During this 20-25 minute pre-recorded lecture, Dr. Michael S. Smith discusses the topic of GERD. This in-depth review will provide an update on this topic for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards. CME pre-requiste of live Q & A webinar, 8th Annual Mount Sinai Intensive Board Review in Gastroenterology & Hepatology on Sept 22.
Hello and welcome to the GERD. Talk for the eighth annual Mount Sinai intensive review in G. I. In Hepatology for september 2020. My name is Mike smith and I'm the chief of Gi in Hepatology and director of the esophageal program at Mount Sinai West and Mount Sinai Morningside hospitals here in Manhattan. Let's jump right into our topic because we've got a lot to cover before we can talk about diagnosing or treating GERD, we need to be able to define it. A recent consensus conference came up with the definition you see on your screen symptoms and or tissue damage secondary to the reflux of normal gastric contents. There are few pieces here. I want to get into a little bit more detail on the first of which is that you don't need to have a roast of esophagitis, Barrett's esophagus or a peptic stricture in order to qualify for having GERD. If the symptoms are there that are linked associated with reflux of gastric contents back into the esophagus, even in the absence of tissue damage. That is sufficient to make the diagnosis. And the second piece is important as well. Normal gastric contents are sufficient to generate GERD, you don't need to have a hyper acidic state like Zollinger Ellison syndrome. As long as those normal contents are re flexing back and causing symptoms tissue damage or both. That's sufficient to make the diagnosis. So let's start with our first question from the board review. A 55 year old male presents to your office with longstanding postprandial heartburn and regurgitation, you believe he has good, what is the most common ideology for this condition, esophageal display utility? Hypertensive resting el es transient el es relaxations. The presence of a hiatus hernia or delayed gastric emptying? The answer is C transient, lower esophageal sphincter relaxations or T. L. E. S. R. S. What are TLS ours? Well, they're the major mechanism underlying gastroesophageal reflux in both normal individuals and in patients with GERD it's normal for us to have up to a 12th duration relaxation of the L. E. S. Following swallow induced peristalsis. However, TLS ours are not preceded by a swallow And they can last up to 45 seconds in duration. Meg Hillary neurons with gabby receptors inhibit the TLS ours. Which is why the gabby agonist back life in has been used to treat regurgitation. In patients with GERD, here's what A. T. L. E. S. R. Looks like an esophageal manama tree. You can see that there's relaxation of the lower esophageal sphincter without a preceding swallow. There's just resting tone and then the absence of that tone and then resumption of that tone and that is what defines a TLS are mana metric lee. Let's talk a little bit about how the normal anatomy prevents good. As you can see in this diagram the alignment of the lower esophageal sphincter with the curragh of the diaphragm creates a single eg junction. High pressure zone. That alignment, combined with the entrance of the G junction into the stomach at an angle called the angle of his creates a one way gastroesophageal flat valve that should stop reflux in the majority of cases when you have a hiatus hernia present. However, the lower esophageal sphincter and the curl diaphragm are no longer an alignment. The two muscles are separated from each other and in between you have the high it'll hernia sac containing the reflux eight reservoir for that reflux eight to get into the esophagus. Now all it has to do is overcome the lower esophageal sphincter as it's already gone past the diaphragm. So that means you have a much lower pressure barrier to reflux, a lot less effective, a barrier to reflux. And that's why patients with high it'll hernias are more likely to present with gastroesophageal reflux disease. There are multiple factors that can lead to the pathogenesis of GERD residing in all of the organs of the upper gi tract. In the esophagus conditions which decrease the production of protective factors such as saliva or esophageal sub mucosal gland secretions or those that take away the normal clearance mechanism which generally removes the reflux eight. After a gastroesophageal reflux event such as peristalsis or gravity can all contribute to good, lower esophageal sphincter dysfunction whether that's inappropriate or prolonged ls relaxations like we discussed earlier. The presence of a hiatus hernia as was seen in the last few slides or a week. Elia's that's either congenitally weak or I apologetically week such as due to old age scleroderma pregnancy or the use of certain medications can all contribute to gird as well. Gastric causes are important to not forget because a backup in stomach emptying will lead to an increased chance that there is sufficient potential reflux in the stomach that can be passed retrograde into the esophagus to cause the symptoms or tissue damage. For example, delayed gastric emptying or a condition that makes the reflux. Eight more caustic such as excess acid production. In addition, it's important to note that duodenal gastric or bile reflux is another potentially contributing factor to the pathogenesis of GERD and in fact there's increasing data that it may contribute to the pathogenesis of barrett's esophagus as well. So let's go to question # two. You recently diagnosed a 47 year old obese patient with GERD. He wants to try dietary and lifestyle modification before starting any medication which of the following changes is most likely to improve his symptoms. Weight loss, smoking cessation, stopping alcohol, stopping carbonated beverages or removal of spicy foods from his diet. The answer is a weight loss. We know that losing weight particularly wait that's stored around the abdomen and not in the hips can be very helpful for decreasing intra abdominal pressure and decreasing the likelihood that someone develops a reflux event as a result of the increased intra abdominal pressure. However, a systematic review demonstrated that while there were a few studies that showed consumption of chocolate and carbonated beverages could lower the pressure of the L. E. S. Others showed absolutely no effect associated with the intake of coffee, caffeine, spicy foods, citrus or fatty foods. And another systematic review concluded that there was a lack of evidence that consumption of carbonated beverages causes or provokes good. And as much as we love to be able to tell our patients to stop smoking and stop drinking tobacco and alcohol cessation has not been shown to raise L. E. S pressures, improve esophageal ph numbers or improve GERD symptoms. Now avoidance of late night meals 2-3 hours before bedtime may be an effective treatment for GERD, but the benefit is largely due to avoidance of fatty foods prior to bedtime And weight loss has been associated with reduction and GERD symptoms and 40-80% of subjects in clinical trials. So as I said at the beginning of the last slide, this is your best option from a dietary and lifestyle modification perspective for improving someone's GERD. So question three A 35 year old woman with established GERD is seen for routine care. She is concerned that her medications and lifestyle worsen her reflux related symptoms ingestion of all the following substances could decrease her resting L. E. S pressure except for a calcium channel blockers. B beta blockers. C progesterone, D the offline or E. Chocolate covered mints and the right answer is beta blockers. We know that many substances are known to decrease Ls tone. Dietary triggers include both caffeine such as coffee or chocolate and karma, natives or mince pharmacologic agents that lower L. E. S. Tone include calcium channel blockers, the offline and progesterone. Which is what happens in pregnancy and why we see more patients who are pregnant, developing GERD. The pathogenic factors that affect the likelihood of developing reflux esophagitis include the volume of reflux fluid, the duration of the reflux events, the type of reflux fluid, how caustic it is whether or not you have intact or impaired clearance mechanisms for the esophagus when a reflux event occurs. And if you have an an atomic setup such as a high it'll hernia. That makes you more likely to have reflux. Now there's quite a spectrum of GERD patients. We know that the majority of patients have symptoms, but a good number, almost half in some studies don't have any symptoms at all. Only about 20-30% of patients have endoscopic Lee visible sequel of reflux such as rows of esophagitis or Barrett's esophagus Los Angeles classification of arose of esophagitis is important to remember because it's a way that we can standardize how we describe endoscopic findings. And you can see as we go from grade eight and grade D. That the size a number of the mucosal breaks and the Bridging of the mucosal breaks from Fold two fold are what determined the classification. This is an important classification system for all of us to use not only in terms of looking at the boards but also in our day to day practices when we think about symptoms of GERD heartburn and regurgitation are classic symptoms and it's important that we define heartburn for each other because our patients all come in with different meanings for it. We as gastroenterologists to find this as sub sternal or retro sternal burning or regurgitation that is postprandial aggravated by a change in position and promptly relieved by antacid therapy. And regurgitation is the sense that there is food or fluid that is reflux ng moving, retrograde from the stomach back up behind the breastbone as part of a reflux event. But there are lots of atypical GERD symptoms that we have to think about as well. And they include hoarseness, chronic cough, global sensation, um loss of dental enamel or dental carries particularly on the backside of the teeth. We have pulmonary folks who will send evaluations for GERD because of asthma that isn't really asthma, chronic bronchitis concern for recurrent aspiration leading to pneumonia and even patients with pulmonary fibrosis that are being worked up for lung transplants because of years of undiagnosed reflux that actually has been causing scarring of the lung tissue from the inside out. And of course all of us have seen a non cardiac chest pain patient who gets worked up with an E. K. G. And a cath and they don't see anything and so we get the referral and we figure out that this is actually a reflux patient. It's important to note that the many diagnostic tests that we have to evaluate for GERD all really serve different purposes. A barium Asafa graham works best in the setting of dysplasia. But whether or not you see reflux when someone happens to be swallowing the barium doesn't necessarily tell you if someone has good endoscopy is great for looking for mucosal injury. But as we showed earlier, the majority of patients with clinically significant reflux disease do not have evidence on endoscopy of damage to the esophagus resulting from reflux ambulatory ph monitoring which will speak about a little bit more can be very helpful to quantitative reflux and evaluating typical symptoms and manama tree really doesn't help in patients perhaps those with dysplasia where you think it might be reflux. But in this particular case the utility is significantly lower than some of the other tests that we have. So what does the ph testing, the quantitative reflux testing that we have available to us provide? Well we have two different options. We have our 48 hour Wireless ph Metro, that's the bravo system or 24 hour ph impedance testing. And you can see that both of them do a good job of looking at the number of reflux events that are acidic the percent time the patient has a ph less than four called the acid exposure time. There's a predictive score called the day. Mr scored a mr johnson score that predicts the response to anti reflux surgery if performed? And there is correlation between the symptoms reported by the patient and acid reflux events. What a 24-hour ph impedance test gives you that the wireless testing does not. Is it allows you to look at weakly acidic a non acidic events as well and you're able to take measurements at multiple points in the esophagus so you can determine whether or not there is proximal reflux. In addition, because of the impedance component of the testing, you're able to determine if there's any esophageal stasis that's present. It is important to note that the extension of the software and improvements with the wireless ph Metro device now allow it to obtain up to 96 hours of data, whereas the 24 hour testing really is limited to one day. So the way we use quantitative reflux testing right now is based off an algorithm that was put out in the guidelines from the American College of Gastroenterology where if you have a low likelihood of GERD, it's best to do quantitative reflux testing off of PPS H two blockers acid producers in general for at least a week to answer the key question, which is does the patient even have reflux disease in the first place? Or are we barking up the wrong tree. Is there another diagnosis that's contributing to the patient's symptoms, it's very unlikely that the patient has excess non acid reflux. If there is no excess acid reflux which is why we can use the wireless ph met Tree to evaluate for all good. However, if there's a higher likelihood of GERD on your pre test probability than the 24 hour ph impedance testing on PP. Particularly by DPP. If there are atypical symptoms or refractory symptoms will be very important in this quantifies the reflux but answers a different question which is can reflux be controlled with medication. Let's go to question for a 44 year old woman was seen by a pulmonologist and then an E. N. T. For evaluation of a chronic cough and NPL examination a month before the visit showed redness of the vocal cords. Which led to a diagnosis of LPR Lauren go for angel reflux. She was started on a standard dose daily P. P. I. And referred to you her cough persists. What is the next best step in her management, continue the PP at standard dozing, add grenadine or promoted in at bedtime to the daily PP. Increase the PP. To be dozing, Discontinue the PP. And perform ph metric testing or perform an upper endoscopy. The right answer here is see increased PP. To be I. D. Dozing and why is that? Well in treating GERD with atypical symptoms? Think about the following the patient's PP. I dosage is probably too low and the treatment duration is too short. Only one month to make a meaningful conclusion regarding the efficacy of PPE therapy in her case, suspected LPR or a typical Presentations of GERD should be treated with twice daily pp for at least 2-3 months to assess for the therapeutic response, deferring more invasive testing such as ph metreon. Upper endoscopy is reasonable until the correct PP. I. Trial has been completed. You can see here in these guidelines from the A. C. C. P. And from R. E. N. T. Colleagues that it is perfectly appropriate to treat with a high dose P. P. I. For a couple of months before moving down the algorithm any further. And so in this particular case, given the atypical symptoms of chronic cough, this would be reasonable for a patient who's only been on one's daily PPS to date. Question five which of the following statements is most accurate regarding LPR chronic cough and GERD. God is the most common cause of chronic cough and 40 to 55 year olds. A positive ph metric test off PP. I highly predicts response to anti reflux therapy. Most of these patients have a rose of esophagitis on upper endoscopy. Most high quality clinical trials showed no advantage to PPS over placebo for these patients or the presence of heartburn does not predict better response to anti reflex therapy. The answer is d most high quality clinical trials showed no advantage to PPS over placebo for these patients. We know that GERD is considered the second most common cause of chronic cough. It's not the most common. And even in the setting of a positive ph metric test, the likelihood of a typical symptom resolution with PP therapy remains lower than what you get with heartburn or regurgitation. The typical symptoms of GERD heroes of esophagitis is an uncommon finding. As we discussed before. Even when typical symptoms of GERD are present. Question six, the patient completes a three month trial of DE I DE PP. I use and returns to your office. Her cough is somewhat better but has not resolved completely. What intervention would you perform next? Asafa Jill manama tree. An egg with wireless ph metric on PP. E. G. With wireless ph metro off pp 24 hour ph impedance testing on PP. Or 24 hour ph impedance testing off PPE. The answer is d 24 hour ph impedance testing on PP. Why is that this patient had a partial response to PP. There was some symptomatic improvement, suggesting that acid reflux is at least playing some role in her cough. It may not be the only contributing factor but it's probably at least a factor. The persistent cough suggests that either her acid reflux persist or that weekly aesthetic or non aesthetic reflux could be responsible for the cough. Manama tree alone will not give you any quantitative data regarding reflux and wireless ph gentry only measures acid reflux. Therefore when you suspect weekly or non aesthetic reflux, you wouldn't want to use that technique. Ph impedance testing off PHP in this case would be less helpful as it does not guide present management. It only reconfirms that acid reflux is present, which you suspect based on the symptomatic response to date. So therefore we want to see whether or not medication can control reflux in this patient with a partial response to PP before thinking about other interventions such as anti reflux surgery. Question seven. A 37 year old male is seen for burning discomfort in the chest of six months duration. There's no dysplasia, regurgitation or weight loss with a bland diet. He has a stressful job but he's convinced that his symptoms are due to reflux disease. Prior trials of daily envied P each for several months produced absolutely no improvement. What tests should be performed again, manama tree E. G. With Wireless ph metric on PP or off pp 24 hour ph impedance testing on PPE or a barium Asafa graham with provocative manoeuvres. The answer is C. E. G. D. With Wireless ph metric OFF PPE. This patient has a low suspicion of GERD their history, particularly the symptoms and the lack of response to a long duration PP. Trial at B. I. D. Dozing give you a low pretest probability that he has reflux disease. So the optimal approach here, as we discussed in the algorithm before is to exclude reflux by doing quantitative testing off medication. Manama tree is of limited value without any dysplasia or other symptoms raising concern for Asafa Jill dis motility and wireless pH men trees should not be used regularly to assess patients while on PPE therapy. PH impedance testing on therapy is most helpful when there has been some kind of symptomatic improvement on medication in this case there was none. So that's not an option for us questioning. This patient has 48 hour wireless ph metric performed and there is no evidence of increased acid exposure to the distal esophagus off medication. You explain to the patient that he doesn't have. GERD what medications should you prescribe next ISIS or by monetary occultism and a trip to lean alprazolam or hyo SIA. Me. The answer is um a trip to line why this patient has visceral hypersensitivity. When quantitative reflux testing is normal. Consider a diagnosis within the family of functional gi disorders, at least partially resulting from visceral hypersensitivity. They include burning mouth syndrome, the esophageal visceral hypersensitivity, functional heartburn and irritable bowel syndrome. Treatment with the neuro modulating agents such as a tricyclic or gabapentin or an SnR I has been shown to be most successful in these patients nitrates, calcium channel blockers. Benzos and anti spasmodic are less likely to help in this particular case And here you can see from the G 2013 Guard guidelines. A nice summary of all of the different things that we've talked about so far today. What are the indications for anti reflux procedures. In 2020. Our best candidates remain healthy patients with GERD confirmed on quantitative testing. Typical symptoms of heartburn and regurgitation and control of those symptoms on PPS. They're doing well on a medication. Why would we want them to switch to a surgical or an atomic intervention? Well, a couple of different reasons. There's a cost of continuing lifelong PP treatment compliance can be an issue in some patients. Some patients have ongoing side effects with current use of acid reducing agents and others have a fear of side effects that could develop with long term use. Now, patients who have a typical GERD symptoms but also have quantitative testing that's proven that they have an abnormal amount of reflux and those that have good symptom relief of those atypical symptoms on PPS are also quite good candidates for this. Patients who have a savage itis that's refractory to medical therapy, volume, regurgitate ear's. Those who have aspiration or concern for aspiration where the amount of reflux eight and not it's acidic component is what's driving the symptoms or the damage such as those with a large Heidel Hernia are often very good candidates for anti reflux surgeries and those who have persistent symptoms documented to be caused by refractory guard on ph impedance testing are all patients to consider. So, as you think about your own practice. Don't forget that we have very good data showing that uh an atomic interventions for reflux can also work quite well in patients, even when they have responded well, two P. P. I. Or other acid reduction therapy. And we should be considering that. So that's it for my lecture. Thanks so much for listening, and I look forward to seeing you in the live session. Take care.