advanced concepts the burning belly: an overview of gerd

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Advanced Concepts The Burning Belly: An Overview of GERD, Dyspepsia and Eosinophilic EsophagitisJason Domagalski, MD, FAAFP

Residency Director

Froedtert Menomonee Falls Hospital Family Medicine Residency

Activity DisclaimerThe material presented here is being made available by the American Academy of Family Physicians

for educational purposes only. Please note that medical information is constantly changing; the

information contained in this activity was accurate at the time of publication. This material is not

intended to represent the only, nor necessarily best, methods or procedures appropriate for the

medical situations discussed. Rather, it is intended to present an approach, view, statement, or

opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using

this material and for all claims that might arise out of the use of the techniques demonstrated therein

by such individuals, whether these claims shall be asserted by a physician or any other person.

Physicians may care to check specific details such as drug doses and contraindications, etc., in

standard sources prior to clinical application. This material might contain recommendations/guidelines

developed by other organizations. Please note that although these guidelines might be included, this

does not necessarily imply the endorsement by the AAFP.

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Disclosure StatementIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

Learning Objectives

1. Identify the recommended treatment strategies to cost effectively management of GERD, dyspepsia and eosinophillic esophagitis.

2. Consider common strategies to address complicated cases and when to to consider surgical and endoscopic interventions.

3. Review the known complications associated with long-term PPI use and effective strategies of weaning patients off these medications.

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Say Hello to Tom

AES Question

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Question 1

Mr. Bernie Belly is a 41 year-old male who has chronic epigastric pain and found to have H. pylori infection which has failed to respond to clarithromycin based triple therapy. Which of the following is an appropriate next step in treatment?

A. Repeat the same triple therapy again

B. PPI+Bismuth+Metronidazole+Tetracycline

C. Antibiotic Sensitivity Testing

D. Rifabutin based therapy

Helicobacter pylori

One of the most common infections worldwide

Known carcinogen Associated with noncardia gastric adenocarcinoma

1-3% infected develop cancer

15% of total cancers worldwide 89% of gastric cancers

Linked to Peptic Ulcer Disease

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Refractory Infection

Positive test 4+ weeks after course completion

Multifactorial Etiologies Non-adherence Antibiotic Resistance

Shah S, et al. AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review. Gastro. Apr 2021:.160 (5).

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Failure Recommendations



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AES Question

Question 2

Mrs. Anita Refill is a 42 year-old female who has been on the same dose of omeprazole for years presents for a routine physical and asks for a refill. When is long-term PPI use appropriate?

A. Patients with Barrett's esophagus

B. Patients with a history of PUD no longer taking NSAIDs

C. Patients with a history of eosinophilic esophagitis

D. Patients with B12 deficiency

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AGA Best Practice Recommendations

Patients with Erosive esophagitis or peptic strictures should should take PPIs for short term healing and long term symptom control Patients with Barrett’s esophagus and symptomatic GERD should

take a long-term PPI. Asymptomatic patients with Barrett’s esophagus should consider a

long-term PPI. Patients at high risk for ulcer-related bleeding from NSAIDs should

take a PPI if they continue to take NSAIDs. The dose of long-term PPIs should be periodically reevaluated so

that the lowest effective PPI dose can be prescribed to manage the condition.

PPI Problems

Hypomagnesemia

B12 Deficiency

Hip fractures

C. difficile infections

Community Acquired Pneumonia

Dementia Association?

Anderson WD, Strayer, SM, et al. Common Questions About the Management of Gastroesophageal Reflux Disease. Amer Fam Phys. 2015 May 15; 91(10): 692‐697El‐Serag HB, et al. Update on the epidemiology of gastroesophageal reflux disease: a systematic review. Gut. Jun 2014; 63(6):871‐880.

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Tapering Protocol

No standardized or evidence proven approach

Try reducing dose 50% every other day for 1 week

Then reduce daily dose by 50% for 1 week

Then reduce dosing to every other day for 1 week

Then Stop

Can try taking daily dose with biggest meal

Alternate with H2 blocker

Farell B, et al. Deprescribing proton pump inhibitors. Can Fam Phys. May 2017. 63 (5): 354-64.

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AES Question

Question 3

Mrs. Mia Chestahertz is a 37 year old female who presents with classic GERD symptoms, but had a recently normal EGD. Which is a NOT a recommended treatment for Functional Heartburn?

A. Proton Pump Inhibitors

B. H2 receptor antagonists

C. Nortriptyline

D. Sertraline

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Functional Heartburn

21%–39% of patients with heartburn refractory to PPIs

Rome IV Criteria

Retrosternal burning pain/discomfort

No improvement with 3-month trial of maximal dosing PPI

Absence of Anatomic and mucosal abnormalities on EGD

Normal manometry and pH testing

Fass R. AGA Clinical Practice Update on Functional Heartburn: Expert Review. Gastro. June 2020. 158 (8): 2286-93

Functional Heartburn Diagnosis


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Functional Heartburn Treatment

PPIs have no therapeutic value

TCAs, SSRIs and H2 antagonists proven benefit

Acupuncture and hypnotherapy have limited evidence

Anti-reflux surgery have no therapeutic benefit


Functional Heartburn Therapeutics


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AES Question

Question 4Mr. Max Doses is a 52 year-old male who has chronic GERD which has only partially responded to medications in the past. He is interested in additional treatments for his reflux. Which of the following is true in regards to patients with chronic GERD?A. 25% fail aggressive medical therapy

B. 40% fail aggressive medical therapy

C. Nissen Fundoplication is the only interventional procedure for chronic GERD

D. Up to 15% of patients with medication refractory GERD pursue fundoplication

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Treatment Gap 40% Fail aggressive medical therapy 5% undergo fundoplication

Fear of complications or treatment failure

Alternative treatment LINX EndoStim Stretta Medigus

Subramanian CR, Triadafilopoulos. Refractory Gastroesophageal Reflux Disease. Gastroenterology Report 3. 2014 Sep 30; 41‐53.

LINXSmall ring of magnetic beads

Augment LES function

Allows preserved belching/vomiting

Reduced ppi use at 4 wks

100% improved QOL at 4 yrs 80% cessation of PPI use

Subramanian CR, Triadafilopoulos. Refractory Gastroesophageal Reflux Disease. Gastroenterology Report 3. 2014 Sep 30; 41‐53.Permision Granted for reproduction by http://www.linxforlife.com. Accessed on May 30, 2015

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EndoStim Implantable Electrical stimulator

Increases resting pressure of LES

91% off ppi at 6 months

Reduced nocturnal heartburn symptoms

Subramanian CR, Triadafilopoulos. Refractory Gastroesophageal Reflux Disease. Gastroenterology Report 3. 2014 Sep 30; 41‐53.

StrettaRadiofrequency to remodel EGJ and LES

32 clinical trials and meta-analysis

Allows future interventions if needed

Subramanian CR, Triadafilopoulos. Refractory Gastroesophageal Reflux Disease. Gastroenterology Report 3. 2014 Sep 30; 41‐53.Permission granted for reproduction from http://www.stretta‐therapy.com. Accessed on May 30, 2015

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Endoscopic partial fundoplicationEndoscopic surgical

stapler64% reduction in GERD

patient scores Still in clinical trials

Medigus

Subramanian CR, Triadafilopoulos. Refractory Gastroesophageal Reflux Disease. Gastroenterology Report 3. 2014 Sep 30; 41‐53.Permission granted for reproduction from http://www.medigus.com. Accessed on May 30, 2015

AES Question

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Question 5

Mr. Hye Risk is a 36 year-old male with a history of Barrett’s Esophagus. He was found to have no dysplasia on his most recent surveillance EGD. When should his next EGD be scheduled?

A. 1-2 years

B. 3-5 years

C. 7-10 years

D. Never. No follow up is needed

Barrett’s Esophagus

Metaplastic columnar epithelium in lower esophagus

Predisposes cancer development

Annual incidence of esophageal cancer is 0.5% per year

Potentially increased risk of CV mortality

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Barrett’s Cancer Risk

Shaheen N, et al. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. Amer J of Gastro. Jan 2016. 111 (1): 30-50.

Screening Recommendations

Men with > 5 years of GERD with weekly symptoms

2+ Risk Factors: 50+ years old Caucasian Central Obesity (waist circumference >102 cm, waist–hip ratio >0.9) Current or past history of smoking Family History of BE or Esophageal Adenocarcinoma


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Surveillance Recommendations

No Dysplasia: 3-5 years 4 quadrant biopsies every 2 cm

Low Grade Dysplasia: 6-12 months

High Grade Dysplasia without intervention 3 months 4 quadrant biopsies every 1 cm

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Barrett’s Management

Acid Suppression No evidence to date for long term prevention of progression No evidence for doses greater than standard dosing

Chemoprevention Aspirin Not recommended for cancer prevention

Dysplasia Radiofrequency Ablation Photodynamic Therapy Endoscopic Mucosal Resection


AES Question

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Question 6

Mr. M. Paction is a 34 year-old male with a history of Eosinophilic Esophagitis (EoE) with multiple ER visits for food impaction. Which of the following is true in regards to the management of EoE?

A. Dilation leads to symptom improvement in >80% of patients

B. There is a 5 % risk of perforation with dilation

C. Severe hemorrhage occurs in 1% of dilations

D. Dilation is higher risk for EoE than other strictures

EoE Management

Elemental Diets resolve inflammation in > 90% of children Poor compliance: taste, oral motor skills, potential gastrostomy tube

6 food Elimination Diet Resolves inflammation in 2/3 of patients Egg, wheat, milk, nuts, soy, fish and shellfish

Allergy Test guided restriction Resolves inflammation in 1/3 of patients

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Medication Management

PPIs resolve inflammation in 1/3 of patients

Topical Steroids Resolve inflammation in 2/3 of patients Risks: fungal/viral infections, adrenal suppression

Oral Steroids Similar to topical Adverse effects in 40%

Biologics No benefit

EoE Dysphagia Management

Caused by strictures

Symptom improvement in 87% of patients

Complications Perforation 0.4% Hemorrhage 0.1% Similar to other benign stricture dilation

Hirano I, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Gastro. May 2020. 158 (6):1776-86.

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Practice Recommendations

The dose of long-term PPIs should be periodically reevaluated so that the lowest effective PPI dose can be prescribed to manage the condition. (SORT: C)

Bismuth based quadruple therapy should be considered for treatment refractory H. pylori. (SORT: B)

In patients with EoE topical steroids should be used rather than oral steroids(SORT: B)

References1. Subramanian CR, Triadafilopoulos. Refractory Gastroesophageal Reflux Disease. Gastroenterology Report 3. 2014 Sep 30; 41‐53.

2. Loyd RA, McClellan DA. Update on the Evaluation and Management of Functional Dyspepsia. Amer Fam Phys. 2011 March 1. 83(5): 547‐52.

3. Talley NJ, Vakil N. Guidelines for the Management of Dyspepsia. Amer J of Gastro. 2005: 2324‐35.

4. Anderson WD, Strayer SM, et al. Common Questions about the Management of Gastroesophageal Reflux Disease. Amer Fam Phys. 2015 May 15. 91(10): 692‐97.

5. Hirano I, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Gastro. May 2020. 158 (6):1776-86.

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Jason Domagalski, MD, FAAFP

[email protected]

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advanced concepts the burning belly: an overview of gerd

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