GERD (Gastro Esophageal Reflux Disease) is one of the commonest medical conditions found in the community today. GERD patients often suffer from frequent symptoms and require long term medication. However, how much of what we know about GERD is truly fact based on medical evidence? We challenge traditional paradigms to GERD

1. GERD: Telling Fact from Fiction
Dr Jarrod Lee
Gastroenterologist & Advanced Endoscopist
Mt Elizabeth Novena Hospital

2. Fact or Fiction?
• Non Erosive Reflux Disease (NERD) is a mild
form of GERD. It can progress to Erosive
Esophagitis
• In Asia, NERD is far more common than
Erosive Esophagitis. Hence, endoscopy is not
useful for diagnosis
• In GERD, if PPIs don’t work, nothing more can
be done except surgery

3. NERD is a mild form of GERD. It can
progress to Erosive Esophagitis

4. Traditional Paradigm
NERD
Erosive
Esophagitis
Barrett’s
Esophagus
• Focus on Erosive Esophagitis
– Most well designed GERD studies focus on mucosa healing
and symptom improvement in Erosive Esophagitis
• Progression along spectrum over time
• NERD is a mild form of GERD

5. What is the Evidence?
NERD
Erosive
Esophagitis
Barrett’s
Esophagus

6. Studies in NERD
• Most community based patients have NERD
• Very few progress to Erosive Esophagitis
– 10-15% over 5-20 years
– Only mild Erosive Esophagitis (Grade A)
• No Barrett’s Esophagus or Esophageal Cancer
• Lower symptom response to PPIs
– Increased number of treatment failures
– Relapse back to NERD after treatment

7. NERD Natural History

8. Changing
Paradigm

9. Non-erosive Reflux Disease (NERD) is
much more common in Asia. Hence,
endoscopy is not useful for diagnosis.

10. Epidemiology:
East vs West
• GERD Incidence:
– West: 10-20%
– Asia: 5%
– Singapore: 10%
• NERD percentage
– West: 50-70%
– Asia: 60-90%

11. Diagnosing GERD
• No gold standard!!
• Presumptive diagnosis can be made with
typical symptoms:
– Heartburn, acid regurgitation
– Frequency: at least weekly
• If presumptive diagnosis made, can proceed
to an empirical trial of PPI

12. Empirical PPI
• Both a diagnostic and therapeutic test
• Sensitivity: 70-80%
• Poor specificity: 25-65%
– May be positive in other acid disorders
– Specificity with placebo 40% !!
• 4-8 weeks of PPI will:
– Heal erosive esophagitis in 85-95%
– Control symptoms in 75-85%

13. How to do it?
•
•
•
•
What drug? Any PPI
What dose? Standard dose
How long? Minimum 1 week
What to look for? > 50% symptom
improvement
• When to review? 2-4 weeks
– No improvement: increase dose, BD dosing
– Improvement: complete 4-8 weeks

15. Role of Endoscopy
• Evaluate alarm symptoms:
– Dysphagia, weight loss, persistent vomiting,
bleeding/ anemia
•
•
•
•
Exclude other differentials
Evaluate other symptoms, e.g. dyspepsia
Evaluate treatment failures
Screen for Barrett’s Esophagus if at risk:
– Males > 50 yrs + chronic GERD + risk factors

16. Endoscopy in Uncomplicated GERD
•
•
•
•
Problem with patients on treatment
Good specificity 95%
Poor sensitivity <30%
In Asia: sensitivity 10%

18. Symptoms
bother me!
I’m worried
and concerned
Heartburn
disturbs my
sleep
I cannot bend
over or exercise
My whole life is
affected
I cannot eat or
drink what I like

19. ‘Next Generation’
Endoscopy

20. Advanced Imaging
Narrow band imaging
20

21. NBI in GERD
Improves visualization of
squamocolumnar junction

22. GERD patients have:
• Increased number, dilatation, tortuosity of intrapapillary
capillary loops (IPCLs)
• Micro-erosions
• Increased vascularity
• Absence of round pit pattern

23. • Endoscopy normal
• Advanced imaging
shows tiny mucosal
break and increased
vascularity

24. How accurate is it?
GERD Patients
Endoscopy Finding
Micro-erosions
Increased vascularity at junction
Conventional
Endoscopy
Advanced
Imaging
0%
0%
52.8%
91.7%

25. Advanced Imaging: NERD vs Controls
Advanced Imaging
Micro erosions
Increase vascularity
Round pit pattern
NERD
52.8%
91.7%
5.6%
Controls
23.3%
36.7%
70%
P
< 0.001
< 0.001
< 0.001
Using a composite of: increased vascularity &
absence of round pit pattern
• Sensitivity 86.1%
• Specificity 83.3%

26. In GERD, if PPIs don’t work,
nothing more can be done
except surgery

27. PPI Failures in
GERD
27

28. PPI Therapy in GERD
• NOT a definite solution
– Symptoms will recur once PPI stop
– Reduces acidity but not frequency or volume of
reflux
• Efficacy in Erosive Esophagitis
– Mucosal healing: 85-95%
– Symptomatic response: 75-85%

29. Reasons for Failing PPI
• Compliance
• Concomitant functional
disorder, e.g. IBS, FD
• Wrong diagnosis
• NERD
– Hypersensitive Esophagus
(non-acid reflux)
– Functional Heartburn

30. Proportion of patients who fail once daily PPI

31. Optimizing PPI Therapy
Sub-optimal PPI therapy is the largest cause of
‘refractory’ GERD
• < 80% of patients take PPI according to prescription
• 25-50% of patients have moderate to poor
compliance
PPI instructions by primary care physicians
Chey WD et al. Am J Gastroenterol 2005
31

32. Partial Responsers
• What next?
– Switch to BD dosing or different PPI
– Provides symptom improvement in 20%
• No clear advantage with either strategy
• If still not responding, consider refer to
gastroenterologist

33. What will the
Gastroenterologist
do?

34. Ambulatory pH Monitoring
• Documents acid reflux: frequency + intensity
• Correlates with symptoms

35. Bravo pH
Capsule

36. Reflux Esophagitis
Increased acid exposure. All acid regurgitation (29
episodes) occurred at times of acid reflux.

37. ? GERD
Significant acid exposure. Only 2 out of 4 episodes of mild
acid regurgitation occurred at times of acid reflux.

38. pH Monitoring in
NERD patients
Proportion of abnormal
pH monitoring

39. Combined pH-Impedance Testing
• Documents ALL reflux;
improves GERD
diagnosis in up to 90%
• Correlates symptoms
with reflux event
• Can differentiate NERD
subtypes

40. What is Impedance?
• Impedance is the electrical resistance measured
with an alternating current
• Catheter with metal rings: a small electrical
current is used to measure the impedance
between 2 rings
Ring
R1
R2
Patient safe
low electrical current

41. Impedance Values
Ohm*cm (at 1 kHz)
Gastric contents
30-100
Bile
90
Saline solution
100
Saliva
110
Skeletal muscle
Milk/ yoghurt
250-700
300
Drinking water/ cola
1,100
Esophageal wall
2,000
Epidermis
Air
2,000 – 100,000
10,000,000

43. 43

45. 45

47. Conclusion
• GERD is a disorder with different phenotypes
• Diagnosis
– PPI test is good
– Gastroscopy for alarm symptoms, treatment failures
– Consider advanced imaging for better yield: 10% vs 85%
• Treatment failures
– Optimize PPI therapy
– Determine GERD or NERD phenotype
47

48. Thank You
48