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acid peptic disorders


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  • Antacids may be no more effective than placebo
    This slide and the one that follows provide data supporting statements made on the previous slide.
    Although antacids have been the traditional therapy for GERD for many years and are still widely used, there is little evidence concerning their efficacy. Indeed, the results of some studies suggest that antacids may be no more effective than placebo in alleviating symptoms and influencing the natural history of the disease.
    For example, in one study, an antacid was compared with placebo in 32 patients with symptomatic gastroesophageal reflux (1). The two test treatments, each taken 7 times daily, both produced significant increases in the time needed to reproduce heartburn with a timed acid perfusion (Bernstein) test. However, the mean increase was somewhat greater with placebo (169 +/- 66 versus 41 +/- 20 seconds, or 4.1-fold) than with the antacid (120 +/- 57 versus 42 +/- 16 seconds, or 2.9-fold).
    (1) Graham, Patterson. Dig Dis Sci 1983; 28: 559–63.
  • PPIs are the most effective drugs for the initial treatment of GERD
    This figure is taken from a meta- analysis of randomized, single- or double-blind clinical trials conducted in GERD patients with endoscopically proven erosive or ulcerative esophagitis (1). The meta-analysis incorporated a total of 43 studies involving 7635 patients treated for 2–12 weeks.
    The figure shows that, for all time points between 2 and 12 weeks, the mean percentage of patients in whom esophagitis was healed was considerably higher with PPIs than with H2RAs. Notably, the mean proportion healed after 2 weeks with PPIs (63.4%) was similar to the mean proportion healed after 12 weeks with H2RAs (60.2%). The overall proportion of cases healed, regardless of the duration of treatment, was 83.6% with PPIs, 51.9% with H2RAs and 28.2% with placebo (p < 0.0005 between groups).
    (1) Chiba et al. Gastroenterology 1997; 112: 1798–810. Reproduced with permission from the American Gastroenterological Association.
  • Transcript

    • 1. Acid Peptic Disorders Acid peptic disorders include a number of diseases, whose etiology can be linked to gastric secretions. Gastroesophageal reflux disease, and peptic ulcer disease, are two most common and well-defined disease states.
    • 2. GERD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. Reflux esophagitis refers to a subgroup of GERD patients with histopathologically demonstrated characteristic changes in the esophageal mucosa Nonerosive reflux disease, also know as endoscopynegative reflux disease, refers to patients with typical GERD symptoms caused by intraesophageal acid who do not have visible mucosal injury at endoscopy.
    • 3. Prevalence Heartburn is a common problem in the United States and in the Western world, since many individuals control symptoms with over-the-counter medications and without consulting a physician, the condition is likely underreported. Approximately 7% of the population experience symptoms of heartburn daily. 20-40% of the people who experience heartburn do indeed have GERD No sexual predilection exists. GERD is as common in men as in women GERD occurs in all age groups. The prevalence of GERD increases in people older than 40 years.
    • 4. Etiology  Lower esophageal sphincter incompetence.  Transient lower esophageal sphincter relaxation.  Hiatal hernia  Obesity: contributing factor in GERD
    • 5. Typical Features  Heartburn  Regurgitation
    • 6. Atypical Features  Coughing and/or wheezing  Hoarseness  Pneumonia  Belching  Laryngitis  Otitis media  Enamel decay.
    • 7. Differentials          Achalasia Choleithiasis Coronary Artery Atherosclerosis Esophageal Spasm Esophageal Cancer Esophagitis Chronic Gastritis Irritable bowel syndrome Peptic Ulcer Disease
    • 8. WORKUP         Barium Esophagogram Esophagogastroduodenoscopy Esophageal manometry Radionuclide measurement of gastric emptying Ambulatory 24-hour pH monitoring Empiric trial of proton pump inhibitor Multichannel intraluminal impedance Bravo system
    • 9. Medical Treatment Lifestyle Modifications  Losing weight (if overweight)  Avoiding alcohol, chocolate, citrus juice, and tomato-based products  Avoiding large meals  Waiting 3 hours after a meal before lying down  Elevating the head of the bed 8 inches
    • 10. Treatment Cont. Pharmacologic Therapy  Antacids  Prokinetic agents: metoclopramide hydrochloride  H2 receptor antagonists: Ranitidine, Cimetidine, Famotidine. Nizatidine  Proton pump inhibitors: Omeprazole, Rabeprazole, Esomeprazole,
    • 11. Treatments Cont.  Antacids    Prokinetics     Prompt but temporary relief No objective proof of superiority to placebo Improvement of symptoms in mild GERD Effective for healing only mild erosive esophagitis Can be useful in a select patient population H2RAs   Relief of symptoms in ~50% of patients Effective for healing only mild erosive esophagitis
    • 12. Antacids may be no more effective than placebo Mean increase in time to reproduce heartburn with Bernstein test x5 * x 4.1 x4 * x 2.9 x3 *p < 0.05 versus pretreatment x2 x1 x0 Placebo Antacid
    • 13. % esophagitis cases healed PPIs are the most effective drugs for the initial treatment of GERD 100 PPIs 80 60 H2RAs 40 Placebo 20 0 2 4 6 8 Weeks of treatment 10 Chiba et al. Gastroenterology 1997 12 p < 0.0005
    • 14. Complications.  Esophagitis  Strictures  Barrett esophagus  Adenocarcinoma  Respiratory complications: pneumonia, asthma, and interstitial lung fibrosis.
    • 15. Complications cont.
    • 16. Complications cont.
    • 17. Points to Remember  Endoscopy reveals that 50% of patients do not have esophagitis.  The only way to determine if abnormal reflux is present and if symptoms are actually caused by GERD is through pH monitoring.  Achalasia can present with heartburn. Only esophageal manometry and pH monitoring can be used to distinguish achalasia from GERD.
    • 18. Peptic Ulcer Disease Peptic ulcers are defects in the gastrointestinal mucosa that extend through the muscularis mucosa.
    • 19. Prevalence Lifetime prevalence is approximately 1114% for men. Lifetime prevalence is approximately 811% for women. Age trends for ulcer occurrence reveal declining rates in younger men, particularly for duodenal ulcer, and increasing rates in older women.
    • 20. Etiology  Helicobacter pylori infection  Consumption of NSAIDS  Severe physiologic stress  Hypersecretory states
    • 21. Symptoms  Epigastric pain  Nausea  Vomiting  Dyspepsia  Heartburn  Chest discomfort  Anorexia, weight loss  Hematemesis or melena
    • 22. Signs  Epigastric tenderness  Epigastric pain  Guaiac-positive stool  Succussion splash
    • 23. Differentials            Biliary Colic Cholecystitis Cholelithiasis Gastritis, Acute Gastritis, Chronic Gastroesophageal Reflux Disease Mesenteric Artery Ischemia Myocardial Ischemia Pancreatic Cancer Pancreatitis, Acute Pancreatitis, Chronic
    • 24. WORKUP  Double-contrast radiography  Detection of H pylori infection  Endoscopic tests  Serum gastrin
    • 25. Medical Treatment  H. pylori eradication: Dual/Triple therapy  Cessation of NSAIDs  H2-receptor antagonists  Proton Pump Inhibitors  Prostaglandins misoprostol  Sucralfate sucrose-aluminum complex promotes ulcer healing
    • 26. FDA-Approved Treatment Regimes for H. pylori Infection  Omeprazole 20 mg BID + Clarithromycin 500 mg BID + Amoxicillin 1 g BID for 10 days  Lansoprazole 30 mg BID +Clarithromycin 500 mg BID + Amoxicillin 1 g BID for 10 days  Bismuth subsalicylate (Pepto Bismol) 525 mg QID + Metronidazole 250 mg QID + Tetracycline 500 mg QID X 14 days + H2 receptor antagonist x 4 wks
    • 27. Adjunctive Treatment    Caffeine and Alcohol - Both of these stimulate the secretion of stomach acid and should be avoided in the acute phase of an ulcer. Cigarettes - Nicotine will delay the healing of an ulcer. Antacids - These agents, can be used for relief of peptic ulcer symptoms. Except for bismuth (Pepto Bismol),- they do not help heal ulcers.
    • 28. Complications  Hemorrhage  Confined Perforation  Open Perforation  Gastric outlet obstruction  Recurrence  Stomach cancer: Adenocarcinoma, Gastric/MALT lymphomas
    • 29. Clean Ulcer Induced by Aspirin
    • 30. Gastric Ulcer H.Pylori & Aspirin
    • 31. MCQS 1) Gold standard for investigating GERD? A) Endoscopic Tests B) Esophageal manometer C) Multichannel intraluminal impedance D) Bravo System E) None of the above
    • 32. 2) Which of the following statements is false? A) Antacids are not clearly superior to placebos B) NSAIDS most common cause of PUD C) Dysphagia is an alarm symptoms D) H2RA Effective healing only mild esophagitis E) Nicotine delays healing of an ulcer
    • 33. Thanks