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Help… I still have Heartburn! Challenges that GERD Patients are Facing Today Reuben K Wong Associate Professor National University of Singapore Gastroenterologist gutCARE President IBS Support Group SG Challenges facing GERD patients… (and their doctors!) Reflux is becoming so common! Do I need to be investigated? I heard that PPIs are dangerous… is it true? My medication no longer works… help me! Why is GERD a significant problem? USA Prevalence Study Prevalence (%) 80 males females 60 Any episode of GERD symptoms 40 At least weekly episodes of GERD symptoms 20 25–34 35–44 45–54 55–64 Age (years) 65–74 Locke et al 1997 Reflux : A major issue? Prevalence of Heartburn… Singapore Community Survey • Jurong Estate • 1994 – 4.6% • 2000 – 10.5% Increasing incidence that indicates we are catching up with rates in the West Ho KY et al Amer Journ Gastroenetrol 1998 Lim SL, Ho KY et al Journ Gastroenterol & Hepatol 2001 • • • • • Increasing Obesity Lifestyle & Stress Ethanol Fatty Food Less H Pylori Definitions & Classification (circa Montreal) Do I need to be investigated? • 43yr old Female • No significant medical history • Episodes of heartburn and a “sourish” sensation • Worse when stressed (vague relationship) • Physical examination unremarkable What would u do… Trial of acid suppression Send her for an OGD ECG/CXR “It’s all in the mind…” RF Diagnostic Algorithms Amer Journ Gastroenterol 2010; 105 RF Diagnostic Algorithms Amer Journ Gastroenterol 2010; 105 RF Diagnostic Algorithms Amer Journ Gastroenterol 2010; 105 Omeprazole 20mg BD for weeks • No response Gastroscopy What are the issues? Is acid the problem? • In absence of overt esophagitis, can we prove that acid is the cause? What if there • Is all reflux acidic? is no acidic • If not, how we document non-acidic reflux? reflux? pH-Impedance Testing Impedance signals Animation IMP PRES April 2007 27 Gastric reflux • / \ shaped waveform Extent of reflux Type of reflux Ambulatory 24hr pH- impedance-manometry reflux cough Sifrim et al Gut impedance pH oes pH fundus manometry weakly acidic reflux (pH 5.6) April 2007 30 cough How much reflux is there? pH4% of the time Is there excessive Reflux? DeMester’s Score >70 refluxes on MII Characteristics of Refluxate Acidic Weakly Acidic Non-acidic Nature of Refluxate Extent of the reflux pH-Impedance measurement Document ALL reflux Correlation with symptoms Utility • Duration of lower esophageal acid exposure (intensity) • No of events (frequency) • Match symptoms with reflux events • Symptom Index (SI) • Symptom Association Probability (SAP) • Acidic reflux • Non-acidic reflux • Air movement (belching) • Explore correlates with extra-esophageal symptoms How to classify reflux patients… Reflux Symptoms Has Reflux Esophagitis Positive pHImpedence No Reflux Functional Heartburn Esophageal Hypersen Challenges facing GERD patients… (and their doctors!) Reflux is becoming so common! GP/GIs - One of the commonest conditions presenting to Do I need to be investigated? - know the diagnostic pathway/algorithm I heard that PPIs are dangerous… is it true? - safe class of drugs - nonetheless use judiciously in the chronic setting My medication no longer works… help me! - confirmatory tests for non-erosive reflux disease - consider other diagnoses When we have more time at this afternoon’s satellite symposia… discuss treatment options run through reading an actual pH-Impedence Study reubenwongkm@gmail.com