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This ppt was presented in ENT deptt of NMCH patna by Dr ZEESHAN AHMAD and appreciated a lot

This ppt was presented in ENT deptt of NMCH patna by Dr ZEESHAN AHMAD and appreciated a lot

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  • --distinction between normal and GERD is blurred because some degree of reflux is physiologic is all folks Physiologic—postprandially, short lived, asymptomatic, not during sleep Pathologic—symptoms or mucosal injury and often with nocturnal symptoms
  • --At level of diaphragmatic hiatus—main deterrant to reflux --disruption due to –review slide--multifactorial
  • --gerd related chest pain may mimic angina—squeezing/burning, substernal, radiates to back, neck, jaw, arms. Minutes to hours. After meals, awakens patient from sleep, exacerbated by emotional stress --water brash—hypersalivation—heartburn and regurg of sour fluid or tasteless saliva into mouth --globus—lump in throat irrespective of swallowing --odynophagia—esophageal ulcer --nausea—infrequent --hrt burn 70-85%//regurg 60%//dysphagi 15-20%//angina 33%//asthma 15-20%
  • --heartburn +/- regurgitation high specificity, low sensitivity
  • --need further eval if any present—egd--
  • Once established h&p dx and no alarm symptoms can proceed with dx/therapeutic trial of tx.
  • --if started with or changed to --prilo 40 qd x 14d as specific/sensitive as pH monitor --remember only works on active pumps. Take 30-60 min prior to eating
  • --if trial of med did not work or if alarm symptoms or long term 5yrs need egd 1a evidence—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia --50-70% of patient’s with gerd will have a neg egd.
  • A number of physiologic factors may contribute to increased esophageal acid exposure during sleep The esophageal response to acid was studied in 14 subjects without GERD while awake and during sleep (<30% awake) 1 Acid caused a greater swallowing rate in awake subjects; this swallowing rate in response to acid decreased during the sleep period Calculated esophageal acid clearance was also found to be impaired compared to the awake condition, taking 180% longer to clear acid when asleep Another study evaluated the effects of different body positions on esophageal acid clearance in 21 healthy subjects 2 Gravity-mediated drainage was found to be more difficult to achieve in a supine position, as a greater number of swallows were needed to achieve a normal esophageal pH in the supine position compared to the upright position 1. Orr WC, et al. Gastroenterology . 1984;86:814-819. 2. Kjellén G, Tibbling L. Scand J Gastroenterol . 1978;13:283-288.
  • --Tums, rolaids, maalox --$1 billion in yearly expenditures --aluminum/calcium—constipation Mag--diarrhea
  • --otc dose uniformly half of standard lowest prescription dose --similar clinical efficacy
  • --no significant differences in symptomatic tx of GERD or healing of erosive esophagitis 1a evidence --works only on active pumps—take 30-60min prior to meals --long-term tx generally benefits outweigh risks
  • This animation depicts proton pump activation following stimulation with food.   The ingestion of food causes a series of biochemical events that ultimately allow proton pumps to reach the surface of the cell and secrete acid 1,2   Only active proton pumps can secrete acid; however not all pumps are stimulated at a given time; some pumps remain unstimulated 2-4   References: 1. Del Valle J, et al. Gastric secretion. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:266-307. 2. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. 3. Sachs G. Pharmacotherapy . 1997;17:22-37. 4. Blair JA, et al. J Clin Invest. 1987;79:582-587.
  • PPIs are only activated in an acidic environment and PPIs only bind to and inhibit active proton pumps PPIs covalently bind to the H + /K + ATPase (proton pump) to inhibit the final step of gastric acid production   Reference: Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376.
  • Gastric acidity is a mechanism of protection against bacterial overgrowth, and PPI use reduces gastric acidity 1-3 In a controlled prospective study, 47 outpatients with peptic disease were examined by endoscopy before and after treatment with a 4-week course of a PPI or an H 2 RA 4 Before treatment only 8% of patients had gastric or duodenal bacterial overgrowth. After treatment 53% of patients treated with a PPI had overgrowth and 17% of those using the H 2 RA had overgrowth 4 Patients treated with the PPI had the highest gastric pH which positively correlated with bacterial count (r=.68; P <0.001) 4   A systematic literature review (11 papers evaluating 126,999 patients on PPI therapy) showed a positive association between PPI use and the risk of developing Clostridium difficile infection 1 A combination cohort and case-control analysis of hospitalized patients (n=1187) linked PPI use with an increased risk of C difficile diarrhea 2   One cohort analysis also observed increased community-acquired pneumonia rates associated with PPI use (adjusted relative risk of current PPI use compared to those who stopped taking PPI=1.89) 3 The study population consisted of 364,638 subjects of whom 5551 developed a first occurrence of pneumonia A more recent study from the General Practice Research Database in the United Kingdom found that current, long-term PPI use did not increase risk of community-acquired pneumonia; however, recently starting PPI therapy (2, 7, or 14 days prior to index date) was found to increase risk 5 The study evaluated case patients (n=80,066) who received an incident diagnosis of community acquired pneumonia and matched controls (n=799,881) “ When we stratified the current PPI recipient group on the basis of duration of exposure before the index date, PPI use for fewer than 30 days was associated with moderately increased risk for CAP. Among current PPI recipients with longer periods of PPI exposure, risk for CAP did not increase. A close examination of the group with current PPI use for fewer than 30 days revealed that new PPI therapy started within the 30 days before the index date accounted for all of the increased risk for CAP in this group. In addition, increases in risk for CAP were progressively larger among recipients who started PPI or histamine-2–receptor antagonist therapy within 14, 7, or even 2 days before the index date.” 5 From Sarkar M, et al. Ann Intern Med. 2008;149:391-398.   References: 1. Leonard J, et al. Am J Gastroenterol . 2007;102:2047-2056. 2. Dial S, et al. CMAJ . 2004;171:33-38. 3. Laheij RJF, et al. JAMA . 2004;292:1955-1960. 4. Thorens J, et al. Gut . 1996;39:54-59. 5. Sarkar M, et al. Ann Intern Med. 2008;14
  • candidacy --esophagitis—by egd --need normal manometry/motility --partial response to acid suppression --reduce hh, repair diaphragm, strengthen ge jxn—antireflux barrier --75-90% effective at alleviating hrtburn/regurg --better at helping with hrtburn/regurg than atypical sx
  • --dysphagia, odynophagia, early satiety, gi bleed, anemia, vomit, wt loss
  • --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --ulcerations in 2-7%
  • 4-20% of patients
  • Figure 11-18. Endoscopic appearance of benign strictures. Acid-septic strictures and Schatzki's rings are the most common strictures requiring dilation. Although in most instances endoscopic examination allows obvious distinction between the two, variation in air insufflation and the differences in magnification over short distances between the lower esophageal sphincter and the endoscope can make the assessment of the lower esophagus difficult in some patients. A subtle peptic stricture may be missed endoscopically, or, more precisely, may be confused with a Schatzki's ring. Contrast radiology can be a more sensitive technique for demonstrating subtle rings and strictures and for calibrating the lumen more precisely. A–C, Endoscopic photographs of several Schatzki's rings. D–G, peptic strictures. Note the esophageal pseudodiverticula proximal to the peptic stricture in panels F and G. Their presence increases the risk of unguided dilatation of the esophagus and mandates the use of a guidewire technique. H, Tight anastomotic stricture (suture at 10 o'clock) and “watermelon esophagus” viewed endoscopically. The watermelon seeds and kernel of corn provide a reference for the pinhole quality of this stricture.
  • Figure 11-21. Types of dilators: balloons. Balloon dilators are an additional option for the endoscopist approaching an esophageal stricture. They may be placed over a guidewire or through the scope (TTS). Theoretically, balloons have the advantage of being safer because of the radial application of force, and elimination of the shearing effect of rigid dilators. Moreover, dilation can be performed under direct visualization using the TTS balloon. Recent balloon innovations facilitating their use include longer balloons that avoid the tendency for slippage with inflation, and high-pressure balloons that should provide a truer diameter for the dilation of more resistant strictures. In the limited number of randomized studies comparing Savory-type dilators with balloon dilators, they appeared equally safe. Efficacy, as assessed by symptom improvement and luminal patency, has been variably reported in the literature favoring either technique [18], [19], [20]. A, Range of available balloons and an inflation gun. B–E, A peptic stricture before and after balloon dilation, thus demonstrating the direct visualization that is possible with the TTS technique. References: [18]. Saeed ZA, Winchester CB, Ferro PA, et al. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc 1995 41 189-195 [19]. Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilation of benign oesophageal stricture? An interim report of a randomized controlled trial. Gut 1988 29 1741-1747 [20]. Shemesh E, Czerniak A, Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures. World J Surg 1990 14 518-522
  • --1950—Norman Barrett --10-15% --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --RFs—male, smoker, age, obese
  • Adenoca with barretts 0.5%/yr--------without barretts 0.07%/yr
  • --alarm symptoms—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia

Zee ppt gerd Zee ppt gerd Presentation Transcript

  • Gastro esophageal Reflux Disease My room My mess ENT Central emergency
  • Gasroesophageal reflux disease (GERD)
  •  
  • Objectives
    • Definition of GERD
    • Epidemiology of GERD
    • Pathophysiology of GERD
    • Clinical Manisfestations
    • Diagnostic Evaluation
    • Treatment
    • Complications
  • Definition
    • American College of Gastroenterology (ACG)
      • Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
      • Often chronic and relapsing
      • May see complications of GERD in patients who lack typical symptoms
  • Physiologic vs Pathologic
    • Physiologic GERD
    • Postprandial
      • Short lived
      • Asymptomatic
      • No nocturnal sx
    • Pathologic GERD
      • Symptoms
      • Mucosal injury
      • Nocturnal sx
  • Epidemiology
    • About 44% of the adult population have heartburn at least once a month
    • 14% of adults have symptoms weekly
    • 7% have symptoms daily
    These are US data In INDIA the prevalence is somewhat lesser but on an INCREASING trend
  •  
  •  
  • Pathophysiology
    • Primary barrier to gastroesophageal reflux is the lower esophageal sphincter
    • LES normally works in conjunction with the diaphragm
    • If barrier disrupted, acid goes from stomach to esophagus
  • Clinical Manisfestations
    • Most common symptoms
      • Heartburn—retrosternal burning discomfort
      • Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions
  •  
  • Clinical Manisfestations
      • Dysphagia—difficulty swallowing
      • Other symptoms include:
        • Chest pain, water brash, globus sensation, odynophagia, nausea
      • Extraesophageal manifestations
        • Asthma, laryngitis, chronic cough
  • Extraesophageal Manifestations of GERD
    • Pulmonary
      • Asthma
      • Aspiration pneumonia
      • Chronic bronchitis
      • Pulmonary fibrosis
    • Other
      • Chest pain
      • Dental erosion
    • ENT
      • Hoarseness
      • Laryngitis
      • Pharyngitis
      • Chronic cough
      • Globus sensation
      • Dysphonia
      • Sinusitis
      • Subglottic stenosis
      • Laryngeal cancer
  • Potential Oral and Laryngopharyngeal Signs Associated with GERD
    • Edema and hyperemia of larynx
      • Vocal cord erythema, polyps, granulomas, ulcers
    • Hyperemia and lymphoid hyperplasia of posterior pharynx
    • Interarytenyoid changes
    • Dental erosion
    • Subglottic stenosis
    • Laryngeal cancer
  • Pathophysiology of Extraesophageal GERD
  •  
  • Diagnostic Evaluation
      • If classic symptoms of heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated
  • Alarms
      • Alarm Signs/Symptoms
        • Dysphagia
        • Early satiety
        • GI bleeding
        • Odynophagia
        • Vomiting
        • Weight loss
        • Iron deficiency anemia
  • When to Perform Diagnostic Tests
    • Uncertain diagnosis
    • Atypical symptoms
    • Symptoms associated with complications
    • Inadequate response to therapy
    • Recurrent symptoms
    • Prior to anti-reflux surgery
  • Diagnostic Tests for GERD
    • Trial of H2RA/PPI
    • Barium swallow
    • Ambulatory pH monitoring
    • Esophagogastroduodenoscopy(EGD)
    • Esophageal manometry
  • Trial of Medications
    • H2RA or PPI
      • Expect response in 2-4 weeks
      • If no response
        • Change from H2RA to PPI
        • Maximize dose of PPI
  • Trial of Medications
    • If PPI response inadequate despite maximal dosage
      • Confirm diagnosis
        • EGD
        • 24 hour pH monitor
  • Barium Swallow
    • Useful first diagnostic test for patients with dysphagia
      • Stricture (location, length)
      • Mass (location, length)
      • Bird’s beak
      • Hiatal hernia (size, type)
    • Limitations
      • Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus
  • Ambulatory 24 hr. pH Monitoring
    • Physiologic study
    • Quantify reflux in proximal/distal esophagus
      • % time pH < 4
      • DeMeester score
    • Symptom correlation
  • Ambulatory 24 hr. pH Monitoring Normal GERD
  • Wireless, Catheter-Free Esophageal pH Monitoring
    • Improved patient comfort and acceptance
    • Continued normal work, activities and diet study
    • Longer reporting periods possible (48 hours)
    • Maintain constant probe position relative to SCJ
    Potential Advantages
  • Esophagogastrodudenoscopy
    • Endoscopy (with biopsy if needed)
      • In patients with alarm signs/symptoms
      • Those who fail a medication trial
      • Those who require long-term tx
    • Lacks sensitivity for identifying pathologic reflux
    • Absence of endoscopic features does not exclude a GERD diagnosis
    • Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD
  • Esophageal Manometry investigation of choice in diffuse esophageal spasm(AI08)
    • Assess LES pressure, location and relaxation
      • Assist placement of 24 hr. pH catheter
    • Assess peristalsis
      • Prior to antireflux surgery
    Limited role in GERD
  • Patient with heartburn Iniate tx with H2RA or PPI H2RA taken BID Good response Frequent relapses On demand tx PPI taken QD Good response Maintenance therapy with lowest effective dose Symptoms persist Consider EGD if risk factors present ( > 45, white, male and > 5 yrs of sx) Increase to max dose QD or BID Good response Confirm diagnosis EGD, ph monitor No Yes Yes No Yes Yes No No
  • Differential diagnosis
    • Angina pectoris
    • Gastritis
    • Peptic ulcer disease
    • Gallstones
    • pancreatitis
    • Achalasia cardia
    • Carcinoma oesophagus
  • Treatment
    • Goals of therapy
      • Symptomatic relief
      • Heal esophagitis
      • Avoid complications
  • Better Living
    • Lifestyle modifications
      • Avoid large meals
      • Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermint
      • Decrease fat intake
      • Avoid lying down within 3-4 hours after a meal
      • Elevate head of bed 4-8 inches
      • Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS)
      • Avoid clothing that is tight around the waist
      • Lose weight
      • Stop smoking
  • 1. Orr WC, et al. Gastroenterology . 1984;86:814-819. 2. Orr WC, et al. Am J Gastroenterol . 2000;95:37-42. 3. Orr WC, et al. Am J Gastroenterol . 1994;89:509-512. 4. Kjellén G, Tibbling L. Scand J Gastroenterol . 1978;13:283-288. Sleep May Impair Esophageal Acid Clearance  Gravity-Mediated Drainage 4  Esophageal Acid Clearance 1–3  Salivary Flow and Swallowing 1 Asleep Awake Factors     FACTORS THAT MAY CONTRIBUTE TO INCREASED ESOPHAGEAL ACID EXPOSURE DURING SLEEP
  • Treatment
    • Antacids
      • Over the counter acid suppressants and antacids appropriate initial therapy
      • Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly
      • More effective than placebo in relieving GERD symptoms
  • Treatment
    • Histamine H2-Receptor Antagonists
      • More effective than placebo and antacids for relieving heartburn in patients with GERD
      • Faster healing of erosive esophagitis when compared with placebo
      • Can use regularly or on-demand
  • Treatment
    • AGENT EQUIVALENT DOSAGE
    • DOSAGES
    • Cimetadine 400mg twice daily 400-800mg twice daily
    • Famotidine 20mg twice daily 20-40mg twice daily
    • Nizatidine 150mg twice daily 150mg twice daily
    • Ranitidine 150mg twice daily 150mg twice daily
  • Treatment
    • Proton Pump Inhibitors
      • Better control of symptoms with PPIs vs H2RAs and better remission rates
      • Faster healing of erosive esophagitis with PPIs vs H2RAs
  • Treatment
    • AGENT EQUIVALENT DOSAGE
    • DOSAGES
    • Esomeprazole 40mg daily 20-40mg daily
    • Omeprazole 20mg daily 20mg daily
    • Lansoprazole 30mg daily 15-10md daily
    • Pantoprazole 40mg daily 40mg daily
    • Rabeprazole 20mg daily 20mg daily
  • Treatment
    • H2RAs vs PPIs
      • 12 week freedom from symptoms
        • 48% vs 77%
      • 12 week healing rate
        • 52% vs 84%
      • Speed of healing
        • 6%/wk vs 12%/wk
  • NOT ALL PROTON PUMPS ARE ACTIVE AT ANY GIVEN TIME 1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. Unstimulated proton pumps Active proton pumps Unstimulated proton pumps in cytoplasmic tubules 1. Blair JA, et al. J Clin Invest. 1987;79:582-587. 2. Sachs G. Pharmacotherapy . 1997;17:22-37. H 2 = Histamine ACh = Acetylcholine Proton pumps become activated in response to food 1 Inactive Parietal Cell After activation, the parietal cell undergoes a series of changes, allowing proton pumps to reach the surface of the parietal cell 1 Active Parietal Cell Only active proton pumps can secrete acid 1 However, not all pumps become activated 1,2 ATPase ATPase MOA     Gastrin H 2 ACh H+ H+ H+ H+ K+ K+ K+ K+
  • PPIs ONLY BIND TO ACTIVE PROTON PUMPS Acid is required to convert a PPI into its active form 1 1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. PPIs only bind to active proton pumps 1 Unstimulated proton pumps remain MOA     PPI PPI PPI PPI
  • PPI USE AND INFECTION RISK: IS THERE A RELATIONSHIP?
    • Gastric acid plays a role in eliminating ingested bacteria from the digestive tract 1
    • PPI use associated with
      • Enteric infection such as Clostridium difficile
      • Nonenteric infection such as community-acquired pneumonia
    C. difficile Safety    
  • Treatment
    • Antireflux surgery
      • Failed medical management
      • Patient preference
      • GERD complications
      • Medical complications attributable to a large hiatal hernia
      • Atypical symptoms with reflux documented on 24-hour pH monitoring
  • Treatment
    • Antireflux surgery candidates
      • EGD proven esophagitis
      • Normal esophageal motility
      • Partial response to acid suppression
  • Treatment
    • Antireflux surgery
      • Tenets of surgery
        • Reduce hiatal hernia
        • Repair diaphragm
        • Strengthen GE junction
        • Strengthen antireflux barrier via gastric wrap
        • 75-90% effective at alleviating symptoms of heartburn and regurgitation
  •  
  • (Nissen’s)
  • Complete vs. partial fundoplication
    • Complete – Nissen fundoplication
    • Ant. partial fundoplication
    •  Thal/Dor procedure
    • Post. partial fundoplication
    •  Toupet procedure
  • Laparoscopic Nissen Fundoplication
  • Treatment
    • Postsurgery
      • 10% have solid food dysphagia
      • 2-3% have permanent symptoms
      • 7-10% have gas, bloating, diarrhea, nausea, early satiety
      • Within 3-5 years 52% of patients back on antireflux medications
  • Treatment
    • Endoscopic treatment
      • Relatively new
      • No definite indications
      • Select well-informed patients with well-documented GERD responsive to PPI therapy may benefit
    • Three categories
      • Radiofrequency application to increase LES reflux barrier
      • Endoscopic sewing devices
      • Injection of a nonresorbable polymer into LES area
  • Complications
    • Erosive esophagitis
    • Stricture
    • Barrett’s esophagus
  • Complications
    • Erosive esophagitis
      • Responsible for 40-60% of GERD symptoms
      • Severity of symptoms often fail to match severity of erosive esophagitis
  • Complications
    • Esophageal stricture
      • Result of healing of erosive esophagitis
      • May need dilation
  • Peptic Stricture Barium Swallow Endoscopy
  • Esophageal Stricture: Dilating Devices
  • TTS Balloon Dilation of a Peptic Stricture
  • Complications
    • Barrett’s Esophagus
      • Columnar metaplasia of the esophagus (AIIMS06)
      • Associated with the development of adenocarcinoma (AIMS97,06)
  • Barrett’s Esophagus
  • Complications
    • Barrett’s Esophagus
      • Acid damages lining of esophagus and causes chronic esophagitis (AIIMS98)
      • Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells
      • This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma
  • Complications
    • Barrett’s Esophagus
      • Manage in same manner as GERD
      • EGD every 3 years in patient’s without dysplasia
      • In patients with dysplasia annual to shorter interval surveillance
  • Complications
      • Patient’s who need EGD
        • Alarm symptoms
        • Poor therapeutic response
        • Long symptom duration
      • “Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice
      • Many patients with Barrett’s are asymptomatic
  • Esophageal Cancer Barium Swallow Endoscopy
  • MCQ’s
    • Most prevalent esophageal cancer worldwide (AI91)
    • Most common site of Ca oesophagus (AIIMS 97)
    • Most common site for squamous cell Ca (AI 01)
    • Most common site of esophageal adenocarcinoma (AIIMS 96,2000)
  • MCQ’s
    • Most common site for Ca oesophagus in india
    • Predisposing fators for Ca oesophagus are all except
    • a-plummer vinson syn
    • b-tulosis palmaris
    • c-gerd
    • d benzene therapy
  • MCQ’s
    • Chemotherapy regimens for Ca oesophagus have improved with the use of (AI96)
    • Commonest adverse effect of cisplatin (AIIMS01)
    • Best substitute for esophagus after esophagectomy (AI96)
  • Summary
    • Definition of GERD
    • Epidemiology of GERD
    • Pathophysiology of GERD
    • Clinical Manisfestations
    • Diagnostic Evaluation
    • Treatment
    • Complications
    • ?QUESTIONS?
    • A slideshow presentation
    • Prepared by
    • Dr. ZEESHAN AHMAD
    • under guidance of
    • DR(Prof)CHANDRA SHEKHAR
    • Head ENT deptt
    • &
    • DR MK VERMA
    • Assoc prof ENT deptt
    • THANK YOU