GERD Categories & Management

• Aims & scopes of iGERD diagnosis
• GERD Symptoms
• Endoscopy & Histopathology
• Manometry & pH-monitoring
• GERD-categories & management

Currently the diagnostic mix complicates GERD-categories (Fig. 5):

1. presence of symptoms and normal endoscopic appearance of the esophagus defines non erosive reflux disease (NERD). Biopsies are not recommended. NERD implicates no specific diagnosis and therapy. PPI therapy may be recommended.
2. presence of symptoms and presence of endoscopic visible esophagitis (=inflammation of the squamous lining) indicates GERD and has to be reconfirmed by pH monitoring. Biopsies of squamous lining are recommended (enlarged intercellular spaces within squamous epithelium are considered to be indicative for GERD).
3. presence of GERD symptoms and endoscopic visible columnar lined esophagus containing intestinal metaplasia defines Barrett's esophagus, biopsies for assessment of intestinal metaplasia are recommended (here the whole length of CLE is considered to contain intestinal metaplasia.). Visible CLE < 3 cm and > 3 cm is considered as short and long segment Barrett's esophagus, respectively. It is recommended that GERD should be reconfirmed by pH monitoring (after manometric information for pH-probe placement).
4. presence of GERD and endoscopic visible lesions containing dysplasia define high cancer risk. Surveillance, endoscopic mucosal resection or ablation (HALO®) are recommended (see common management trunk within novel concept)

Drawbacks of the diagnostic mix:

1. At a normal appearing endoscopic esophagogastric junction premalignant Barrett's esophagus and its precursor are present in 17% and 80-100% of GERD patients, respectively, and are missed with the current concept.
2. Early GERD limited to the distal part of the LES (NERD, functional heartburn) is missed. These are 60% of those with GERD symptoms.
3. No specific therapy can be recommended to those with early GERD, because they are not identified (frequently they are considered to have a psychological disorder).

The current concept does not:

1. Assess early GERD (limited to the LES)
2. Assess morphology and length of ?dilated end stage esophagus?
3. provide information for tailoring of GERD treatment (depending on the length and histopathology of 'dilated end stage esophagus').

Resolution of symptoms and endoscopic esophagitis upon treatment with proton pump inhibitor (PPI) is indicative for GERD.

Functional disorders are excluded by manometry (differential diagnosis includes achalasia, distal esophageal spasm, intra-, or extramural esophageal tumor, cardiopulmonary disease).

Reflux is assessed by pH monitoring or combined pH impedance monitoring. Pathologic acid exposure and/or reflux activity (impedance) confirm GERD.

Radiology: if dysphagia is the leading symptom, barium swallow is recommended prior to endoscopy for exclusion of a tumorous stenosis, diverticula, rings, webs and large hernias. Computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography are included into the diagnosis and management of esophageal cancer.

The current concept misses 60% of those with GERD symptoms, i.e. those with reflux limited to the distal portion of the LES. Intra-LES reflux is assessed by the novel concept (histopathology, multi level pH monitoring).

Patients with GERD are recommended to undergo medical or surgical treatment.

First line treatment is medical and includes administration of PPI±H-2 receptor antagonists against nocturnal acid break through), prokinetics.

Conceptually those with PPI sensitive GERD and positive pH-monitoring are good candidates for surgical treatment (fundoplication) (see Fig. 6).

Recent studies demonstrated that endoscopic ablation, endoscopic mucosal resection represent good options for treatment of Barrett's esophagus and low-, and high grade dysplasia (=intraepithelial neoplasia). Combination of endoscopic and surgical therapies (fundoplication) are currently under investigation.

About ablation, mucosal resection, fundoplication see the common therapeutic trunk presented within the novel concept.

Chromoendoscopy including narrow band imaging (NBI) increases the yield to detect Barrett's esophagus, dysplasia and carcinoma. Use of chromoendoscopy with the novel concept has not been investigated (see current versus novel concept).

Management of esophageal adenocarcinoma is tumor stage dependent (Fig. 7). T1a cancers can be treated by mucosal resection and vagal sparing esophagectomy (0-4% lymph node involvement). T2 tumors and advanced stages are treated by multimodal therapy including neoadjuvant treatment, esophagectomy and surgical resection (50% lymph node involvement for T2 tumors).

For more details see European Surgery 2006; 38/1 and Eur Surg 2007; 39/4 & 5.