Published on February 23, 2014
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
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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