Moderator : Dr.Nawin KumarPresenter : Vamsi Alluri

Management of GERD

Definition of GERD…*

• A condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications

*Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group, Am J Gastroenterol. 2006;101(8):1900.

• Most common symptoms are heartburn, regurgitation, and dysphagia

• Extraesophageal manifestations :- bronchospasm- laryngitis and - chronic cough

• Other symptoms of GERD include chest pain, water brash, globus sensation, odynophagia, and nausea.

Diagnosis…

• Can be based upon clinical symptoms alone• Response to antisecretory therapy is not a

diagnostic criterion for GERD• In a subset of patients, diagnostic testing is

required to confirm the diagnosis of GERD, assess for complications and to rule out other diagnoses

Differential diagnoses…

• Infectious esophagitis • Pill esophagitis • Eosinophilic esophagitis • Peptic ulcer disease • Non-ulcer dyspepsia • Coronary artery disease and • Esophageal motor disorders

Upper GI Endoscopy

• Upper endoscopy is not required in the presence of typical GERD symptoms of heartburn or regurgitation*

• Upper endoscopy provides a mechanism for detecting, stratifying, and managing the esophageal manifestations of GERD

*[Katz PO, Gerson LB, Vela MF, Am J Gastroenterol. 2013;108(3):308]

Indications for UGI endoscopy…• To rule out complications of GERD. Alarm features are : dysphagia odynophagia gastrointestinal bleeding anemia

weight loss and recurrent vomiting • Severe erosive esophagitis (LA classification Grade C and D)

on initial endoscopy - follow-up endoscopy after a two-month course of PPI therapy to assess healing and rule out Barrett's esophagus.

• Men older than 50 years with chronic GERD symptoms (>5 yrs) and additional risk factors for Barrett's esophagus and esophageal adenocarcinoma (nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, and intra-abdominal distribution of fat).

• If symptoms persist despite a therapeutic trial of four to eight weeks of twice-daily PPI therapy.

Ambulatory 24 hr. pH monitoring…• Gold standard for diagnosing and quantifying

acid reflux• Catheter• 2 solid state

electrodes – sense pH between 2 and7.

• Connected to a data recorder.• Data gained from the study :

- Total number of reflux episodes (pH<4)- Longest episode of reflux- No. of episodes longer than 5mins- Extent of reflux in upright position and supine position

Esophageal manometry…• Primarily done to rule out motility disorders,

which may mimic symptoms of reflux• Also allows the surgeon to plan for the operative

procedure• Catheter – flexible tube with pressure sensing

devices arranged at 5cm intervals• LES is analysed for mean resting pressure and

response to swallowing• Body is assessed for the effectiveness od

peristalsis

• Normal pressures at LES range from 12 to 30mm of Hg

• Sphincter generally relaxes to the pressure of gastric baseline for several seconds when a swallow is initiated

• Ineffective esophageal motility is defined as <70% peristalsis

• Distal esophageal amplitudes <30mm of Hg is associated with significant GERD

Medical management

Initial therapy…• Step up approach or step down approach

• Step up approach provides the advantage of minimum usage of PPIs

• Step down approach provides faster symptom relief.

• Step-up therapy for GERD in patients with mild and intermittent symptoms (fewer than two episodes per week) who have no evidence of erosive esophagitis on upper endoscopy, if performed.

Step-up therapy…

• Lifestyle and dietary modification +/- low-dose H2RAs +/- antacids

• Lifestyle and dietary modification +/- standard dose H2RAs +/- antacids

• Lifestyle and dietary modification +/- low-dose PPIs (once daily) +/- antacids

• Lifestyle and dietary modification +/- standard dose PPIs +/- antacids

Step-down therapy…

• Patients with erosive esophagitis• Frequent symptoms (two or more episodes

per week) • Severe symptoms that impair quality of life

• lifestyle and dietary modification + standard-dose PPI once daily

• lifestyle and dietary modification + low-dose PPIs

• lifestyle and dietary modification + H2RAs

• lifestyle and dietary modification + acid suppression discontinued

Exceptions : Severe esophagitis Barrett’s esophagusMaintenance PPI therapy

Lifestyle modifications…

• Weight loss• Elevation of head end of the bed in patients

with nocturnal or laryngeal symptoms• Refraining from assuming a supine position

after meals• Avoidance of meals two to three hours before

bedtime.

• Dietary modification – elimination of dietary triggers

• Promotion of salivation through oral lozenges or chewing gum

• Avoidance of tobacco and alcohol• Abdominal breathing exercise

Antacids…

• Combination of magnesium trisilicate, aluminum hydroxide, or calcium carbonate

• Neutralizes gastric pH• Relief of heartburn within five minutes• Short duration of effect of 30 to 60 minutes

H2 receptor antagonists…

• Decrease the secretion of acid by inhibiting the histamine 2 receptor on the gastric parietal cell.

• Slower onset of action, around 2.5 hours• Significantly longer duration of action of 4 to

10 hours• Tachyphylaxis within 2 – 6 weeks of initiation

Proton pump inhibitors…

• Irreversibly binds and inhibits the H-K ATPase pump

• Should be administered daily rather than on-demand

• Standard doses for eight weeks relieve symptoms of GERD and heal esophagitis in up to 86% of patients with erosive esophagitis

Medication Low dose (adult, oral) Standard dose (adult, oral)

Histamine 2 receptor antagonists

Famotidine 10 mg twice daily• 20 mg twice dailyΔ

Ranitidine 75 mg twice daily• 150 mg twice dailyΔ

Nizatidine 75 mg twice daily• 150 mg twice daily

Cimetidine 200 mg twice daily• 400 mg twice dailyΔ

Proton pump inhibitors

Omeprazole 20 mg daily• 40 mg daily

Lansoprazole 15 mg daily• 30 mg daily

Esomeprazole 20 mg daily 40 mg daily

Pantoprazole 20 mg daily• 40 mg daily

Dexlansoprazole Not available 30 mg daily, 60 mg daily

Rabeprazole 10 mg daily◊ 20 mg daily

Recurrent symptoms

• 2/3rd of patients with non erosive reflux disease and all patients with erosive esophagitis replase when acid suppression is discontinued

• Recurrence after 3 months of discontinuation : Repeat 8 weeks course of acid suppressive therapy

• Recurrence < 3 months of discontinuation : Upper GI endoscopy to rule out complications and long term acid suppressive therapy

Refractory GERD

• Partial or lack of response to PPI twice daily should be considered as refractory GERD

Endoluminal therapies

Techniques• Radiofrequency energy

- Stretta System• Endoscopic plication suturing

- Bard EndoCinch Endoscopic Suturing System- EsophyX™ System with SerosaFuse™ Fastener (transoral incisionless fundoplication procedure)

• Injection or implantation techniques- Gatekeeper Reflux Repair System- Plexiglas (polymethylmethacrylate [PMMA]) procedure- Enteryx procedure

Stretta…

• Principle : Radiofrequency energy delivery• Equipment : RF control module and Flexible Stretta catheter• Catheter : 20Fr soft bougie tip and a balloon,

which opens into a sorrounding basket.• 4 electrodes deliver 60 to 300 J of RF energy to

each needle, heating the surrounding muscle tissue to the target temperature between 650C to 850C

• Continuous irrigation of the esophageal mucosa and surface temperature monitoring is utilized to prevent thermal mucosal injury

RF energy delivery

Shrinkage of esophageal collagen fibres

Tightening of LES

Prevents acid reflux

Remodelling of stretch fibres in the cardia

Interruption of vagal afferent signals to brainstem

Reduces transient LES relaxations

Endocinch technique…

• Effective in short-term follow-up period and the complication rate was relatively low

• Sutures were significantly lost within the 6-month follow-up period, thus necessitating reprocedure in about 25% of the patients.

BARD Endocinch…

Transoral Incisionless Fundoplication…

• EsophyX™ System with SerosaFuse™ Fastener• The device retracts the gastric cardia, and

creates full-thickness serosa to serosa plication and valve

• Less invasive alternative to laparoscopy

Gatekeeper reflux repair system

• utilizes a poly-acrylonitrile based hydrogel (HYPAN) rod

• Procedure

• Over the next 24 hours, the prosthesis swells, narrowing the luminal diameter of the lower esophagus.

Plexiglas technique

• Suspension of polymethylmethacrylate microspheres in gelatin solution

• Gelatin is phagocytosed by macrohages within 3 months and is replaced by fibroblasts and collagen fibres

EnteryX system

• 6-8ml of 8% ethylene vinyl alcohol(EVOH) polymer infused at a rate of 1ml/min to the muscle or deep submucosal layer 1-2mm caudal to the Z-line

• Although Enteryx does not affect LES pressure, the distensibility and shape of GE junction is changed

Surgical management

Inidications for surgery…

• Failed optimal medical management• Noncompliance• High volume reflux• Severe esophagitis by endoscopy• Benign stricture• Barrett's columnar-lined epithelium (without

severe dysplasia or carcinoma)

Principles of surgery…

• Restoration of intra-abdominal portion of esophagus to maintain a pressure differential between thoracic and abdominal esophagus

• Creation of a loose wrap around the G-E junction to restore the mechanical effect of it

• Reduction of any hiatus hernia and approximation of the crural fibres to narrow the hiatus

• Identification and management of any associated anatomical abnormalities

Specific anti-reflux surgeries…

Belsey Mark IV

• Gold standard before the advent of laparoscopy

• Partial anterior wrap, through left 5th intercostal space posterolateral thoracotomy

• Procedure

Collis gastroplasty

• Isolating the upper part of lesser curve in the form of a tube in continuity with the esophagus

• Procedure• Drawbacks :

- Distal neo esophagus will not co ordinate with the esophageal peristaltic wave- Continues to secrete acid

Nissen fundoplication• Full 3600 posterior wrap around the lower 4cm of

esophagus• Standard laparoscopic technique• Lithotomy position• Port placement• Chief surgeon – between patient’s legs• 1st assistant – Right side

- right hand : camera- left hand : liver retraction

• 2nd assistant – Left side : stomach retraction

Port placement

Step 1 : Division of the gastrohepatic ligament

2. Retraction of the fat pad, blunt dissection, and creation of a window posterior to the esophagus

3. Division of the short gastric vessels to the base of the left crus to allow complete fundic mobilization

4. The “Shoe-shine” manoeuvre

5. Closure of the crural opening posterior to the esophagus with interrupted, nonabsorbable suture

6. Fundopilcation : Creation of a 2 cm wrap

Types of fundoplication failure

Partial fundoplications

Toupet fundoplication

• Partial posterior wrap• Procedure

Toupet fundoplication

Dor fundoplication

Completed Dor fundoplication

Complications of laparoscopic fundoplication

• Intra operative• Early post operative• Delayed post operative

Intra operative

• Access injuries- Vascular- Hollow viscus or solid organ

• Dissection injuries- Stomach & Esophagus- Vagus nerve

• Bleeding- Aberrant arteries- Aorta, vena cava- Short gastric arteries

Early post operative

• Delayed perforation- Stomach- Esophagus

• Deep vein thrombosis• Pulmonary complications• Dysphagia • Early wrap herniation

Delayed post operative• Dysphagia

- Poor motility- Tight wrap- Twisted wrap

• Gas bloat syndrome• Recurrence of reflux

- Wrap herniation- Wrap disruption- Incompetent wrap

• Diarrhea- Vagal injury

Choice of surgery…

• Factors influencing :- degree of esophageal shortening- disturbances of esophageal motility- prior operations and - local expertise with laparoscopic techniques

• Early uncomplicated disease : Trans-abdominal Nissen (laparoscopic if possible) fundoplication

• Decreased motility : Although surgery cannot directly influence esophageal motility in patients with GERD, Nissen fundoplication can lead to improvement in esophageal contraction amplitude. Benefit limited to patients with preoperative amplitudes above the 5th percentile

• Normal length but decreased motility : Complete fundoplication is discouraged; (lap or open) Toupet or Hill or transthoracic Belsey procedure could be performed

• Shortened esophagus : Collis (esophageal lengthening) gastroplasty combined with an intra-abdominal or intra-thoracic fundoplication

Laparoscopy vs. Open

• Laparoscopic approach had a faster convalescent rate (3 fewer days in hospital), a faster return to work (8 days sooner), and a similar treatment outcome*.

• But patients undergoing laparoscopic surgery also had a higher rate of reoperation

*Peters MJ, Mukhtar A, Yunus RM, Khan S, Pappalardo J, Memon B, Memon MA, Am J Gastroenterol. 2009;104(6):1548.

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