Evaluating the GERD Patient – Minimum to Maximum

Blair A. Jobe, MD

Professor of Surgery

Department of Surgery

University of Pittsburgh

Pittsburgh, Pennsylvania

Failure of Antireflux Surgery

“It is well recognized that inadequate or inaccurate preoperative evaluation can be a major contributor to a poor outcome following antireflux surgery”

Gastrointest Endoscopy Clin N Am 2005;15:347

Symptoms are not a Reliable Indicator of Reflux Status Prior to ARS

DeMeester et al. J Thorac Cardiovasc Surg. 1980;79:656Patti MG et al. Dig Dis Sci. 2001;46:597

73%

27%

Typical GERD Symptoms (N=179)

Normal pHTest

Abnormal pHTest

Symptoms are not a Reliable Indicator of Reflux Status After Antireflux Surgery

Symptoms (N=58) Asymptomatic (N=151)

29.3%

70.6%

11.9%

88.1%

AbnormalDeMeester

NormalDeMeester

Khajanchee et al. Arch Surg. 2002;137:1008

PPV=29% NPV=88%

The majority of patients taking acid suppression medications after ARS do not have GERD

PPI (N=37)

Lord et al. J Gastrointest Surg. 2002;6:3

pH +

pH -

76%

24%

Antireflux Surgery Eliminates Symptoms of GERD

Author Resolution of Symptoms

Postoperative Complications of GERD

Follow-up period

Hinder (1994) 97% 2 strictures 12 mos

Hunter (1999) 94% None 2.5 years

Hunter (1996) 93% None 17 mos

Peters (1998) 96% no 20 mos

Cuschieri (1993)

95% None

Watson (1995) 98% no 10 Years

Campos (1999) 92% no 15 mos

Lundell

(2001)

95% Minimal esophagitis 5 Years

Antireflux Surgery is Effective and Durable

Surg Endosc 2006;20:159

Antireflux Surgery Improves Quality of Life

Author Year Tool Follow-up

Result

Trus 1999 SF-36 1 year Significant Improvement

Rattner 2000 PGWB,GSRS 1 year Normalized

Capelluto 2001 GIQLI 1 year Near Normal

Fernando 2002 SF-36 Significant Improvement

Blomqvist 1996 PGWB,GSRS,

RVAS

1 year Normalization

Granderath 2002 GIQLI 3-5 years Significant Improvement

Success in Antireflux Surgery:What is Essential?

1. Patient Selection

2. Patient Selection

3. Patient Selection

4. Surgeon Training

5. Procedure Tailoring– Wrap type, length, tightness

Technique for Nissen Fundoplication

• Hernia reduction• Esophageal mobilization• Hiatal Closure• Short gastric division• Short and Floppy

Fundoplication

Goals in Workup• Query GERD-related symptoms• Assess co-morbid conditions as they

relate to surgery• Objectify GERD• Identify anatomic abnormalities• Identify functional abnormalities• Set expectations with patient• Pick procedure (complete fundoplication)

Gastrointest Endoscopy Clin N Am 2005;15:347

The History and Expectation Setting

• Typical vs. atypical symptoms• R/O non-GERD causes of atypical symptoms• Primary and secondary symptoms• Response to medical therapy• Associated symptoms

– Bloating, emesis, nausea

• Eating disorder• Counsel patient as to the probability of success

The Quiver• Esophagram• Upper Endoscopy• Manometry

– High resolution

• pH testing– Catheter-based– “Wireless”

• Impedance– pH or Manometry

• Gastric Emptying• Esophageal Emptying

Video Esophagram (Required)

• Dynamic imaging of entire organ– Contour– Obstructive lesions– Some functional

information

Upper Endoscopy (Required)

• Mucosal Inspection– Complications of reflux– Barrett’s esophagus

and cancer

• Structural Inspection

• Therapy prior to surgery

Native Flap-Valve AnatomyNative Flap-Valve Anatomy

Lesser curvature

Anterior Valve

Body

Lip

Posterior Valve

Tightness around scope Tightness around scope

Relationship to diaphragmRelationship to diaphragm FundusFundus

Fundoplication as an Anatomic Fundoplication as an Anatomic Remedy Remedy

Pre-fundoplicationPre-fundoplication Post-fundoplicationPost-fundoplication

EUS: Normal NissenEUS: Normal Nissen

Gopal et al. J Gastrointest Endosc 2005Gopal et al. J Gastrointest Endosc 2005

Manometry (Required)

• Identify etiology and severity of GERD (LES)• Assess ability to tolerate fundoplication• Exclude primary motility disorder (Body)• Guide pH probe placement

24-Hour pH Testing (Required)

• Detects esophageal acid exposure

• Correlate symptoms with reflux episodes

• ? Tailor fundoplication

• Considered the “gold standard” for making diagnosis

Potential Pitfalls with pH Testing

• Wrong position

• “Good day”

• Acidic foods

• Atrophic gastritis

• Sensitive esophagus

• Achalasia

• Poor sensitivity in LPR

Refluxate pH Changes During Migration

Weusten, Bas L. et al, American. Journal GI. 266:G357-G362, 1994

How Do You Select the Correct Patient with GERD?

The Three Most Important Factors which Predict the Likelihood of Success

• Abnormal 24-hour pH score

• Typical primary symptom

• Clinical response to PPI

J Gastrointest Surg 1999;3:292

Situations in which ARS may be Applied

• Typical GERD

• NERD

• PEH

• Achalasia

• Primary, Secondary, Tertiary Failure

• Asthma and other Extraesophageal Sxs

• Atypical

Pitfall #1Missed Achalasia

•Perform manometry on everyone

•Think of this with re-dos

•Read your own tracings

•Be suspicious–Positive pH–Esophagitis

Pitfall #2Eating Disorder

•History

•Physical–Finger nails–Dentition–Body habitus may be normal

•Esophagitis with normal manometry or pH

•Index of suspicion

Pitfall #3Functional Dyspepsia

•History and physical

•Don’t mistake for GERD

•Listen to your objective evidence

•Order more tests

•If uncertain, refer for second opinion

Pitfall #4Structural Gastric Outlet

Obstruction

•Be suspicious with normal LES physiology and abnormal pH

•Bloating, nausea

•NSAID use or prior treatment for H. pylori

•EGD

Pitfall #5: Occult GERD-Pitfall #5: Occult GERD-Proving Association with Proving Association with

Extraesophageal SymptomsExtraesophageal Symptoms

1) Gastric juice, of either acid or alkaline pH, can cause damage to the 1) Gastric juice, of either acid or alkaline pH, can cause damage to the laryngeal or airway mucosalaryngeal or airway mucosa

2) Airway desquamation is followed by mucosal regeneration over 3-7 2) Airway desquamation is followed by mucosal regeneration over 3-7 daysdays

3) Microaspiration can be asymptomatic and occur with a normal 24 3) Microaspiration can be asymptomatic and occur with a normal 24 hour pH scorehour pH score

4) Symptoms can occur with only distal esophageal acid exposure4) Symptoms can occur with only distal esophageal acid exposure

Gastroesophageal Reflux of Fluid Gastroesophageal Reflux of Fluid Over an Impedance Electrode PairOver an Impedance Electrode Pair

No bolusNo bolus=few ions==few ions=

high impedancehigh impedance

Bolus presentBolus present=many ions==many ions=

low impedancelow impedance

Air

liquid

Refluxate

ProximalProximal

pHpH

ProximalProximal

DistalDistal

Hypopharyngeal Sensor Positions

0.25 cm

1.75 cm

3.25 cm

1.0 cm

UES

2.5 cm

Mr. EMr. E

•75 year old male 75 year old male •non-smoker non-smoker •17 months of non-productive cough and dysphonia17 months of non-productive cough and dysphonia

–Worse when supine and after mealsWorse when supine and after meals–Mild HB symptoms and no regurgitationMild HB symptoms and no regurgitation

•History of post-nasal dripHistory of post-nasal drip•Two episodes of pneumonia in last yearTwo episodes of pneumonia in last year•No history of AsthmaNo history of Asthma•Does not take ACE inhibitorsDoes not take ACE inhibitors

Mr. EMr. E

•Physical ExamPhysical Exam–Fit appearingFit appearing–VSSVSS–normalnormal

CXRCXR

“PPI Test”

Omeprazole 40mg bid for 4mosOmeprazole 40mg bid for 4mos– Mild subjective improvement in Mild subjective improvement in

hoarseness but cough is samehoarseness but cough is same

– Chronic throat clearingChronic throat clearing

– GERD symptoms resolvedGERD symptoms resolved

ENT: Granulation tissue on vocal cords with gastric matter in pyriform recess; ENT: Granulation tissue on vocal cords with gastric matter in pyriform recess; no other identifiable ENT-related etiology for symptomsno other identifiable ENT-related etiology for symptoms

Esophagram NLEsophagram NL

ManometryManometry

-Esophageal Body-NL

-LES-NL

DeMeester Score=22DeMeester Score=22

-off meds

-all upright reflux

-no symptom correlation with cough

-some symptom correlation with GERD

-cough more pronounced off meds

-3 proximal reflux events

Upper EndoscopyUpper Endoscopy

No esophagitis

No hiatal hernia

Slightly varigated squamocolumnar junction

-less than 2 cm

Biopsy obtainedBarrett’s esophagus without dysplasia

LPR ImpedanceLPR Impedance

“Wisdom and understanding can only become the possession of individual men (and women) by traveling the old road of observation, attention, perseverance, and industry”

-Samuel Smiles

LETS VOTELETS VOTE

• Nissen Fundoplication after lengthy Nissen Fundoplication after lengthy informed consent?informed consent?

• Increase PPI therapy?Increase PPI therapy?

• Promotility Agent?Promotility Agent?

• Antihistamines, beta-2 agonists, Antihistamines, beta-2 agonists, corticosteroidscorticosteroids

• Other TestsOther Tests

SE sxsSE sxs GERD sxsGERD sxs

Very PrevalentVery Prevalent

(PND, Asthma, Allergies, (PND, Asthma, Allergies, TOB)TOB)

Very PrevalentVery Prevalent

Why is Making the Diagnosis so Difficult?