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INTRODUCTION
The reported incidence of GERD in Singapore was estimated at 1.5% in 1994. It was reported to be 10% in 2005 Ho KY et al. This compares to about 40% for Western countries. Though the incidence is low, the full spectrum of disease from non-erosive to Barrett’s is seen. GERD is often under diagnosed, under-evaluated and inadequately treated.
DEFINITION
GERD is defined as reflux of gastric acid and pepsin into the oesophagus resulting in either pathological changes (oesophagitis, stricture, Barrett’s, etc.) or changes in quality of life (heartburn, food limitations, inability to perform certain activities etc.) Genvaal Consensus. Where symptoms are present but endoscopy is normal, the term NERD or Non Erosive Reflux Disease is used.
SYMPTOMS
Typical
- Heartburn
- Acid regurgitation
Atypical
- Atypical chest pain
- Sore throat
- Ear infections
- Voice changes
- Chronic cough
- Asthma
- Dyspepsia (indigestion, bloatedness)
- Vomiting
- Dysphagia (difficulty in swallowing)
- Epigastric pains (abdominal pain)
- Haematemasis (blood in vomit)
EVALUATION
The most important step is a careful history. Heartburn is a burning retrosternal pain that occurs after meals, varies with body position and is relieved with antacids. Patients with acid regurgitation experience coughing or choking at night, acid brash and being able to taste the flavor of their dinner. Chest pain not brought about by exertion is called atypical chest.
Endoscopy
To confirm diagnosis, evaluate grade, screen for Barrett’s and exclude other upper GI pathology (cancer, acid related disorders). Endoscopy is not very sensitive but very specific. Patients with non-erosive disease may have severe symptoms while those with grade-3 disease may only have mild symptoms.
It is permissible in a PRIMARY CARE setting to start patients on a maximum of 2-plus-4 wk. period of proton pump inhibitors without endoscopy Asian consensus on GERD in the following instances: age below 40 yr. old, first presentation and absence of alarm symptoms*.
* Upper GI alarm symptoms: (1) loss of weight or appetite (2) dysphagia (3) vomiting (4) evidence of frank or occult bleeding e.g. Haematemesis, malaena, occult blood and anaemia.
Abnormal areas should be biopsied. In Barrett’s, intestinal metaplasia with varying degrees of dysplasia is found. Only Oesophagitis and Barrett’s are recognized gross and histological features of GERD Genvaal.
Contrast swallow
Demonstration of reflux of contrast during a barium study is NOT diagnostic of GERD Genvaal. A contrast study is performed in GERD to look for hiatus hernias, strictures and certain motility disorders. It is not part of the routine workup for GERD.
24 Hr. pH monitoring
The pH of the lower oesophagus is measured over a 24 hour period and recorded by a Holter type device. It is indicated to confirm GERD (if endoscopy was negative) and evaluate severity. A 24 hr. transnasal catheter is usually employed but the same data can now be achieved with a radio-transmitting capsule.
The 24 hr. pH Study is positive if the pH is positive for longer than 6% of the recording. In this case, it is below a pH of 4 for over 20% of the time. Most of the reflux is seen after dinner and when asleep. This patient also had SM Grade-3 oesophagitis (see above)
Manometry
Strength of oesophageal contractility and lower oesophageal sphincter are measured. It is indicated in motility disorders, prognosticating need for lifelong PPI therapy and before surgery.
Therapeutic trial of PPI therapy
This is perhaps the most important diagnostic test. Patients are started on full dose PPI therapy for a 2-plus-4 week period (Omeprazole 40 mg daily or its equivalent).
Patients who do not respond are not suffering from GERD.
MANAGEMENT
Subsequent therapy
In patients with NERD and mild oesophagitis, PPI is stopped after initial therapy. In about 60% of these patients, symptoms will recur and they will go on to require maintenance therapy. The remaining 40% will be cured. Maintenance is started with full dose PPI, tailed down to half dose PPI and then H2RA (cimetidine, famotidine, ranitidine).
In severe oesophagitis, maintenance therapy should follow initial therapy Genvaal. It is however difficult to convince patients that they need life-long therapy and I often stop initial therapy. Ninety four percent of patients with severe GERD will however have early recurrence of symptoms and go on to require long-term maintenance therapy.
Patients with SEVERE oesophagitis require a repeat endoscopy after initial therapy as some patients may not show healing on standard doses.
A small number of patients with NERD and mild GERD may respond to ‘demand’ therapy. On-demand therapy with 20 mg slow release omeprazole (Prilosec OTC) daily x 14 days was FDA approved in 2003.
Lifestyle changes
The Genvaal consensus stated that lifestyle modification was over-rated for the majority of patients with GERD. This included weight loss, cessation of smoking, meal modification and bed-head elevation. The only useful exception was bed-head elevation in patients with nocturnal acid regurgitation which actually constitutes only 5% of GERD patients.
Locally, spicy food makes GERD symptoms worse and avoidance provides relief. Avoidance however will not result in healing of oesophagitis. Alcohol ingestion relaxes the LOS and makes symptoms, especially nocturnal, worse.
HIATUS HERNIA
Four types of hiatal hernia are described. The commonest is the sliding hiatus hernia. Presence of a small hiatus hernia is not diagnostic of reflux disease. Many patients with hiatus hernias are completely normal. Absence of a hiatal hernia does not exclude reflux. The other types of hiatal hernia are the rolling, massive or combined and para-hiatal hernias. Sliding hiatus hernias do not need surgery unless indicated for reflux. All the other types require surgical reduction and closure of the defect.
BARRETT’S OESOPHAGUS
The management of Barrett’s oesophagus is still highly controversial. It is believed that while oesophagitis is due to acid reflux, Barrett’s is due to alkaline duodeno-gastro-oesophageal reflux. Barrett’s consists of tongues of gastric mucosa with intestinal metaplasia replacing oesophageal mucosa. It may be associated with varying degrees of dysplasia, carcinoma in-situ and then Barrett’s cancer.
The role of PPI in stopping progression of Barrett’s to dysplasia and cancer is controversial. PPI are however clearly indicated in treating reflux symptoms in Barrett’s patients.
Laparoscopic fundoplication is effective for symptomatic Barrett’s patients. The role of laparoscopic fundoplication for asymptomatic Barrett’s is again controversial. Proponents Demeeter TR, J Am Coll Sur, May 2003 recommend fundoplication for asymptomatic Barrett’s to prevent progression to cancer.
Barrett’s with severe dysplasia should, like carcinoma-in-situ and invasive cancer, be treated with an oesophagectomy if the patient is fit. The reason is that 7% of patients with severe dysplasia are eventually found to have foci of invasive cancer in their resected specimens.
The role of yearly endoscopic follow-up is accepted. Patients with a fundoplication should also be screened annually.
LAPAROSCOPIC FUNDOPLICATION
Indications
1. Absolute
GERD with complications (bleeding, peptic stricture, aspiration, acid regurgitation)
Types II, III and IV hiatus hernias
Escalation of PPI dosages in patients on maintenance therapy (when dosages reach 60mg daily)
2. Relative
Any patient who requires life-long therapy with PPI
Barrett’s with mild or moderate dysplasia
Types of surgery
Laparoscopic fundoplication is recognized as the state of surgery, open and thoracosopic approaches are suboptimal. The most commonly performed operations are the modified Nissen (complete) and the Dor and Toupet (partial) fundoplications.
Post-operative expectations
Patients may experience:
1. Transient dysphagia- 15% (in patients with non-specific oesophageal dysmotility)
2. Transient gas bloating- 25% (as patients are no longer able to burp)
Patients will be allowed only soft foods for 2 weeks to allow for healing of the sutures
Results
Laparoscopic fundoplication provides effective and durable relief with high satisfaction scores and dramatic improvement in quality of life. Ninety five percent of patients can expect to be satisfied or very satisfied with the results of their surgery, with appropriate patient selection and good surgical technique.
CONCLUSION
Many aspects of the management of GERD are controversial. There are many different regimens. This is how I manage GERD patients based on my understanding of current literature.
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