GERD and Peptic Ulcer Disease

Robert Volodarsky, MD

Outline

1. Case
2. Differentials
3. GERD
4. PUD
5. Summary
6. Fin

Case 1

KA is a 71yo M with PMH seasonal allergies, ADHD, GERD presenting for annual wellness visit.

• Having intermittent symptoms (burning in throat with bad taste) despite limiting triggers
• Limiting etoh intake
• Eating smaller meals
• Avoiding intake before bed/lying down
• Still has occasional symptoms when avoiding triggers
• Not taking PPI or pepcid regularly

Differential Diagnosis?

• Can’t miss: malignancy (oral, esophageal, gastric)
• Most likely: GERD
• A few others: achalasia/stricture, esophageal spasm, EoE, hiatal hernia, PUD, atypical cardiac disease

Case 1: What Questions Do You Have?

• Onset: many years ago, around age 30-40, slowly progressive over time
• Substance use:
• Former tobacco smoker, 4 pack years, quit 10+ years ago
• Current etoh use: 1-2 drinks on weekends only, previously 2-4
• Current marijuana use: smokes one joint most nights before bed, occasional day time use on weekends
• Denies other substance use
• Does not have IDA*
• DENIES:
• Unintentional weight loss/early satiety*
• Pain with chewing/swallowing*
• Vomiting, hematemesis, melena/hematochezia*
• Globus sensation
• Chronic/recurrent cough, laryngitis, sore throat, chest pain

GERD

• AJG definition: “the condition in which the reflux of gastric contents into the esophagus results in symptoms and/or complications… objectively defined by… mucosal injury seen at endoscopy and/or abnormal esophageal acid exposure demonstrated on a reflux monitoring study”
• Prevalence 18-28% in North America, appears to be increasing since 1990s
• Approximately ⅔ of pregnant patients experience heartburn, the majority resolve after delivery
• Non-Erosive Reflux Disease (NERD) vs Erosive Esophagitis (EE)
• Inadequately treated GERD predisposes to Barrett’s esophagus and malignancy

GERD: Alarm Symptoms

• Dysphagia
• Weight loss
• Bleeding
• Vomiting
• Anemia

What is the next step?

→ Urgent endoscopy

GERD: AJG Diagnostic Algorithm^{1, Fig. 1}

GERD: Diagnosis Discussion

• AJG 2023 guidelines:
• Suggest EGD* to confirm diagnosis
• Suggest reflux (pH) monitoring off PPI therapy if normal/low grade esophagitis on EGD to confirm diagnosis
• AAFP algorithm from 2003 suggests continuing PPI unless refractory, in which case pursue further testing
• PPI-based diagnosis pooled sensitivity and specificity are 78% and 54%, respectively, when compared with EGD/pH monitoring per meta-analysis and prospective study

GERD: Nonpharmacologic Treatment

GERD: Pharmacologic Treatment

• PPI both diagnostic and therapeutic
• Lowest effective dose 30-60min daily before meal
• Continue daily in patients w EE/Barrett’s
• Consider prn PPI vs H2B use after 8-12 weeks daily use in patients with NERD
• Per AJG PPI preferred over H2 blockers, esp for certain subtypes
• Theoretical increased risk: intestinal infections, pneumonia, stomach cancer, osteoporosis-related fracture, vitamin deficiency, MI, CVA, dementia, early death
• Per AJG theoretical risks of PPI < known benefits of preventing GERD complications given poor quality evidence on risks (without causal link) vs high quality evidence on benefits
• Special cases:
• Consider adding H2B at night to daily PPI if nocturnal predominant
• Antacids, alginates, sucralfate for pregnant patients
• If a patient doesn’t have GERD, STOP THE TREATMENT

GERD: Refractory Sx/Invasive Treatment

• If GERD refractory (to daily PPI):
• Objectively diagnose if not done
• PPI BID at higher dose, switch PPI
• Consider surgery if primary symptom regurgitation or abnormal impedance pH monitoring ON PPI BID
• At this point we are in the “consider other causes” step
• Manometry often helpful identifying alternative causes, also r/o contraindications to some procedures

Peptic Ulcer Disease

• Characterized by:
• Abdominal (epigastric) pain/discomfort, classically:
• Described as “burning” or “gnawing”
• Relieved with food/antacids
• Worse between meals/at night
• Dyspepsia (bloating, burping)
• Due to H. pylori (implicated in roughly 50% of cases) and chronic NSAID use
• Other contributors include chronic steroids, stress (ICU, TBI), malignancy (GIST, ZE syndrome)
• Differential similar to and includes GERD, also gastritis/enteritis, hepatobiliary pathology, IBS/IBD, ACS
• Has dangerous potential complications

PUD: Alarm Symptoms

• Hematemesis, melena, anemia —> bleeding*
• Vomiting, progressive dysphagia —> obstruction*
• Radiation to back, spreading through abdomen/upper chest —> perforation/penetration*
• Anorexia, early satiety, weight loss, family hx —> malignancy

What is the next step?

→ Urgent/*Emergent endoscopy

PUD: Diagnosis

• In patients <55yo w/o alarm signs, test & treat for H. pylori and reduce NSAID use
• Breath test is consistent but most expensive/least available
• Stool antigen test (SAT) more feasible in general
• Serologic testing typically not helpful in the individual
• In patients >55yo and/or those with alarm signs → EGD with biopsy
• Hold PPI 2 weeks, bismuth/abx 4 weeks prior for urease testing, culture
• If H. pylori present can do TOC non-invasively

PUD: Diagnosis Caveat (Thanks Dr. Beckman)

• Since time immemorial we have held PPI 2 weeks before H. pylori stool studies (SAT)…
• Have you been personally victimized by this?
• Oct 2024 meta-analysis compared 6 studies in which 247/393 patients had H. pylori
• No sig difference in specificity on/off PPI (0.92 / 0.94)
• No sig difference in sensitivity on/off PPI after 2004 (see right)
• How might this affect your practice?

Sensitivity of SAT off PPI before 2004

Sensitivity of SAT on PPI before 2004

Sensitivity of SAT off PPI after 2004

Sensitivity of SAT on PPI after 2004

H. pylori: Prevalent in Marginalized Groups

• H. pylori rates are decreasing overall in N. America, theorized due to widespread PPI use; likely 30-40%
• This is NOT true in communities with lower income or those who live in crowded conditions eg:
• Canadian gen pop prevalence 20-30% vs 56-95% in First Nations Canadians
• Significantly higher prevalence in immigrant populations from South Asia, Latin America
• Unequal prevalence in America by reported race:
• White 20.1%
• Hispanic 36.7%
• Black 40.2%
• H. pylori is classified as a carcinogen by WHO

PUD: Treatment

• Standard tx includes PPI > H2B due to healing rate, pain scales
• 4 weeks for duodenal ulcers (unless refractory, large, or fibrosed)
• 8 weeks for gastric ulcers
• High risk patients may continue on maintenance therapy
• Possibly some benefit from probiotics in conjunction
• Surgery for extremely refractory or special cases
• H. pylori treatment:
• BQT with tetracycline emerging as favorite
• If treatment fails try to get resistance profile
• Or just refer to GI
• Other regimen choices exist
• TOC 4 weeks after tx, ~10-20% fail

Summary

• GERD
• If alarm signs, urgent EGD
• Tailor lifestyle modifications to the individual
• AJG recs EGD if QoL affected, if EGD and reflux testing negative consider other causes
• PPI at lowest intensity for 8-12 weeks then prn if NERD , indefinite if other
• Up-titrate therapy if refractory -> consider manometry/surgery if remains refractory
• PUD
• If alarm signs, urgent/emergent EGD
• Reduce NSAID, etoh use; consider probiotics
• AJG recs H. pylori testing and treatment, TOC if no EGD
• Treatment preferably with BQT
• TOC after 4 weeks

Sources

1. Katz, Philip O. MD, MACG1; Dunbar, Kerry B. MD, PhD2,3; Schnoll-Sussman, Felice H. MD, FACG1; Greer, Katarina B. MD, MS, FACG4; Yadlapati, Rena MD, MSHS5; Spechler, Stuart Jon MD, FACG6,7. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology 117(1):p 27-56, January 2022. | DOI: 10.14309/ajg.0000000000001538
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC10658748/#:~:text=GERD%20is%20a%20frequent%20digestive,symptoms%20and%20acid%20suppression%20response.
3. https://www.aafp.org/pubs/afp/issues/2003/1001/p1311.html
4. https://www.aafp.org/pubs/afp/issues/2015/0515/p692-s1.html
5. https://www.aafp.org/pubs/afp/issues/2015/0215/p236.html
6. https://www.aafp.org/pubs/afp/issues/2007/1001/p1005.html
7. https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
8. https://www.thelancet.com/journals/langas/article/PIIS2468-1253(23)00070-5/abstract