Frazzoni M. MRGE: una Patologia non solo Gastroenterologica. ASMaD 2013


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Frazzoni M. MRGE: una Patologia non solo Gastroenterologica. ASMaD 2013

  1. 1. MRGE Una malattia non solo gastroenterologica? Marzio Frazzoni Fisiopatologia Digestiva Ospedale Baggiovara - Modena
  2. 2. GASTROESOPHAGEAL REFLUX DISEASE (GERD) Gastroesophageal reflux occurs when the pressure gradient between the esophagogastric junction and the stomach is lost Acid     Pepsins Transient LES relaxations accompanied by reflux Hypotonic LES Hiatal hernia Impaired esophageal clearance Bile
  3. 3. Definition and classification of GERD (AGA Guidelines, Gastroenterology, 2008)
  4. 4. GERD – The iceberg disease  The prevalence of frequent (at least 2 days per week) typical reflux symptoms was 23.7% in the adult Loiano-Monghidoro population  The prevalence rates of esophagitis and Barrett’s esophagus in adults who accepted to undergo EGD were 11.8% and 1.3%, respectively (Zagari et al, Gut, 2008) Endoscopy is required for alarm symptoms (dysphagia, vomiting, anemia, involuntary weight loss) (AGA Guidelines, 2008)
  5. 5. ATYPICAL REFLUX SYNDROMES  Reflux or reflex?  Casual or causal association?  Efficient reflux treatment should improve symptoms
  6. 6. Response of NCCP to PPIs in patients with and without GERD (Kahrilas et al, Gut, 2011) RR meta-analysis plot of PPI symptomatic response for patients with NCCP and with (Panel A) and without (Panel B) objective evidence of GERD
  7. 7. REFLUX COUGH SYNDROME (Chang et al, Cochrane Review, 2011) In adults, there is insufficient evidence to conclude that GERD treatment with PPIs is beneficial for cough associated with GERD
  8. 8. REFLUX ASTHMA SYNDROME (Gibson et al, Cochrane Review, 2009)  In asthmatic subjects with GERD, there was no overall improvement in asthma following PPI treatment for GERD  Subgroups of patients may gain benefit, but it is difficult to predict responders
  9. 9. REFLUX LARYNGITIS SYNDROME Meta-Analysis Studies  PPI therapy may offer a modest, but non-significant, clinical benefit over placebo in suspected GERD-related chronic laryngitis (Qadeer et al, AJG, 2006)  Therapy with a high-dose PPI is no more effective than placebo in producing symptomatic improvement or resolution of laryngopharyngeal symptoms (Gatta et al, APT, 2007)
  10. 10. Posterior laryngitis – a reliable diagnosis?  Concordance among 5 physicians blindly evaluating 120 video recordings was very low for edema, erythema, as well as likelihood and severity of laryngopharyngeal reflux (Branski et al, Laryngoscope, 2002)  Several signs of posterior laryngeal irritation (e.g. interarytenoid bar, erythema of the median wall of the arytenoids), which are generally considered signs of laryngopharyngeal reflux, are present in more than 80% of nonsymptomatic individuals (Milstein et al, Laryngoscope, 2005)
  11. 11. High economic burden of caring for patients with suspected extraesophageal reflux (Francis et al, Am J Gastroenterol, 2013) PPIs Only 54% of patients improved or resolved over a 5-year period
  12. 12. IMPEDANCE-PH MONITORING REFLUX IS A PHYSICAL EVENT 80 Weakly Alkaline Refluxes 60 (n) 40 Weakly Acidic Refluxes 20 Acid Refluxes 0 OFF PPI ON PPI PPI transform the vast majority of acid refluxes into weakly acidic refluxes (Frazzoni et al, APT, 2009) Activation of pepsins occurs at pH <4, but proteolytic activity is maintained up to pH 6 (Pearson & Parikh, APT, 2011)
  13. 13. Refractory GERD as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication (Frazzoni et al, Surg Endosc, 2013) A 3-year outcome study Preoperative ON-PPI findings Patients (n) (%) SAP/SI+ for acid refluxes only 4 (11%) SAP/SI+ for acid and weakly acidic refluxes 4 (11%) SAP/SI+ for weakly acidic refluxes only 16 (42%) Abnormal %EAET 6 (16%) Abnormal number of total refluxes 31 (82%) No symptom during the study but abnormal number of total refluxes only 11 (29%)
  14. 14. Refractory GERD as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication (Frazzoni et al, Surg Endosc, 2013) - A 3-year outcome study 35 300 P = 0.002 30 25 200 20 %EAET Total refluxes (n) 15 150 100 10 5 50 0 0 Before surgery 90 ON PPI After surgery Before surgery OFF PPI 200 After surgery ON PPI OFF PPI 180 P = 0.011 70 60 50 40 30 20 10 Weakly acidic refluxes (n) 80 Acid refluxes (n) P = 0.001 250 P = 0.001 160 140 120 100 80 60 40 20 0 0 Before surgery After surgery Before surgery After surgery  Normal reflux parameters + heartburn/regurgitation remission in 34/38 (89%) patients Remission of concomitant preoperative NCCP in 4/4 cases and of concomitant preoperative cough in 5/6 cases
  15. 15. MRGE Una malattia non solo gastroenterologica? TAKE HOME MESSAGES
  16. 16. GERD ATIPICA - RACCOMANDAZIONI (Katz et al, ACG Guidelines, AJG, 2013)  Accurata esclusione delle cause più frequenti di manifestazioni atipiche  La diagnosi di laringite da reflusso non può essere basata sulla sola laringoscopia  La gastroscopia è indicata solo per sintomi di allarme, non serve per la diagnosi di GERD atipica  Un PPI trial è indicato solo nei pazienti che riferiscano anche pirosi retrosternale  Nei pazienti che negano pirosi retrosternale è indicato un test diretto di reflusso (pH-impedenzometria o pH-metria)  Nei pazienti non responsivi ai PPI sono indicati ulteriori accertamenti  La fundoplicatio laparoscopica non è indicata per il trattamento delle sole manifestazioni atipiche non responsive ai PPI