Answering the burning questions of acid reflux


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June 2013 Via Christi Women's Connection presentation on acid reflux by Kyle Vincent, MD, with Via Christi Clinic.

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Answering the burning questions of acid reflux

  1. 1. Answering the burningquestions of Acid RefluxKyle B. Vincent, MDJune 11, 2013
  2. 2. ObjectivesWhat causes acid reflux?When is it more than just “heartburn”?What are the surgical options for reflux?Can it lead to anything bad?
  3. 3. Prevalence of GERD59% of the population has symptoms on amonthly basis19.8 symptoms on a weekly basis4-7% symptoms on a daily basis(Locke et al. Gastroenterology 1997;112:1148.)
  4. 4. What causes acid reflux?
  5. 5. DefinitionAny symptoms or esophageal mucosaldamage that results from reflux of gastricacid into the esophagus.Classic GERD symptoms Heartburn (pyrosis): substernal burning discomfort After eating (postprandial) Aggravated by change in position Prompt relief by antacids Regurgitation (water brash): bitter, acidic fluid in themouth when lying down or bending over
  6. 6. PhysiologyAcidity necessary fordigestion
  7. 7. AnatomyThe only organ totraverse threebody cavities
  8. 8. GE Junctionsquamous epitheliumcolumnar epithelium
  9. 9. HistologyMucosal layer is squamous epithelium Through most of the courseZ-line Distal 1 – 2cm of esophageal mucosa Transition to columnar epithelium
  10. 10. Mechanisms to Prevent InjuryClearanceMucosal liningLES competence Decrease in resting tone Hiatal herniaGastric emptying
  11. 11. Hiatal HerniaNOT everyone with a hiatal hernia hasGERD.
  12. 12. When is it more than just“heartburn”?
  13. 13. WARNING!Reflux symptoms are almost neverassociated with shortness of breath, difficultybreathing, feeling like you’re going to passout, or a feeling of impending doom.“Better to be in the emergency room and feelsilly than at home and feel dead”
  14. 14. Work UpTraditional symptoms No further work up Treat empiricallySymptoms associated with complications Barium swallow EndoscopyPrior to surgical intervention Ambulatory pH monitoring Esophageal manometryH2 BlockersPepcidZantacPPIProtonixPrevacidNexium
  15. 15. ENTHoarsenessLaryngitisPharyngitisChronic coughGlobus sensationDysphoniaSinusitisSubglottic stenosisLaryngeal cancerPulmonaryAsthmaAspiration pneumoniaChronic bronchitisPulmonary fibrosisOtherChest painDental erosionExtraesophagealManifestationsVaezi et al. Clin Gastro Hep 2003;1:333-344.
  16. 16. TreatmentMedical Options
  17. 17. TreatmentLifestyle Modifications Elevate head of bed 4-6 inches Avoid eating within 2-3 hours of bedtime Lose weight if overweight Stop smoking Modify diet Eat more frequent but smaller meals Avoid fatty/fried food, peppermint, chocolate, alcohol,carbonated beverages, coffee and teaOTC medications as neededPrescription medications
  18. 18. ComplicationsEsophagitisPeptic StrictureBarrett’
  19. 19. Imaging/DiagnosticsEsophagramEndoscopy
  20. 20. Barrett’s EsophagusMetaplasia – One kind of fully differentiatedcell replaces another kind of fullydifferentiated cell Usually squamous epithelium replaces a columnarepitheliumIntestinal, columnar epithelium replaces thestratified squamous epithelium at the distalesophagus More resistant to injury More susceptible to developing carcinoma 40 Fold increase in risk
  21. 21. Barrett’s HistologyBenign glands inthe lower rightBarretts columnarcell metaplasia witha large goblet cellcontaining bluemucin in the lowercenterAdenocarcinomaon the left
  22. 22. Endoscopic Views of Barrett’sSalmon Colored Lesion
  23. 23. Barrett’s Monitoring4 Quadrant Bx every 1cm
  24. 24. ControversyAnti-reflux Surgery in Barrett’s Proponents Regression of metaplasia in 57% of Patients Controls symptoms without medications Opponents Screening becomes more difficult 20% failure rate at 5 years in controlling symptoms
  25. 25. TreatmentSurgical Options
  26. 26. Helping???
  27. 27. When is surgery an option?Intractable GERD Difficult to manage strictures Severe bleeding from esophagitis Non-healing ulcersGERD requiring long-term PPI (10 years) Healthy young patient “…operative therapy is considered an alternative tomedical therapy rather than a treatment of lastresort.” – Sabiston’s 18th EditionPersistent regurgitation/aspiration symptomsNot Barrett’s esophagus aloneWARNING: Bewarethe patient that does notrespond to PPItreatment!
  28. 28. pH ProbeMedscape: General Surgery Edition
  29. 29. DeMeester ScoreMeasure of lower esophageal acidity A score of >14.72 shows significant reflux.Scored in comparison to mean values Supine reflux Upright reflux Total reflux Number of episodes Number of episodes longer than 5 min Longest episodeAm J Gastroenterol. 1974 Oct;62(4):325-32.
  30. 30. Manometry
  31. 31. Anti-Reflux SurgeryNissen
  32. 32. FundoplicationsWrap tailored tosituation
  33. 33. Complications of SurgeryCollapsed lung 3%Difficulty swallowing(Dysphagia) 30% Post-op 2% after 2 monthsDeath 0.5% 8.3% for patients over age 80Failures 5%GI Motility online (May 2006) | doi:10.1038/gimo56Mechanisms of fundoplication failure.
  34. 34. Cancer of the EsophagusCan it lead to anything bad?
  35. 35. EpidemiologyAdenocarcinoma of esophagus has the fastestgrowing incidence rate of all cancers in the U.S. 17,460 new cases per year 15,070 deathsDrastic shift in epidemiology Prior to 1970 90-95% of all esophageal cancer was squamous cellcarcinoma Thoracic esophagus in African American males whosmoke & drank EtOH Currently Adenocarcinoma of the distal esophagus& GE junction accounts for nearly 70%86% mortality rateOverall 5 yearsurvival rate was16.9%
  36. 36. SymptomsDysphagia Solid food first 2/3 of the lumen may be obstructed beforeany symptoms are noted On average 24mm esophagus will narrow toless than 12mm before dysphagia is noticedWeight Loss
  37. 37. Squamous Cell Carcinoma of theEsophagusUpper and middle 2/3 of the esophagusSmoking and alcohol Both increase risk 5 fold Together the risk increases to 25 foldNitrosamines Food additive to pickled & smoked foodsLong term ingestion of hot liquids
  38. 38. Adenocarcinoma of the EsophagusDistal 1/3 of the esophagusGERDWestern diet Caffeine, fats, acidic, & spicy food alldecrease LES tone
  39. 39. STAGING
  40. 40. RecapWhat causes acid reflux?When is it more than just “heartburn”?What are the surgical options for reflux?Can it lead to anything bad?
  41. 41. SURPRISE!The End