1 1

Update of GERD

Diagnosis

Taichung Veterans General Hospital

臺中榮總胃腸肝膽科

Han-Chung Lien

連漢仲 醫師

2 2

Outline

• Diagnostic challenges of GERD

• 2017 Porto consensus on reflux

monitoring

• Diagnostic challenges of

laryngopharyngeal reflux

2

3 Vakil 2006 Am J Gastroenterol

The goal of antireflux treatments

1. To relieve GERD-related symptoms,

2. To heal and maintain remission of EE,

3. To prevent complications of GERD,

4. To improve health-related quality of life.

4

5 5

Nearly 40% of Patients on PPI Therapy

have Breakthrough Symptoms (Harris study)

Only 23% of patients on a PPI reported that they were completely

satisfied with their current therapy

Those with breakthrough symptoms

most often have symptoms at night

At night

During sleep

In the middle of

the day

In the morning 16%

45%

65%

28%

Breakthrough

Symptoms

38%

No Breakthrough

Symptoms

62%

N=1,064

5 American Gastroenterological Association. GERD Patient Study: Patients and Their Medications. Harris Interactive Inc; 2008.

6 6

About 50% of NERD group demonstrates poor

response to qd PPI, is the main contributor for PPI

failure.

6 Fass R, 2005 Aliment Pharmacol Ther

Endoscopic and impedance-pH test to

categorize phenotypes of GERD

7 Savarino E, 2013 Nature Rev Gastroenterol & Hepatol

Symptom response rates of PPI therapy

– A Meta-analysis

8 Weijenborg, 2012 Neurogastroenterol Motil

EE

0.72

NERD

0.5

NERD, pH (+)

0.74

More acid exposure in NERD, while

more hypersensitivity in reflux

hypersensitivity

9 Aziz Q, 2016 Gastroenterology

Rome IV adopts reflux hypersensitivity

(triggering of symptoms by physiological reflux) as a functional esophageal disorder

10 Aziz Q, 2016 Gastroenterology

11 11

The rate of abnormal pH monitoring

in a patient on twice daily PPI is Low.

11 Charbel, 2005 Am J Gastroenterol

Limited ability of 2w esomeprazole 40 mg to

identify GERD patients among primary care

patients with dyspepsia. (Diamond study)

12 Bytzer, 2012 Clin Gastroenterol Hepatol

GERD was

proved by EE,

pH+, or Reflux

hypersensitivity.

N= 308

Bottom Line

• NERD constitutes the majority of the

diagnostic challenges of GERD.

• Although poor response to high dose PPI

treatment is likely to exclude GERD as the

cause of refractory symptom, short-term

PPI is of limited value to diagnose GERD.

• Reflux monitoring may play a role in

patients with poor or partial response to

PPI therapy.

13

14 14

2017 Porto consensus

on reflux monitoring

14

15

pH monitoring

pH-impedance

monitoring Wireless pH monitoring

16 16

On PPI ? or off PPI ?

What Technique to Use?

• Off PPI

• when a need for a definite diagnosis of

GERD.

• pH catheter, wireless pH, or pH-impedance

• On PPI

• when GERD is proven, but partial or no

response to PPI

• pH-impedance only

16

Indications for GERD testing

17

Other considerations of choosing

reflux monitoring tests pH-impedance

• Gold standard for the detection of reflux episodes.

• Detect weakly acidic or non-acidic reflux

• Differentiate reflux from swallow events

• Provide mean nocturnal basal impedance (MNBI)

Wireless pH

• intolerance of the catheter.

• negative catheter-based pH study with high suspicion of

GERD to elicit day to day variation.

• increases sensitivity of reflux

However availability, cost and patient preference may drive

the choice

18

Do impedance parameters predict

medical or surgical outcome?

19

Interpreting reflux monitoring

• The total acid exposure time (AET)

o The most reproducible

o more specific than the DeMeester score

o predict a positive response to PPI trial and

antireflux therapy.

• Off PPI therapy, normal total AET

o from 3.9% to 7.2%

o sensitivity of 77%-100%

o specificity of 85%-100% in discrimination of

esophagitis from normals.

• Total AET value of <4% is consistently normal

20

Interpreting reflux monitoring

• AET >6% was considered abnormal

o total AET of 9.6%-27.6% in esophagitis

• Within a gray area AET values of 4%-6%,

oOverlap between normal controls and

symptomatic GERD without esophagitis,

o additional evidence from alternate testing

• Similar AET thresholds can also be applied to

wireless pH monitoring, and pH-impedance on

or off PPI. 21

Definition of pathological GERD based on the

findings on endoscopy and reflux monitoring

22

Baseline impedance

23 Ates F, Gastroenterology. 2015

24 24

Ambulatory Reflux Monitoring

• Catheter-based pH, Wireless pH,

Impedance-pH

• Three Possible Results:

1. Ongoing Acid Reflux

2. Ongoing Symptomatic Non-acid Reflux

3. No Reflux (Functional Heartburn or

Non-GERD causes)

24

GERD phenotypes off and on medication

25

Symptom Reflux Association–

Reflux hypersensitivity • Symptom index (SI)

o the number of reflux related symptom events divided by

total number of symptom events.

o Above 50% of SI is considered positive.

• Symptom association probability (SAP)

o the strength of relationship between symptom and reflux.

o A SAP above 95% (P<.05, Fisher’s exact test 2×2 table)

is considered positive.

• A positive SI and/or SAP

o support an association between reflux and symptom,

o predicts response to treatment in retrospective,

uncontrolled, studies.

26

Bottom Line

• Pathological GERD is defined by at least one of

the following criteria:

oGrade C or D esophagitis,

o peptic stricture,

o Barrett’s mucosa >1 cm and

o esophageal acid exposure >6%.

• Baseline impedance should be considered as

exploratory tools for further research.

27

28 28

Diagnostic challenges of

laryngopharyngeal reflux

28

29

Pathophysiology

• The “reflux” and “reflex” theories are proposed as the pathophysiological mechanisms of LPR symptom generation.

30

Three-Site pH Probes (composite pH parameter

incorporating pharynx and distal esophagus)

Hypopharynx

Proximal Esophagus

Distal Esophagus

Hypothesis • We hypothesized that composite pH may predict response to

anti-reflux therapy in those with isolated LPR symptoms.

31

1 3 2 4

Lien 2011 Aliment Pharmacol Ther

32 Lien 2011 Aliment Pharmacol Ther

33 Lien, 2013 Laryngoscope

Abnormal composite pH predicts 50%

improvement of the primary laryngeal symptom in

suspected LPR patients without GERD symptoms

Physiological Characteristics of Isolated

Laryngopharyngeal Reflux Symptoms

↓ Ineffective

motility( better

acid clearing)

↑ UES resting

pressure

(competence)

↓ Pharyngeal

acid reflux

Referred pain or reflex

↓ Acid perfusion test

(hyposensitivity)

34 Lien, 2017 DDW oral presentation

35

Bottom Line

• In patients with suspected LPR and without

concomitant typical GERD symptoms, reflux

monitoring test using composite pH parameter

incorporating pharynx and distal esophagus may be

able to predict treatment response.

35

36 36

Thanks for Your Attention!!