Monday, May 4, 2015

Atypical Gastroesophageal Reflux Disease

By: David J. Landy, MD, Birmingham Gastroenterology Associates

Atypical GERD is a subset of gastroesophageal reflux disease (GERD), and is a common problem seen by gastroenterologists in private practice. Garden variety GERD is one of the most common diagnoses that we see. The prevalence of GERD in the western world is reported to be between 10 and 20%. In a typical specialty practice, we are likely to be seeing only the tip of the iceberg when it comes to severity. With the current availability of over the counter medications, i.e. Nexium, Prilosec, Zantac, etc., many people are able to effectively treat transient esophageal reflux on their own. We suspect that there are also many people that likely have full blown GERD who we don't see and are also self medicating. Because of potential complications and issues that can arise from chronic GERD, we do recommend consultation with either a primary physician or a specialist if GERD symptoms require medications for greater than 8 weeks. Many patients who have simple GERD are cared for by their primary physicians and not sent to a gastroenterologist, unless they either become refractory or have had GERD for many years. The Atypical GERD patients can be a complicated endeavor for both the patient and the treating physician to handle.

It is important to make a distinction between what we consider GERD and what is considered "normal" esophageal reflux, which almost everyone has experienced from time to time. Physiologic (or "normal") reflux happens typically after meals, is short lived, and rarely occurs during sleep. GERD is more symptomatic frequently with inflammatory changes (esophagitis) seen as erosions/ulcers on endoscopy or pathology. About half of patients who are untreated with GERD have this kind of inflammatory response. Heartburn, or sometimes indigestion, can be typical presenting symptoms. If an individual has heartburn or any other reflux type symptom consistently more than 2 days a week, it is considered to be GERD. These symptoms of GERD respond easily to acid lowering medications, such a proton pump inhibitor (PPI), e.g., Prilosec.

Atypical GERD is not as easily treated with over the counter Prilosec or Nexium. Most of the problems associated with atypical GERD are considered complications of extraesophageal reflux. When stomach acid and/or other contents of the stomach, sometimes including bile acids, reflux past the lower esophagus and up to the area of the airway opening, we can then see complications such as asthma, posterior laryngitis (hoarseness), chronic cough, dental erosions, chronic sinusitis, recurrent pneumonitis, amongst other issues. Gastroenterologists are ready and available to help deal with these complicated problems.

About one half of patients with atypical GERD, i.e., chronic cough, noncardiac chest pain, or hoarseness, will respond to high dose proton pump inhibitors, such as Nexium. When starting a new regimen, the perceived effects can be fairly rapid, but it is typically helpful to wait at least two full months to get the maximum effect. At least some improvement should be expected over 2 weeks. A generic PPI prescribed twice daily for two months, followed by either a different generic PPI for two months, and if possible a trial of a high dose brand name PPI, such as Dexilant or Nexium will be used to treat these atypical symptoms. If there is an adequate response, the medication would be continued at that high dose for 6 months and then attempt to wean back down to a once daily regimen. The high dose regimen could be continued indefinitely if that is what is controlling the patient's symptoms.

Unfortunately, about half of patients will not respond to any manner of PPI medication. Most of those patients may have some but not adequate benefit from PPI and will live with the symptoms. In these cases, discussion of further options to diagnose or treat these refractory symptoms should occur. The evaluation and treatment become more cumbersome, expensive, risky and not as effective at this point in the process. Many times patients will learn to live with atypical GERD symptoms, which can be fortunately very mild before moving on to more complicated evaluation and treatment. Of course, we have patients with more severe symptoms who choose to be further evaluated, and we have success with many of these patients but not all of them.

Many times, the recommendation is an EGD with Bravo probe to obtain 24 hour pH data. This is usually done while the patient is off of acid lowering medication to see if acid is actually the culprit. Sometimes, reflux and associated symptoms can be secondary to bile reflux and/or reflux of stomach contents, which can be noxious to the throat, airway, and/or sinuses. This can be very important data to obtain; because if acid is NOT the culprit, it would make sense why acid lowering medications are not effective. These patients will potentially benefit from a lap Nissen's fundoplication (or similar surgical type treatment).

A fundoplication procedure is aimed at tightening the lower esophageal sphincter (LES) by wrapping part of the upper portion of the stomach around the LES in an effort to help stop stomach contents from refluxing back up into the esophagus. Getting the correct degree of tightness on the wrap is fairly subjective at the time of surgery, and patients will respond differently in many cases. If the wrap is not tight enough, it will be ineffective, but if it is too tight patients may experience difficulty swallowing (dysphagia) or can develop gas/bloat syndrome. A fundoplication procedure is sometimes indicated for atypical GERD and refractory symptoms not responsive to PPI's. However, these procedures are not commonly offered because it requires the risk of anesthesia and surgery, and patients are extremely variable as to how they respond. However, if the surgery is pursued, the Bravo 24 hour pH would be obtained, as well as an esophageal motility study to make sure that the patient doesn't have achalasia or scleroderma esophagus, which would be contraindications to the surgery. Another medical pharmaceutical option that is even less attractive is a trial of reglan. Reglan is a pro-motility drug commonly used for nausea. However, the drug has fallen out of favor, because it is not overly effective. It is a hard medication to take long term because of potential side effects notably tardive dyskinesia, which is an irreversible condition that causes tremors.

In conclusion, atypical GERD or gastroesophageal reflux with extraesophageal complications, is sometimes difficult to identify and frequently difficult to treat. It is important to recognize since it can mimic other diseases and potentially can be treated simply with the correct dose of a PPI medication.

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