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USAFP Presentation

USAFP Presentation

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    Ge Rd Ge Rd Presentation Transcript

    • Hard Core CME GERD Robert A.Solomon M.D. Associate Director Montgomery Family Practice Residency Program Norristown, PA
    • GERD Objectives
      • Cost effective treatment
      • Complications of GERD
      • Beyond medications
    • GERD
      • Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
      • American College of Gastroenterology
    • GERD
    • GERD Only 2-3 % of acid reflux events reach the level of perception by the patient
    • GERD statistics
      • Monthly GERD symptoms- 44 % or 61 million Americans
      • Weekly GERD symptoms- 14 %
      • Daily GERD symptoms- 7 %
    • GERD etiology
    • GERD Diagnosis
      • Symptoms
      • Heartburn (pyrosis)
      • Regurgitation-especially after large meal
      • Aggravated by recumbency/bending over
      • Relieved with antacids
      • Difficult cases
      • 24 hr pH monitoring
    •  
    • Atypical GERD Presentations
      • Asthma
      • Chest pain
      • Chronic cough
      • Recurrent laryngitis
      • Recurrent sore throat
      • Globus sensation
    • GERD Alarm Symptoms
      • Dysphagia
      • Early satiety
      • GI bleeding
      • Iron deficiency anemia
      • Odynophagia
      • Vomiting
      • Weight loss
    • GERD-Etiology of Complications
    • GERD Complications Esophagitis
    • GERD-Etiology of Complications
    • GERD-Barrett’s Esophagus Normal endoscopy Barrett’s esophagus
    • Barrett’s Esophagus
      • Progression to adenocarcinoma of esophagus
      • 0.2-2 % annual incidence of CA in Barrett’s
      • Aggressive acid suppression (high dose PPI) may not lead to regression in transformation to malignancy
      • Surveillance endoscopy- looking for dysplasia-intervals are controversial
    • Esophageal Stricture
    • Esophageal Stricture Balloon dilator Stricture Balloon Post dilation
    • Complications of GERD
      • Reflux induced asthma
      • Laryngeal and tracheal stenosis
      • Laryngeal cancer
    • Treatment of GERD
      • Lifestyle modifications
      • Antacids
      • Histamine-2 receptor antagonists
      • Proton pump inhibitors
      • Anti-reflux surgery
      • Endoscopic treatment
    • GERD-Lifestyle Modifications
      • Elevate head of bed
      • Decrease fat intake
      • Stop smoking
      • Avoid lying down 3 hrs post prandially
      • Avoid chocolate, alcohol, peppermint, coffee, ?onions/garlic= all lower LES pressure
    • GERD-Antacids
      • Good for milder forms of GERD
      • Gaviscon-antacid/alginic acid may be superior to antacid alone
    •  
    • GERD H2 Blockers
      • Multiple trials showed faster healing vs. placebo of erosive esophagitis
      • Four available-cimetidine (Tagamet),famotidine (Pepcid), nizatidine (Axid), ranitidine (Zantac)-all equally effective
      • Side effects-drug interactions with cimetidine, confusion in elderly,rare cytopenias, elevated LFTs, gynecomastia
    •  
    • GERD- PPIs
      • Proton pump inhibitors provide the most rapid symptomatic relief
      • Five available-esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex)
      • All are generally equal
    • GERD- PPIs
      • Administer prior to meals
      • Side effects-headache, diarrhea, abdominal pain
      • Long term safety
      • ?gastric atrophy
      • ?impaired B12 absorption
      • ?increase in community acquired pneumonia
      • ?decreased absorption of calcium-
      • osteoporosis
    •  
    •  
    • Suggested algorithm for treatment of GERD
    • GERD-Beyond Meds
      • Antireflux surgery
      • Endoscopic treatment
    • Refractory GERD
      • Failed medical management
      • Patient preference for surgery despite successful medical management
      • Complications of GERD
    • GERD-Antireflux Surgery
      • Nissen fundoplication
      • complete (360 degree) wrap of stomach
      • around esophagus
      • Toupet fundoplication
      • partial (270 degree) wrap of stomach
      • around esophagus
    •  
    • GERD-Endoscopic Therapy
      • Stretta-radiofrequency
      • Endocinch-endoscopic sewing
      • Full thickness plication
      • Enteryx-Injection of a nonresorbable polymer
    •  
    • Endocinch
    •  
    • Enteryx-Polymer injection
    • GERD-Summary
      • Cost effective treatment
      • Complications of GERD
      • Newer treatments beyond meds
    • References
      • 1.Devault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterology 2005;100:190-200
      • 2.Heidelbaugh JJ,Nostrant TT et al. Management of Gastroesophageal Reflux Disease. Am Fam Physician 2003;68:1311-16
      • 3.Richter JE, Bradley LC.Psychophysiological interactions in esophageal diseases. Semin Gatrointest Dis 1995;7:169-84
      • 4.DaCosta LR. Value of a therapeutic trial to diagnose gastroesophageal reflux disease:step up versus step down therapy. Can J Gastroenter 1997;11(suppl B):788-818
      • 5.Van Pinxteren B, Numans ME et al. Short term treatment with proton pump inhibitors,H2-receptor antagonists and prokinetics for gastroesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2001;(4):CDO02095
      • 6.Inadomi JM, Jamal R et al. Step-down management of gastroesophageal reflux disease. Gastroenterology 2001;121:1095-100
      • 7.Up to Date On Line
      • 8.Society of American Gastrointestinal Endoscopic Surgeons website- SAGES.org