UPDATE ON THERAPY OF GERD Luca Dughera Endoscopy and Motility Unit, Gastroenterology 2, Dpt. of Internal Medicine, San Giovanni Battista Hospital, Turin

GERD IS A DISEASE WITH WORLDWIDE DISTRIBUTION Up to 10–25% Western Europe , Nord America and Canada

3–6.2% Asia 15% Japan

25 millions in USA refer daily heartburn

10% Sud America

Very rare in North Africa Up to 10% in South Africa and Botzwana

8-10% Australia and South Pacific

Western lifestyle, urban communities in developed countries

Dent J et Al, Gut, 2005

MONTREAL DEFINITION OF GERD • GERD is a common condition that occurs when gastric refluxate into the esophagus causes troublesome symptoms or complicances

Vakil N et al, Am J Gastroenterol 2006

A patient-centered approach ! • The main objectives for therapy of GERD are: – To restore the perceived quality of life – To heal the lesions, when present – To avoid complications Galmiche & Scarpignato, Br Med J 1998

GERD REDUCES QUALITY OF LIFE

THE SYMPTOMS-BASED MONTREAL CLASSIFICATION OF GERD Esophageal Syndrome Symptomatic

• Typical Syndrome (heartburn, regurgitation, belching) • Non cardiac chest pain (NCCP)

Symptoms + mucosal damage

Extraesophageal Syndrome Established Association

Hypothetic Association

• Esophagytis

• Chronic cough

• Bronchitis

• Stenosis • Barrett’s Es.

• Laryngitis • Asthma

• Otitis media • Sinusitis

• Adenocarcinoma

• Dental erosions • Glossitis

• Pulmonary Fibrosis

Vakil N et al, Am J Gastroenterol 2006

RATIONALE FOR THERAPY OF GERD From a therapeutic perspective, GERD is a disorder of both motility and esophageal acid exposure, exposure in as much that the signs, symptoms, and clinical conditions result primarily from recurrent reflux of gastric contents into the oesophagus Tytgat NJ et Al, APT 2007

LIFESTYLE MEASURES AFFECTING GERD Alimenti che riducono pressione SEI (grassi, caffeina, cioccolata, menta, alcol) DRUGS: • Ca-antagonists • Nitrates • Xantines • Antispasmodics • Beta blockers • Sidenafil

GERD

Gravidanza

Pasti abbondanti che distendono lo stomaco

Fumo?

Posizione postprandiale supina

LIFESTYLE MEASURES CORRECTION Lifestyle correction and antacids are of minimal, if any, benefit for

initial and long-term therapy of patients with NERD and GERD The GENVAL Consensus, Dent , Gut 1999

BMI directly correlates with symptoms severity and esophageal acid exposition time so far loose of weight is mandatory (grade A)

Smoking and alcohol consumption do not worsen symptoms and esophageal pH (grade B) Kaltenbach et al, Arch Intern Med 2006

GERD IS NOT ONLY ACIDIC REFLUX •

Historically, acid reflux was believed to be the predominant

cause

of heartburn and other GERD symptoms, based on the induction of heartburn or chest pain during perfusion of the oesophagus with strongly acidic solutions. •

Current evidence, however, suggests that weakly acidic events in the oesophagus may also play a role in GERD symptom generation, particularly in patients NON RESPONDERS to proton pump inhibitors (PPIs), the main class of drugs prescribed for this condition Talley N et Al, APT 2006

pH IMPEDANCE REVEALS DIFFERENT TYPES OF REFLUX

weakly acid reflux

acid reflux

weakly alkaline

superimposed reflux

Cho YK, Neurogastroenterol Motil 2010

ACIDIC REFLUX TAKE A GOOD HISTORY ! What is Heartburn ? ‘A burning feeling rising from your stomach or lower chest towards your neck’

Sensitivity 96% (PPV 87%) for GERD compared with endoscopy/ 24-hour pH monitoring

Carlsson a, et al. Scand J Gastroenterol. 1998

SYMPTOMS OCCURRENCE DEPENDS UPON TIME OF pH ESOPHAGEAL EXPOSURE 8

Intraesophageal acid exposure (% time pH