaplastic, columnar lining of the oesophagus is relatively insensitive to acid.

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*These findings provide clear evidence that Barrett's columnar lined oesophagus does not represent the end of a spectrum in GORD but rather a different phenotypic response of the oesophageal mucosa to acid reflux. *In summary: distinct oesophageal physiology and mucosal responses to acid reflux explain the differing presentation, clinical course, and malignant potential of patients with endoscopy negative reflux disease, erosive oesophagitis, or Barrett's columnar lined oesophagus.

Symptoms and conditions associated with gastro-oesophageal reflux disease : 

Symptoms and conditions associated with gastro-oesophageal reflux disease Typical symptoms Heartburn, acid regurgitation Atypical symptoms Dysphagia, globus sensation, non-cardiac chest pain, dyspepsia or abdominal pain ,IBS ,sleep apnea and sleep disturbance. Extra-oesophageal symptoms Hoarseness or sore throat, or both; sinusitis; otitis media; chronic cough; laryngitis or polyps on the vocal cords, or both; dental erosions; non-atopic asthma; recurrent aspiration or pulmonary fibrosis, or both Malignancy Oesophageal adenocarcinoma, head and neck cancer

Extra oesophageal reflux disease: another member of the GORD family : 

Extra oesophageal reflux disease: another member of the GORD family *Epidemiological studies report an association between GORD and extraoesophageal symptoms and disease. Moreover, clinical experience suggests that antireflux therapy improves these problems in many patients. * Affected patients may not have typical reflux symptoms or mucosal injury on endoscopy.

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*Even weakly acidic reflux (pH 4-6) can trigger extraoesophageal symptoms. *Thus extraoesophageal reflux disease is different to typical GORD and seems to represent a distinct response to the reflux of gastric contents.

GORD and oesophageal adenocarcinoma: who is at risk? : 

GORD and oesophageal adenocarcinoma: who is at risk? *The relative risk of developing oesophageal adenocarcinoma in patients with GORD is affected by personal factors and clinical history, increasing with male sex, smoking, obesity, age, and the frequency and severity of reflux symptoms. *Nevertheless, even for patients with all these risk factors, the absolute risk remains low (1 in 600 population per year); too low to justify screening on this basis.

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*A high risk population can also be defined by endoscopy because the risk of cancer is not shared by all patients with reflux symptoms but is largely restricted to those with Barrett's columnar lined oesophagus . *Even for patients with "long segment" Barrett's columnar lined oesophagus, the absolute risk of developing oesophageal adenocarcinoma is small (1 in 200 population per year) in the absence of premalignant, dysplastic change on histology.

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*A recent retrospective study of patients with this condition suggests that the risk of developing dysplasia may be reduced by 75% by acid suppression. *Non-steroidal anti-inflammatory drugs may also protect against oesophageal cancer. *The large, prospective AspECT (aspirin and esomeprazole chemoprevention in Barrett's metaplasia) trial is seeking to determine the effects of high dose and low dose proton pump inhibitors with and without low dose aspirin as chemoprevention.

How to manage GORD: treat first, endoscope later : 

How to manage GORD: treat first, endoscope later *The UK National Institute for Health and Clinical Excellence has recently published guidelines on the management of dyspepsia (including reflux symptoms) that will have a major impact on clinical practice. *Routine endoscopic investigation is not necessary for patients of any age presenting with dyspepsia but no alarm symptoms. *However referral for endoscopy is appropriate for patients aged 55 years and older with unexplained treatment resistant dyspepsia of more than four weeks' duration.

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*Patients with reflux symptoms but no alarm symptoms initial treatment with full dose proton pump inhibitors for one month . *Eradication therapy for H pylori can also be provided if infection is evident on serology or urea breath test. *If symptoms return after treatment, and long term acid suppression is required, a step-down strategy to the lowest dose of proton pump inhibitor that provides effective relief of symptoms is more cost effective than the step-up approach

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*If endoscopy is carried out and oesophagitis is present, a healing dose of proton pump inhibitor should be prescribed for two months. In such patients symptoms usually relapse when treatment is withdrawn, and maintenance proton pump inhibitor therapy is usually required *Long term management with proton pump inhibitors for over 10 years has been shown to be safe and effective, although the dose requirement may increase over time.

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*Persistence of reflux symptoms Changing the proton pump inhibitor preparation or increasing the dose (twice daily dosing) may be required for control of symptoms in patients with severe acid reflux.This may also be effective in patients with endoscopy negative reflux disease and in patients with extra oesophageal reflux disease. *Adding an H2 receptor antagonist before bedtime may be useful if symptoms are prominent at night.

Factors determining immediacy of endoscopy : 

Factors determining immediacy of endoscopy Symptoms requiring urgent referral of patients for endoscopy -Gastrointestinal bleeding -Iron deficiency anaemia -Progressive unintentional weight loss -Progressive difficulty swallowing -Persistent vomiting -Epigastric mass on palpation -Suspicious barium meal result or other suspicious imaging result.

Factors requiring consideration of referral of patients for endoscopy : 

Factors requiring consideration of referral of patients for endoscopy -Previous gastric ulcer -Previous gastric surgery -Non-steroidal anti-inflammatory drug use. -Pernicious anaemia. -Family history of gastric cancer.

What to do when proton pump inhibitors fail : 

What to do when proton pump inhibitors fail *If reflux symptoms fail to respond to full dose acid suppression then investigations must be carried out to confirm the diagnosis of GORD. *Endoscopy is appropriate, but many patients who fail to respond to treatment have no evidence of mucosal injury (endoscopy negative reflux disease). *Barium studies may show a hiatus hernia but are poor at detecting upper gastrointestinal inflammation or ulceration.

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*Ambulatory monitoring of pH over 24 hours remains the standard for the diagnosis of GORD, confirming disease related exposure of the oesophagus to acid and the association of symptoms with acid reflux events. *Prolonged monitoring of pH over 48 hours with the catheter free Bravo system may improve patient tolerance and increase diagnostic yield. *Combining pH and multichannel intraluminal impedance measurements detects both acid and non-acid reflux.

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*Multichannel intraluminal impedance is a new technique that uses changes in electrical conductivity to follow the movement of fluid and gas in the oesophagus. *Recent studies using this investigation have shown that proton pump inhibitors reduce acid reflux but have no effect on the overall number of reflux events. *Clinical investigations have supported the promise of multichannel intraluminal impedance by confirming that non-acid volume reflux is a common cause of persistent reflux symptoms in patients receiving treatment for acid suppression.

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*Combining pH, multichannel intraluminal impedance, and manometry (to detect cough) has also shown great promise in extraoesophageal reflux disease. This technique documents when acid or non-acid reflux triggers cough and identifies patients who would be missed or wrongly diagnosed by standard pH studies. *Non-acid reflux can now be detected, medical management remains unsatisfactory. * Increasing the dose of proton pump inhibitors does not tackle the cause of persistent non-acid reflux by reducing the volume of gastric secretion or strengthening the reflux barrier.

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*Adding an H2 receptor antagonist may reduce gastric acid secretion by direct inhibition of the parietal cell. *Alginate preparations (for example, Gaviscon) form a viscous barrier over gastric contents. *Prokinetics (for example, domperidone) may increase lower oesophageal sphincter tone and accelerate gastric emptying. *Antireflux surgery may be appropriate for young, otherwise healthy patients in whom medical management of GORD is ineffective or not tolerated.and those with H.hernia.

Non medical treatment : 

Non medical treatment *Recently, endoscopic techniques have been developed with the aim of providing an alternative to antireflux surgery. *These endoluminal therapies augment the reflux barrier by submucosal implants, radiofrequency energy delivery, or plication of the lower oesophageal sphincter. *Short term benefits are reported by up to two thirds of patients. *Long term results have been disappointing, however, and these techniques are not ready for routine use.

Anti-reflux surgery compared to PPI : 

Anti-reflux surgery compared to PPI 12- years follow up showed, a sustained remission,53% in ARS compared to45% in PPI group .during the study,38% of ARS patients required maintenance PPI ,compared to 15% of PPI patients were operated on.

ThanksDr\Mohamed Emam : 

ThanksDr\Mohamed Emam