This document summarizes recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). It discusses definitions, pathophysiology, epidemiology, clinical presentation, diagnostic tests including 24-hour pH monitoring and endoscopy, and treatment options including lifestyle modifications, medications like PPIs, and surgical procedures. Key recent advances mentioned include new diagnostic markers, multichannel intraluminal impedance pH monitoring, narrow-band imaging, and endoscopic assessment of mucosal impedance. Surgical treatments discussed are laparoscopic anti-reflux surgery and the Linx device, and recent studies comparing partial versus complete fundoplication and surgical versus medical therapy.

1. GASROESOPHAGEAL
REFLUX DISEASE-RECENT
ADVANCES
PRESENTOR: DR.ANAND PRAKASH
MODERATOR: DR. BINAYA TIMILSINA

2. OVERVIEW
 DEFINITION
 PATHOPHYSIOLOGY
 EPIDEMIOLOGY
 CLINICAL PRESENTATION
 DIAGNOSIS (RECENT ADVANCES)
 TREATMENT
 RECENT ADVANCES IN SURGICAL
MANAGEMENT

3. Gastroesophageal reflux
disease (GERD) : DEFINITION
 “Symptoms or complications resulting
from the reflux of gastric contents into
the esophagus or beyond, into the oral
cavity (including larynx) or lung”
 The American College of Gastroenterology (ACG) guidelines
Am J Gastroenterol 2016;108:308-328

4. PATHOPHYSIOLOGY
ENDOGENOUS
ANTIREFLUX MECHANISM
LOWER ESOPHAGEAL
SPHINTER (LES)
SPONTANEOUS
ESOPHAGEAL
CLEARANCE

5. Gasroesophageal reflux (GER)
Intragastric pressure is > high-
pressure zone of the distal
esophagus
LES resting pressure is too low :
Hypotensive LES
LES relax in the absence of
peristaltic contraction of esophagus:
Spontaneous LES relaxation

6. EPIDEMIOLOGY
 Prevalence of GERD ranged from 18.1% to
27.8% in North America
 8.8% to 25.9% in Europe
 2.5% to 7.8% in East Asia
 8.7% to 33.1% in the Middle East
 Several longitudinal studies have shown a
significant increase in the prevalence of
GERD in the East
El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal
reflux disease: a systematic review. Gut 2017;63:871-880

7. RISK FACTORS
 Obesity
 Dietary fat intake or alcohol consumption
 Ethnic predisposition:Caucasians
ethnicity
 Helicobacter pylori infection
With an increase in obesity and Western
diet, the incidence of GERD is rising and
reported to be 10-20% of the population

8. CLINICAL PRESENTATION
Three phenotypic presentations of
GERD
 Erosive esophagitis (EE)
 Nonerosive reflux disease (NERD)
 Barrett’s esophagus
El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the
epidemiology of gastro-oesophageal reflux disease: a systematic review.
Gut 2017;63:871-880

9.  Erosive esophagitis : symptoms and
biopsy or visually proven erosion of the
esophagus is present
 NERD : Pathologic esophageal acid
exposure is present without evidence of
erosion
 Barrett Esophagus : Histologic change of
the distal esophageal mucosa from
normal squamous epithelium to columnar
configuration

10. Symptoms
Troublesome symptoms are defined as
 Mild symptoms occurring 2 or more days
a week
• Moderate/severe symptoms occurring
more than once a week.
Vakil N, van Zanten S V., Kahrilas P, Dent J, Jones R, Global Consensus Group.
The Montreal Definition and Classification of Gastroesophageal Reflux Disease:
A Global Evidence-Based Consensus. Am J Gastroenterol. 2016

11. Typical Symptoms
 Retrosternal burning sensation
(heartburn)
 Perceived reflux of gastric contents
(regurgitation)
 Water brash

12. Atypical Symptoms
 Chest pain, Abdominal pain
 Dysphagia for solids
 Belching, Bloating
 Chronic cough, sore throat
 Excessive throat clearing, Chronic
laryngitis, hoarseness ,Globus
 Episodic shortness of breath, Aspiration,
Wheezing
 Dental erosions
 Sleep disturbances

13. Diagnosis
 History and physical examination, noting
typical and atypical reflux symptoms
 Most patients with typical symptoms receive
empiric treatment with a proton pump
inhibitor (PPI) ,do not undergo diagnostic
testing
 Esophagoduodenoscopy (EGD) - initial
diagnostic test of choice in patients with
alarm symptoms
Dysphagia, odynophagia, anorexia, weight
loss and upper gastrointestinal bleed

14. PREOPERATIVE DIAGNOSTIC
TESTING
 24-hour Ambulatory pH monitoring
 Esophageal Manometry
 Esophagoduodenoscopy (EGD)
 Barium esophagram

15. 24-hour Ambulatory pH
monitoring
 Quantifies distal esophageal acid
exposure
 “gold standard” test
 24-hour pH monitoring
 Thin catheter is passed into
esophagus through patient’s nares
 Dual –probe pH catheter ,two solid
state electrodes,spaced 10 cm apart
 Detects fluctuation in pH b/w 2 and 7

16. Data collected from ambulatory
pH monitoring
 Total no. of reflux episode(pH <4)
 Longest episode of reflux
 No. of episode lasting > 5 minutes
 % of time spent in reflux in upright and
supine position
 DeMeester score is calculated
 Score > 14.7 defines abnormal distal
esophageal acid exposure

17. Esophageal Manometry
 Most effective way to assess function of
esophageal body and the LES
 Linear tracing of the pressure waves
 Can exclude achlasia and identify
patient with ineffective esophageal
body peristalsis
 “gold standard” for diagnosis of
Achalasia

18. Esophagoduodenoscopy
(EGD)
 Essential for patient who are candidate
for LARS
 Examine for mucosal injury , ulceration ,
peptic stricture, and Barrett esohagus
 Esophagitis : several scoring system
 Savary-Miller and Los Angeles ( LA)
classification
 Peptic stricture and grade C and D
esophagitis is pathognomonic for GERD

19. Los Angeles classification
 Grade A : 1 or more mucosal breaks no
longer than 5 mm, not extending between
two mucosal folds
 Grade B : 1 or more mucosal breaks more
than 5 mm, not extending between two
mucosal folds
 Grade C : 1 or more mucosal breaks that is
continuous between two mucosal folds but
involves <75% of the esophageal
circumference
 Grade D : 1 or more mucosal breaks that is
continuous between two mucosal folds but

20. Barium esophagram
 Provide detailed anatomic evaluation
of esophagus and stomach
 Useful for preoperative evaluation
 Can identify additional
gasroesophageal conditions
 Hiatal hernia, esophageal diverticula ,
tumors , peptic strictures , achalasia ,
dysmotility and gastroparesis

21. Publisher: Taylor & Francis
Journal: Expert Review of Gastroenterology & Hepatology
DOI: 10.1080/17474124.2017.1309286
Article type: Review
Recent advances in diagnostic testing for
gastroesophageal reflux disease
Rishi D Naik1, Michael F Vaezi1
1Division of Gastroenterology, Hepatology, and Nutrition
Center for Swallowing and Esophageal Disorders
Vanderbilt University Medical Center
Expert Review of Gastroenterology &
Hepatology (2017)

22. Immunohistochemical markers
 Proteinase-activated receptor -2
(PAR-2) over-expressed in both
erosive and non-erosive GERD
 Interleukin-33, G-protein coupled
receptor 84, and triggering receptor
expressed on myeloid cells (TREM)-1
The role of any of the above markers as
diagnostic markers in GERD continues to
evolve

23. Multichannel intraluminal
impedance-pH monitoring
Requires an ambulatory monitoring with
insertion of the impedance catheter
Unlike traditional ambulatory pH
monitoring, impedance testing can detect
non-acidic reflux
 Helps determine the extent of reflux
 attempt to correlate these findings to
patients’ symptom

24. Narrow-band imaging
 Uses spectral narrow band filter for the
visualization of mucosal patterns and
microvasculature
 Allows increased contrast for better
enhancement to detect changes in the
microvasculature
 NBI findings on endoscopy include
intrapapillary capillary loop dilatation,
microerosions, and vascularity
prominence at the squamocolumnar
junction

25. Endoscopic assessment of
mucosal impedance
 Allow real time measurement during
endoscopy
 Mucosal impedance (MI) is an
endoscopically placed probe that goes
through the working channel of the
endoscope that makes direct contact with
the mucosa to obtain measurements

26. Diagnostic modalities currently under
clinical investigation
 The Endo Functional Luminal Imaging Probe system
(EndoFLIP - Crospon, Ltd., Galway, Ireland) -
dynamic measurements of gastroesophageal
distensibility;
 Dx-pH measurement system (Respiratory Technology
Corp., San Diego, CA) -measures aerosolized acid
 The pepsin lateral flow device or PEP-Test
(RDBiomed, Hull, UK) - a non-invasive test for
salivary pepsin
 Confocal laser and volumetric endomicroscopy-
provide in vivo histologic imaging of mucosa surfaces

27. Currently Available Therapeutic
Modalities for Gastroesophageal
Reflux Disease
 Lifestyle modifications
 Medical
 Surgical
 Endoluminal therapies

28. Lifestyle modifications
 The first-line treatment
 Raising head end of the bed
 Avoiding meals within 3 hours of bedtime
 Weight loss for patients with recent weight
gain or BMI >25
 Avoidance of acidic foods, carbonated
beverages, alcohol, and tobacco

29. Medical
 Antacids
 Gaviscon
 Proton pump inhibitors
 H2 receptor antagonists
 Prokinetics
 Baclofen
 Carafate

30. Proton Pump Inhibitors (PPI)
 Considered the most effective
medical therapy for GERD
 Profound and consistent acid
suppression
 With typical symptoms , an 8 week
course of PPI is recommended
 Demonstrate different levels of
satisfaction that range between 56%
to 100% as compared with other
antireflux medications
 Sandhu DS and Fass R: Current Trends in the Management of
Gastroesophageal Reflux Disease 2017

31. Currently Available Proton Pump
Inhibitors
 Omeprazole
 Esomeprazole
 Lansoprazole
 Rabeprazole
 Pantoprazole
 Dexlansoprazole
 Omeprazole with sodium bicarbonate

32.  Several large scale studies : PPI
treatment is superior to H2RA treatment
for the symptomatic relief of both EE and
NERD patients
 Recently, long-term safety of PPIs have
been called into question with some
evidence of increased infectious
complications and nutritional deficiencies
 Sandhu DS and Fass R: Current Trends in the Management of
Gastroesophageal Reflux Disease 2017

33. • PPIs can provide symptom relief in ~
57% to 80% of patients with EE and
about 50% of the patients with NERD.
 Healing of EE (all grades) can be
obtained in greater than 85% of GERD
patients undergoing treatment with a
standard dose PPI.
 Current Trends in the Management of Gastroesophageal
Reflux Disease
Gut and Liver, Vol. 12, No. 1, January 2018, pp. 7-16

34. Candidates for Surgical
Therapy
 Side effects from medical therapy
 Poor compliance with medical therapy
 Concern about or wish to discontinue
chronic medical therapy
 Symptomatic with a large hiatal hernia
 Regurgitation
 Not interested in medical therapy
 Abnormal pH test on maximum PPI dose
 Symptoms correlate with nonacid reflux
while on maximum PPI dose
 Current Trends in the Management of Gastroesophageal Reflux Disease Gut and
Liver, Vol. 12, No. 1, January 2018, pp. 7-16

35. SURGICAL MANAGEMENT
 Laparoscopic antireflux surgery
(LARS)
 Gastric Bypass
 Linx reflux management system
 Electrical Stimulation
 Current Trends in the Management of Gastroesophageal Reflux Disease
Gut and Liver, Vol. 12, No. 1, January 2018, pp. 7-16

36. Laparoscopic antireflux surgery
(LARS)
Creation of a
360-degree
Fundoplication
Laparoscopic
Nissen
Fundoplication
(LNF)

37. Creation of a partial
fundoplication
• Stomach is wrapped
180 to 270 degree
posterior aspect of
esophagus
Toupet
fundoplication
(Posterior)
• No need to disrupt
posterior attachment of
esophagus
• Fundus is folded over ant.
aspect of esophagus
(180 degree wrap)
Thal or Dor
fundoplication
(Anterior)

38. al

40. Operative complications and side
effects of antireflux surgery
 Pneumothorax m/c intraoperative
complication yet reported in less than 2%
 Gastric and esophageal injury 1 %
 Spenic/liver injury or bleeding 2.3 %
 Acute herniation
 Postoperative ileus
SIDE EFFECTS
 Bloating , Dysphagia
Sabiston textook of surgery, 2o th edn.

41. Partial versus Complete
Fundoplication
• Evaluated LNF & Toupet
Fundoplication
• At 1 year, no difference for
heart burn and regurgitation
• Dysphagia more frequent with
LNF
Booth et al,2010 (RCT)
• Evaluated Laproscopic
anterior,posterior and total
fundoplication
• Anterior Fundoplication a/w greater
risk of recurrent GERD
• LNF a/w greater risk of dysphagia,
bloating
Fein and
Seyfried,2011(reviewed 9
RCT)

42. Partial versus Complete
Fundoplication
• Compared LNF and Toupet
Fundoplication
• No d/f in patient satisfaction with
operation or perioperative
morbidity
• Patient with abnormal esophageal
motility, LNF a/w greater rate of
dysphagia
Shan et al, 2010
(reviewed 32
studies)
• Increased rate of postoperative
gas bloat , inability to
belch,dysphagia who underwent
LNF
• Toupet Fundoplication is the
treatment of choice,effective
GERD symptom control and fewer
Meta analysis by
Shan and
colleagues

43. Fundoplication
(Take home message based on
studies) In patients with GERD and esophageal
dysmotility,
partial fundoplication is preferred
Because Nissen fundoplication will lead
to greater postoperative dysphagia
 Anterior Fundoplication provide less
durable control of GERD than posterior
and total fundoplication

44. Continued…
 Despite numerous RCT and 2
metaanalysis, conflicting evidence about
the fundoplication that provide most
durable control of reflux and best side
effect profile
 Because of heterogenicity in terms of
patient characteristics , patient selection ,
operative technique
 Surgeons should perform the
fundoplication that they are most
comfortable performing

45. RCT comparing Surgical and
Medical Therapies for GERD
• ARS and PPI provided equal
symptom control
• ARS – more heart-burn free days
Anvari et
al, 2011
• ARS – good symptom control
after 10-year follow-up
Spechler
et al, 2016
• Treatment failure :
• PPI – 55% , ARS – 47 %
Lundell et
al , 2009

46. Gastric Bypass
 Laparoscopic Roux-en-Y gastric bypass
 American Society for Metabolic and
Bariatric Surgery (ASMBS) qualifications
with refractory or intolerant GERD.
 BMI ≥40 , BMI ≥35, and at least two
obesity-related co-morbidities
 Type II diabetes (T2DM), hypertension,
sleep apnea and other respiratory
disorders,
 non-alcoholic fatty liver disease,
osteoarthritis, lipid abnormalities,

47. Linx reflux management
system
 Consists of a series of titanium beads
with a magnetic core connected with
titanium wires to form a ring.
 This ring is placed around the lower
end of the distal esophagus by
laparoscopy
 Helps to augment the lower
esophageal sphincter and thus
prevent gastroesophageal reflux
 Sandhu DS and Fass R: Current Trends in the Management of Gastroesophageal
Reflux Disease2017

48. LINX
(magnetic sphincter augmentation
device)

49. Electrical Stimulation
 Laparoscopic implantation of
electrodes in the lower esophageal
sphincter
(EndoStim LES Stimulation System)
 The electrodes are placed anteriorly
along the esophagus at the GEJ and
the generator is implanted in the
abdominal wall.
 Decreased distal esophageal acid
exposure, improved GERD-HRQL,
and less use of PPI medications at 3
years.

50. ENDOLUMINAL THERAPIES
FOR GERD
Fixation
Ablation
Injection
Mucosal excision
& suturing

51. ENDOLUMINAL THERAPIES
FOR GERD
 Also known as transoral incisionless
fundoplication (TIF)
 EsophyX
 The Stretta
 MUSE system
 Sandhu DS and Fass R: Current Trends in the Management of
Gastroesophageal Reflux Disease2017

52. EsophyX
 Used to restore the angle of His by
creating a valve at the
esophagogastric junction (EGJ).
 This is achieved by delivering multiple
full thickness, nonabsorbable
fasteners at the EGJ.
 Since its first use in 2005, about
17,000 TIF procedures have been
done
Transoral endoscopic fundoplication in the treatment of gastroesophageal reflux disease: the
anatomic and physiologic basis for reconstruction of the esophagogastric junction using a
novel device. Ann Surg. 2017

53. Diagrammatic and anatomic illustration of
a transoral fundoplication using
performed using the Esophyx

54. The Stretta system (Mederi
Therapeutics, Inc., Norwalk, CT)
 A balloon-tipped four-needle catheter
that delivers radiofrequency energy
into the smooth muscle of the EGJ.
 The first published report in 2001
showed promising results
 Over the last 17 years this therapeutic
modality has markedly improved and
has been used in more than 20,000
patients.
 TriadafilopoulosG. Stretta: a valuable endoscopic treatment modality for
gastroesophageal reflux disease. World J Gastroenterol. 2014;20(24):7730–7738

55. MUSE system
(Medigus, Israel)
 An ultrasonic surgical stapler
embedded
within a custom endoscope to perform
a transoral fundoplication
 Kim HJ, Kwon C-I, Kessler WR, et al. Long-term follow-up results of endoscopic
treatment of gastroesophageal reflux disease with the MUSE™ endoscopic stapling
device. Surg Endosc. 2016

56. Efficacy of Laparoscopic Nissen Fundoplication
vs Transoral Incisionless Fundoplication or Proton
Pump Inhibitors in Patients With
Gastroesophageal Reflux Disease: A Systematic
Review and Network Meta-analysis
Joel E. Richter, Ambuj Kumar, Seth Lipka,Branko Miladinovic, and Vic
Velanovich
Gastroenterology 2018;154:1298–1308
© 2018 by the AGA Institute
0016-5085/$36.00
https://doi.org/10.1053/j.gastro.2017.1
2.021

57. BACKGROUND AND CONTEXT
 The gold standard for anti-reflux
surgery is the Nissen fundoplication.
 New endoscopic treatments such as
transoral incisionless fundoplication
(TIF) claim short term efficacy and
safety but there are no direct
comparisons.

58. NEW FINDINGS
 LNF has the greatest durability to
increase LES pressure and decreases
% time pH<4 up to 5 years of follow-
up.
 TIF was superior in symptom
improvement over 6-12 months but
not years.
 Perforation rate was high with TIF
compared to LNF

59. .
LIMITATIONS
 No direct comparison between TIF and
LNF necessitating network meta-
analysis.
 Quality of studies varied from moderate
to very low.
IMPACT
 Until more good quality evidence is
available including direct comparison to
LNF, TIF cannot be recommended as
an alternative to PPI or traditional
Nissen fundoplication.

60. THANK YOU