GERD: Telling Fact from Fiction

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Information about GERD: Telling Fact from Fiction
Health & Medicine

Published on February 23, 2014

Author: drjarrodlee



GERD (Gastro Esophageal Reflux Disease) is one of the commonest medical conditions found in the community today. GERD patients often suffer from frequent symptoms and require long term medication. However, how much of what we know about GERD is truly fact based on medical evidence? We challenge traditional paradigms to GERD

GERD: Telling Fact from Fiction Dr Jarrod Lee Gastroenterologist & Advanced Endoscopist Mt Elizabeth Novena Hospital

Fact or Fiction? • Non Erosive Reflux Disease (NERD) is a mild form of GERD. It can progress to Erosive Esophagitis • In Asia, NERD is far more common than Erosive Esophagitis. Hence, endoscopy is not useful for diagnosis • In GERD, if PPIs don’t work, nothing more can be done except surgery

NERD is a mild form of GERD. It can progress to Erosive Esophagitis

Traditional Paradigm NERD Erosive Esophagitis Barrett’s Esophagus • Focus on Erosive Esophagitis – Most well designed GERD studies focus on mucosa healing and symptom improvement in Erosive Esophagitis • Progression along spectrum over time • NERD is a mild form of GERD

What is the Evidence? NERD Erosive Esophagitis Barrett’s Esophagus

Studies in NERD • Most community based patients have NERD • Very few progress to Erosive Esophagitis – 10-15% over 5-20 years – Only mild Erosive Esophagitis (Grade A) • No Barrett’s Esophagus or Esophageal Cancer • Lower symptom response to PPIs – Increased number of treatment failures – Relapse back to NERD after treatment

NERD Natural History

Changing Paradigm

Non-erosive Reflux Disease (NERD) is much more common in Asia. Hence, endoscopy is not useful for diagnosis.

Epidemiology: East vs West • GERD Incidence: – West: 10-20% – Asia: 5% – Singapore: 10% • NERD percentage – West: 50-70% – Asia: 60-90%

Diagnosing GERD • No gold standard!! • Presumptive diagnosis can be made with typical symptoms: – Heartburn, acid regurgitation – Frequency: at least weekly • If presumptive diagnosis made, can proceed to an empirical trial of PPI

Empirical PPI • Both a diagnostic and therapeutic test • Sensitivity: 70-80% • Poor specificity: 25-65% – May be positive in other acid disorders – Specificity with placebo 40% !! • 4-8 weeks of PPI will: – Heal erosive esophagitis in 85-95% – Control symptoms in 75-85%

How to do it? • • • • What drug? Any PPI What dose? Standard dose How long? Minimum 1 week What to look for? > 50% symptom improvement • When to review? 2-4 weeks – No improvement: increase dose, BD dosing – Improvement: complete 4-8 weeks

Role of Endoscopy • Evaluate alarm symptoms: – Dysphagia, weight loss, persistent vomiting, bleeding/ anemia • • • • Exclude other differentials Evaluate other symptoms, e.g. dyspepsia Evaluate treatment failures Screen for Barrett’s Esophagus if at risk: – Males > 50 yrs + chronic GERD + risk factors

Endoscopy in Uncomplicated GERD • • • • Problem with patients on treatment Good specificity 95% Poor sensitivity <30% In Asia: sensitivity 10%

Symptoms bother me! I’m worried and concerned Heartburn disturbs my sleep I cannot bend over or exercise My whole life is affected I cannot eat or drink what I like

‘Next Generation’ Endoscopy

Advanced Imaging Narrow band imaging 20

NBI in GERD Improves visualization of squamocolumnar junction

GERD patients have: • Increased number, dilatation, tortuosity of intrapapillary capillary loops (IPCLs) • Micro-erosions • Increased vascularity • Absence of round pit pattern

• Endoscopy normal • Advanced imaging shows tiny mucosal break and increased vascularity

How accurate is it? GERD Patients Endoscopy Finding Micro-erosions Increased vascularity at junction Conventional Endoscopy Advanced Imaging 0% 0% 52.8% 91.7%

Advanced Imaging: NERD vs Controls Advanced Imaging Micro erosions Increase vascularity Round pit pattern NERD 52.8% 91.7% 5.6% Controls 23.3% 36.7% 70% P < 0.001 < 0.001 < 0.001 Using a composite of: increased vascularity & absence of round pit pattern • Sensitivity 86.1% • Specificity 83.3%

In GERD, if PPIs don’t work, nothing more can be done except surgery

PPI Failures in GERD 27

PPI Therapy in GERD • NOT a definite solution – Symptoms will recur once PPI stop – Reduces acidity but not frequency or volume of reflux • Efficacy in Erosive Esophagitis – Mucosal healing: 85-95% – Symptomatic response: 75-85%

Reasons for Failing PPI • Compliance • Concomitant functional disorder, e.g. IBS, FD • Wrong diagnosis • NERD – Hypersensitive Esophagus (non-acid reflux) – Functional Heartburn

Proportion of patients who fail once daily PPI

Optimizing PPI Therapy Sub-optimal PPI therapy is the largest cause of ‘refractory’ GERD • < 80% of patients take PPI according to prescription • 25-50% of patients have moderate to poor compliance PPI instructions by primary care physicians Chey WD et al. Am J Gastroenterol 2005 31

Partial Responsers • What next? – Switch to BD dosing or different PPI – Provides symptom improvement in 20% • No clear advantage with either strategy • If still not responding, consider refer to gastroenterologist

What will the Gastroenterologist do?

Ambulatory pH Monitoring • Documents acid reflux: frequency + intensity • Correlates with symptoms

Bravo pH Capsule

Reflux Esophagitis Increased acid exposure. All acid regurgitation (29 episodes) occurred at times of acid reflux.

? GERD Significant acid exposure. Only 2 out of 4 episodes of mild acid regurgitation occurred at times of acid reflux.

pH Monitoring in NERD patients Proportion of abnormal pH monitoring

Combined pH-Impedance Testing • Documents ALL reflux; improves GERD diagnosis in up to 90% • Correlates symptoms with reflux event • Can differentiate NERD subtypes

What is Impedance? • Impedance is the electrical resistance measured with an alternating current • Catheter with metal rings: a small electrical current is used to measure the impedance between 2 rings Ring R1 R2 Patient safe low electrical current

Impedance Values Ohm*cm (at 1 kHz) Gastric contents 30-100 Bile 90 Saline solution 100 Saliva 110 Skeletal muscle Milk/ yoghurt 250-700 300 Drinking water/ cola 1,100 Esophageal wall 2,000 Epidermis Air 2,000 – 100,000 10,000,000



Conclusion • GERD is a disorder with different phenotypes • Diagnosis – PPI test is good – Gastroscopy for alarm symptoms, treatment failures – Consider advanced imaging for better yield: 10% vs 85% • Treatment failures – Optimize PPI therapy – Determine GERD or NERD phenotype 47

Thank You 48

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