gastritis, peptic ulcer,

2. Acid Peptic DisordersAcid Peptic Disorders
Acid peptic disorders include a number ofAcid peptic disorders include a number of
diseases, whose etiology can be linked todiseases, whose etiology can be linked to
gastric secretions.gastric secretions.
Gastroesophageal reflux disease, andGastroesophageal reflux disease, and
peptic ulcer disease, are two mostpeptic ulcer disease, are two most
common and well-defined disease states.common and well-defined disease states.

4. GERD is defined as chronic symptoms or mucosalGERD is defined as chronic symptoms or mucosal
damage produced by the abnormal reflux of gastricdamage produced by the abnormal reflux of gastric
contents into the esophagus.contents into the esophagus.
Reflux esophagitis refers to a subgroup of GERDReflux esophagitis refers to a subgroup of GERD
patients with histopathologically demonstratedpatients with histopathologically demonstrated
characteristic changes in the esophageal mucosacharacteristic changes in the esophageal mucosa
Nonerosive reflux disease, also know as endoscopy-Nonerosive reflux disease, also know as endoscopy-
negative reflux disease, refers to patients with typicalnegative reflux disease, refers to patients with typical
GERD symptoms caused by intraesophageal acid whoGERD symptoms caused by intraesophageal acid who
do not have visible mucosal injury at endoscopy.do not have visible mucosal injury at endoscopy.

5. PrevalencePrevalence
Heartburn is a common problem in the United States andHeartburn is a common problem in the United States and
in the Western world, since many individuals controlin the Western world, since many individuals control
symptoms with over-the-counter medications and withoutsymptoms with over-the-counter medications and without
consulting a physician, the condition is likelyconsulting a physician, the condition is likely
underreported.underreported.
Approximately 7% of the population experienceApproximately 7% of the population experience
symptoms of heartburn daily. 20-40% of the people whosymptoms of heartburn daily. 20-40% of the people who
experience heartburn do indeed have GERDexperience heartburn do indeed have GERD
No sexual predilection exists. GERD is as common inNo sexual predilection exists. GERD is as common in
men as in womenmen as in women
GERD occurs in all age groups.GERD occurs in all age groups.
The prevalence of GERD increases in people older thanThe prevalence of GERD increases in people older than
40 years.40 years.

6. EtiologyEtiology
 Lower esophageal sphincter incompetence.Lower esophageal sphincter incompetence.
 Transient lower esophageal sphincterTransient lower esophageal sphincter
relaxation.relaxation.
 Hiatal herniaHiatal hernia
 Obesity: contributing factor in GERDObesity: contributing factor in GERD

7. Typical FeaturesTypical Features
 HeartburnHeartburn
 RegurgitationRegurgitation

8. Atypical FeaturesAtypical Features
 Coughing and/or wheezingCoughing and/or wheezing
 HoarsenessHoarseness
 PneumoniaPneumonia
 BelchingBelching
 LaryngitisLaryngitis
 Otitis mediaOtitis media
 Enamel decay.Enamel decay.

10. DifferentialsDifferentials
 AchalasiaAchalasia
 CholeithiasisCholeithiasis
 Coronary Artery AtherosclerosisCoronary Artery Atherosclerosis
 Esophageal SpasmEsophageal Spasm
 Esophageal CancerEsophageal Cancer
 EsophagitisEsophagitis
 Chronic GastritisChronic Gastritis
 Irritable bowel syndromeIrritable bowel syndrome
 Peptic Ulcer DiseasePeptic Ulcer Disease

11. WORKUPWORKUP
 Barium EsophagogramBarium Esophagogram
 EsophagogastroduodenoscopyEsophagogastroduodenoscopy
 Esophageal manometryEsophageal manometry
 Radionuclide measurement of gastric emptyingRadionuclide measurement of gastric emptying
 Ambulatory 24-hour pH monitoringAmbulatory 24-hour pH monitoring
 Empiric trial of proton pump inhibitorEmpiric trial of proton pump inhibitor
 Multichannel intraluminal impedanceMultichannel intraluminal impedance
 Bravo systemBravo system

15. Medical TreatmentMedical Treatment
Lifestyle ModificationsLifestyle Modifications
 Losing weight (if overweight)Losing weight (if overweight)
 Avoiding alcohol, chocolate, citrus juice,Avoiding alcohol, chocolate, citrus juice,
and tomato-based productsand tomato-based products
 Avoiding large mealsAvoiding large meals
 Waiting 3 hours after a meal before lyingWaiting 3 hours after a meal before lying
downdown
 Elevating the head of the bed 8 inchesElevating the head of the bed 8 inches

16. Treatment Cont.Treatment Cont.
Pharmacologic TherapyPharmacologic Therapy
 AntacidsAntacids
 Prokinetic agents:Prokinetic agents: metoclopramide hydrochloridemetoclopramide hydrochloride
 H2 receptor antagonists:H2 receptor antagonists: Ranitidine, Cimetidine, Famotidine.Ranitidine, Cimetidine, Famotidine.
NizatidineNizatidine
 Proton pump inhibitors:Proton pump inhibitors: Omeprazole, Rabeprazole, Esomeprazole,Omeprazole, Rabeprazole, Esomeprazole,

17. Treatments Cont.Treatments Cont.
 AntacidsAntacids

Prompt but temporary reliefPrompt but temporary relief

No objective proof of superiority to placeboNo objective proof of superiority to placebo
 ProkineticsProkinetics

Improvement of symptoms in mild GERDImprovement of symptoms in mild GERD

Effective for healing only mild erosive esophagitisEffective for healing only mild erosive esophagitis

Can be useful in a select patient populationCan be useful in a select patient population
 HH22RAsRAs

Relief of symptoms in ~50% of patientsRelief of symptoms in ~50% of patients

Effective for healing only mild erosive esophagitisEffective for healing only mild erosive esophagitis

18. Placebo
Meanincreaseintime
toreproduceheartburn
withBernsteintest
x 4.1
x 2.9
x 0
x 1
x 2
x 3
x 4
x 5
Antacid
*
*
*p < 0.05
versus
pre-
treatment
Antacids may be no moreAntacids may be no more
effective than placeboeffective than placebo

19. Chiba et al. Gastroenterology 1997
%esophagitiscaseshealed
0
20
40
60
80
100
2 4 6 8 10
Weeks of treatment
12
PPIs
H2RAs
Placebo
p < 0.0005
PPIs are the most effective drugsPPIs are the most effective drugs
for the initial treatment of GERDfor the initial treatment of GERD

20. Complications.Complications.
 EsophagitisEsophagitis
 StricturesStrictures
 Barrett esophagusBarrett esophagus
 AdenocarcinomaAdenocarcinoma
 Respiratory complications:Respiratory complications: pneumonia, asthma, andpneumonia, asthma, and
interstitial lung fibrosis.interstitial lung fibrosis.

21. Complications cont.Complications cont.

22. Complications cont.Complications cont.

23. Points to RememberPoints to Remember
 Endoscopy reveals that 50% of patients do notEndoscopy reveals that 50% of patients do not
have esophagitis.have esophagitis.
 The only way to determine if abnormal reflux isThe only way to determine if abnormal reflux is
present and if symptoms are actually caused bypresent and if symptoms are actually caused by
GERD is through pH monitoring.GERD is through pH monitoring.
 Achalasia can present with heartburn. OnlyAchalasia can present with heartburn. Only
esophageal manometry and pH monitoring canesophageal manometry and pH monitoring can
be used to distinguish achalasia from GERD.be used to distinguish achalasia from GERD.

24. Peptic Ulcer DiseasePeptic Ulcer Disease
Peptic ulcers are defects in thePeptic ulcers are defects in the
gastrointestinal mucosa that extendgastrointestinal mucosa that extend
through the muscularis mucosa.through the muscularis mucosa.

25. PrevalencePrevalence
Lifetime prevalence is approximately 11-Lifetime prevalence is approximately 11-
14% for men.14% for men.
Lifetime prevalence is approximately 8-Lifetime prevalence is approximately 8-
11% for women.11% for women.
Age trends for ulcer occurrence revealAge trends for ulcer occurrence reveal
declining rates in younger men,declining rates in younger men,
particularly for duodenal ulcer, andparticularly for duodenal ulcer, and
increasing rates in older women.increasing rates in older women.

26. EtiologyEtiology
 Helicobacter pyloriHelicobacter pylori infectioninfection
 Consumption of NSAIDSConsumption of NSAIDS
 Severe physiologic stressSevere physiologic stress
 Hypersecretory statesHypersecretory states

27. SymptomsSymptoms
 Epigastric painEpigastric pain
 NauseaNausea
 VomitingVomiting
 DyspepsiaDyspepsia
 HeartburnHeartburn
 Chest discomfortChest discomfort
 Anorexia, weight lossAnorexia, weight loss
 Hematemesis or melenaHematemesis or melena

28. SignsSigns
 Epigastric tendernessEpigastric tenderness
 Epigastric painEpigastric pain
 Guaiac-positive stoolGuaiac-positive stool
 Succussion splashSuccussion splash

29. DifferentialsDifferentials
 Biliary ColicBiliary Colic
 CholecystitisCholecystitis
 CholelithiasisCholelithiasis
 Gastritis, AcuteGastritis, Acute
 Gastritis, ChronicGastritis, Chronic
 Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease
 Mesenteric Artery IschemiaMesenteric Artery Ischemia
 Myocardial IschemiaMyocardial Ischemia
 Pancreatic CancerPancreatic Cancer
 Pancreatitis, AcutePancreatitis, Acute
 Pancreatitis, ChronicPancreatitis, Chronic

30. WORKUPWORKUP
 Double-contrast radiographyDouble-contrast radiography
 Detection ofDetection of H pyloriH pylori infectioninfection
 Endoscopic testsEndoscopic tests
 Serum gastrinSerum gastrin

31. Medical TreatmentMedical Treatment
 H. pyloriH. pylori eradication: Dual/Triple therapyeradication: Dual/Triple therapy
 Cessation of NSAIDsCessation of NSAIDs
 H2-receptor antagonistsH2-receptor antagonists
 Proton Pump InhibitorsProton Pump Inhibitors
 ProstaglandinsProstaglandins misoprostolmisoprostol
 SucralfateSucralfate sucrose-aluminum complex promotes ulcer healingsucrose-aluminum complex promotes ulcer healing

32. FDA-Approved TreatmentFDA-Approved Treatment
RegimesRegimes
forfor H. pyloriH. pylori InfectionInfection

Omeprazole 20 mg BID + ClarithromycinOmeprazole 20 mg BID + Clarithromycin
500 mg BID + Amoxicillin 1 g BID for 10 days500 mg BID + Amoxicillin 1 g BID for 10 days

Lansoprazole 30 mg BID +ClarithromycinLansoprazole 30 mg BID +Clarithromycin
500 mg BID + Amoxicillin 1 g BID for 10 days500 mg BID + Amoxicillin 1 g BID for 10 days

Bismuth subsalicylate (Pepto Bismol) 525 mgBismuth subsalicylate (Pepto Bismol) 525 mg
QID + Metronidazole 250 mg QID +QID + Metronidazole 250 mg QID +
Tetracycline 500 mg QID X 14 days + HTetracycline 500 mg QID X 14 days + H22
receptor antagonist x 4 wksreceptor antagonist x 4 wks

33. Adjunctive TreatmentAdjunctive Treatment
 Caffeine and AlcoholCaffeine and Alcohol - Both of these stimulate- Both of these stimulate
the secretion of stomach acid and should bethe secretion of stomach acid and should be
avoided in the acute phase of an ulcer.avoided in the acute phase of an ulcer.
 CigarettesCigarettes - Nicotine will delay the healing of an- Nicotine will delay the healing of an
ulcer.ulcer.
 AntacidsAntacids - These agents, can be used for relief- These agents, can be used for relief
of peptic ulcer symptoms. Except for bismuthof peptic ulcer symptoms. Except for bismuth
(Pepto Bismol),- they do not help heal ulcers.(Pepto Bismol),- they do not help heal ulcers.

34. ComplicationsComplications
 HemorrhageHemorrhage
 Confined PerforationConfined Perforation
 Open PerforationOpen Perforation
 Gastric outlet obstructionGastric outlet obstruction
 RecurrenceRecurrence
 Stomach cancer:Stomach cancer: Adenocarcinoma, Gastric/MALTAdenocarcinoma, Gastric/MALT
lymphomaslymphomas

35. Clean Ulcer Induced by AspirinClean Ulcer Induced by Aspirin

36. Gastric Ulcer H.Pylori & AspirinGastric Ulcer H.Pylori & Aspirin

37. MCQSMCQS
1) Gold standard for investigating GERD?1) Gold standard for investigating GERD?
A) Endoscopic TestsA) Endoscopic Tests
B) Esophageal manometerB) Esophageal manometer
C) Multichannel intraluminal impedanceC) Multichannel intraluminal impedance
D) Bravo SystemD) Bravo System
E) None of the aboveE) None of the above

38. 2) Which of the following statements is false?2) Which of the following statements is false?
A) Antacids are not clearly superior to placebosA) Antacids are not clearly superior to placebos
B) NSAIDS most common cause of PUDB) NSAIDS most common cause of PUD
C) Dysphagia is an alarm symptomsC) Dysphagia is an alarm symptoms
D) H2RA Effective healing only mild esophagitisD) H2RA Effective healing only mild esophagitis
E) Nicotine delays healing of an ulcerE) Nicotine delays healing of an ulcer

39. ThanksThanks