COMMENTARY

GERD: Expert Panels Offer New Advice for Management

David A. Johnson, MD

Disclosures

June 25, 2018

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

We gastroenterologists see a number of patients presenting with the diagnosis of gastroesophageal reflux disease (GERD) with extraesophageal manifestations. This is a very common presentation, with earlier findings suggesting that 1 out of 10 new ENT evaluations resulted in a referral with a diagnosis of laryngopharyngeal reflux disease.[1]

Recently, the Clinical Practice Updates Committee of the American Gastroenterological Association (AGA) proposed recommendations for extraesophageal symptoms and diseases attributed to GERD,[2] while another group of esophageal experts provided guidance regarding management options in patients with GERD and persistent symptoms on proton pump inhibitors (PPIs).[3]

I would like to summarize these publications here, as well as giving you five additional "pearls of experience" of my own.

AGA Recommendations

When it comes to extraesophageal symptoms and diseases attributed to GERD, where is the pendulum swinging now?

The AGA's experts sought to answer that question by highlighting nine different areas of best practice, which are well worth reading in the full publication.[2] Here I'll provide some of the areas of greatest interest.

They recommend that fundoplication only be considered in patients with a mechanical defect—that is, those with a large hiatal hernia with moderate to severe reflux at baseline off a PPI or with continued reflux in the face of PPI therapy who have failed more conservative measures. This is something that should certainly be considered in patients who have a prominent regurgitation component.

The second piece of expert advice is that non-GI evaluations by ENT, pulmonary, and allergy specialists are essential. I would agree with that, but we gastroenterologists are the target for a lot of these referrals sent to us with a diagnosis of GERD. In my mind, the challenge is rectifying the idea that they do not need surgery, because a lot of these patients do not respond to PPIs as they do not necessarily have GERD.

This paper suggests that we should use empiric therapy with aggressive acid suppression (twice-daily dosing for 6-8 weeks). However, we have to recognize that the majority of these extraesophageal manifestations, if in fact they are related to reflux, are multifactorial. This is something we will come back to at the end when I provide my five pearls.

There is no single test methodology for definitively identifying reflux in these extraesophageal complications. The authors reviewed a variety of ways to look at on-therapy or off-therapy impedance-pH testing and found that it depends on their pretest probability. If they have a high likelihood for reflux disease, you can do it off therapy. If they have a low likelihood, you can do it on therapy, and certainly while looking for concordance with symptoms and their symptom-associated index.

The authors recommend that if there is a lack of response to aggressive acid-suppressive therapy combined with normal pH monitoring, you should keep these patients away from further testing and surgery in particular.

We will talk in a moment about how you manage these patients with a process known as habituation, because I think that becomes the crux of most of their problems.

When to Consider Surgery

The other recent publication comes from a group of 14 esophagologists,[3] who looked at different algorithms for managing patients with GERD and persistent symptoms on twice-daily PPI therapy.

They recommended that for patients with persistent symptoms and an esophageal acid exposure time of > 6%, which is huge when you are on a twice-daily PPI, that it was reasonable to consider surgery. This is certainly true in patients who had moderately significant reflux symptoms and a larger hiatal hernia, who are optimal candidates for surgical intervention.

The authors pretty much dismissed the idea of any type of incisionless fundoplication or radiofrequency ablation techniques, which they thought should never be indicated in patients who have persistent symptoms and are allegedly on twice-daily PPI. Those two therapies really got a black box in terms of not being recommended.

Surgery was considered reasonable in patients who had regurgitation, which we know is a mechanical defect that is not effectively treated by PPIs.

Magnetic sphincter augmentation was deemed moderately appropriate if they had an elevated esophageal acid exposure index, in particular with small hiatal hernia. Although they recognize the limits of this procedure, they reported that it seems to be very safe and effective in this highly selected patient population.

Five Pearls of Experience

Although these two papers give us some guidance, I wanted to give you five additional pearls that I have learned from treating these patients for a long time.

Number 1 is to make sure your patients are taking their PPIs correctly: 30-60 minutes before breakfast and 30-60 minutes before dinner. Over time, a lot of these patients change to taking their PPIs with meals or at bedtime, which does not work as well.

Number 2 is to consider alginic acid or alginate products, like Gaviscon®. They are very effective at augmenting the PPI effect. I find it particularly helpful with the postprandial symptoms or with patients who are experiencing nighttime symptoms. I tell patients that this is an alginate made from seaweed, and it works like putting a cap on a bottle; it effectively coats the hiatal hernia, keeping the acid regurgitation reflux recycling in the hernia or the fundic pool. I find this treatment inordinately helpful at producing that coating effect, particularly in its liquid, rather than tablet, form.

Number 3, which is particularly important for gastroenterologists, is to consider habituation. When the patient comes in [and starts coughing], I find in the course of my dialogue with them that I can usually tell exactly what is going on. Look at their hoarseness and their patterns of speech, and seek out elements that they may have acquiesced to as a result of their initial symptoms. I do not care if they got it from reflux or postnasal drip; look for symptoms that they are perpetuating because they are now in a cycle of habituation. Once you identify that, you now have to train and work with them to break that cycle.

Number 4 is do not forget diaphragmatic breathing. This sounds kind of hokey, but it is what I call "yoga for the diaphragm"—belly breathing. We found it helpful in specific populations, such as patients with rumination, refractory belching, and refractory hiccups (singultus), and there are some data in patients with persistent symptoms of GERD, particularly belching, but also heartburn symptoms. It is an easy technique. I have done a video on this topic before. Take some time to learn it, and don't forget it, because it is valuable and [inexpensive]. You do not need a referral.

Number 5, the final pearl, is something I have found to be successful in patients who have so-called "GERD-induced cough." Look for patients with this bronchogenic cough. They have been cleared by their pulmonologist as not having asthma, but they get into this cough cycle that is difficult to break. If their reflux symptoms are gone and they do not have acid contributing to it, you may study them on a PPI and do pH monitoring. I find what these patients get into is habituation, but they have a bronchogenic cough. My advice for the best way to control that is to consider a low dose of tramadol or a low dose of a tricyclic amitriptyline (Elavil) at bedtime, with which I have had high success rates. Once you come down to that bronchogenic cough, it just does not go away. I have seen patients who have had it for 25-30 years, and after a week or so of this treatment, they come back and say, "Wow, I'm no longer recognized in public because nobody is looking for my cough."

These two recent publications are of great interest, and I recommend reading them in their entirety. I hope that by summarizing them, along with some pearls I have learned from 39 years in practice, I have provided valuable guidance for a problematic area of patient care, looking at persistent symptoms on PPIs and the swinging pendulum on extraesophageal GERD manifestations.

I am Dr David Johnson. I look forward to talking with you again soon. Thanks for listening.

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