Git Gerd 08.


Published on

Medical college lectures: GIT 4th year.

Published in: Education, Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Git Gerd 08.

    1. 1. Gastroesophageal Reflux Disease (GERD) <ul><li>Any symptoms or esophageal mucosal damage,causing discomfort, that results from reflux of gastric acid into the esophagus </li></ul><ul><li>GERD resulting in heartburn affects 30% of the general population </li></ul><ul><li>Classic GERD symptoms </li></ul><ul><ul><li>Heartburn (pyrosis): substernal burning discomfort </li></ul></ul><ul><ul><li>Regurgitation: bitter, acidic fluid in the mouth when lying down or bending over </li></ul></ul>
    2. 2. High Prevalence of Gastroesophageal Reflux Symptoms
    3. 4. Important Reasons to Diagnose and Treat GERD <ul><li>Negative impact on health-related quality of life 1 </li></ul><ul><li>Risk factor for esophageal adenocarcinoma 2 </li></ul><ul><li>Revicki et al. Am J Med 1998;104:252. </li></ul><ul><li>Lagergren et al. N Engl J Med 1999;340:825. </li></ul>
    4. 5. Pathophysiology: <ul><li>Occasional episodes of GERD are common in health. </li></ul><ul><li>Reflux is normally followed by oesophageal peristaltic waves which efficiently clear the eso, alkaline saliva neutralises residual acid& symptoms do not occur. </li></ul><ul><li>GERD develops when the oesophageal mucosa is exposed to gastric contents for prolonged periods of time, resulting in symptoms & in a proportion of cases, oesophagitis. </li></ul><ul><li>Several factors are known to be involved: </li></ul>
    5. 7. 1.AbnormaL LES: <ul><li>In health, LES is tonically contracted, relaxing only during swallowing. </li></ul><ul><li>Some patients with GERD have reduced LES, permitting reflux when intra-abdominal pressure rises. </li></ul><ul><li>In others, basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter relaxation </li></ul>
    6. 8. 2.HH: <ul><li>Hiatus hernia causes reflux because: </li></ul><ul><li>A. The pressure gradient between the abdominal & thoracic cavities, which normally pinches the hiatus, is lost. </li></ul><ul><li>B. The oblique angle between the cardia& oesophagus disappears. </li></ul><ul><li>Many patients who have large hiatus hernias develop reflux symptoms, but the relationship between the presence of a HH& symptoms is poor. </li></ul><ul><li>Hiatus hernia is very common in individuals who have no symptoms& some symptomatic patients have only a very small or no hernia. </li></ul><ul><li>Nevertheless, almost all patients who develop oesophagitis, Barrett's oesophagus or peptic strictures have a hiatus hernia. </li></ul>
    7. 9. 2.HH: <ul><li>IMPORTANT FEATURES OF HIATUS HERNIA </li></ul><ul><li>Herniation of the stomach through the diaphragm into the chest </li></ul><ul><li>Occurs in 30% of the population > 50 years </li></ul><ul><li>Often asymptomatic </li></ul><ul><li>Heartburn & regurgitation can occur </li></ul><ul><li>Gastric volvulus may complicate large para-oesophageal hernias </li></ul>
    8. 11. 3.Delayed oesophageal clearance : <ul><li>Defective oesophageal peristaltic activity is commonly found in patients who have oesophagitis. </li></ul><ul><li>It is a primary abnormality, since it persists after oesophagitis has been healed by PPI. </li></ul><ul><li>Poor oesophageal clearance leads to increased acid exposure time. </li></ul>
    9. 12. 4.Gastric contents <ul><li>Is the most important oesophageal irritant& there is a close relationship between acid exposure time & symptoms. </li></ul>
    10. 13. 5. Defective gastric emptying <ul><li>Gastric emptying is delayed in GERD. </li></ul><ul><li>The reason for this is unknown. </li></ul>
    11. 14. 6. Others <ul><li>Recent attention on the importance of duodenogastro-oesophageal reflux, containing bile, pancreatic enzymes&pepsin in addition to acid. </li></ul>
    12. 15. 7. Increased inra abd pressure: <ul><li>Pregnancy </li></ul><ul><li>Obesity: Weight loss may improve symptoms </li></ul>
    13. 16. 6. Diet / environmental factors : <ul><li>Dietary fat, chocolate, alcohol , coffee relax LES & provoke symptoms. </li></ul><ul><li>There is little evidence to incriminate smoking or NSAIDs as a causes. </li></ul>
    14. 17. Clinical features <ul><li>The major symptoms are heartburn /regurgitation, often provoked by bending, straining or lying down. </li></ul><ul><li>'Waterbrash‘: salivation from reflex salivary gland stimulation as acid enters the eso, is often present. </li></ul><ul><li>A history of weight gain is common. </li></ul><ul><li>Some patients are woken at night by choking as refluxed fluid irritates the larynx. </li></ul><ul><li>Others develop odynophagia or dysphagia. </li></ul><ul><li>A few present with atypical chest pain which may be severe, can mimic angina probably due to reflux-induced oesophageal spasm. </li></ul>
    15. 18. Clinical features <ul><li>Classic GERD </li></ul><ul><li>Extraesophageal/Atypical GERD </li></ul><ul><li>Complicated GERD </li></ul>Clinical Presentations of GERD
    16. 20. Extraesophageal Manifestations of GERD <ul><li>Pulmonary </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Aspiration pneumonia </li></ul></ul><ul><ul><li>Chronic bronchitis </li></ul></ul><ul><ul><li>Pulmonary fibrosis </li></ul></ul><ul><li>Other </li></ul><ul><li>Chest pain </li></ul><ul><li>Dental erosion </li></ul><ul><li>ENT </li></ul><ul><ul><li>Hoarseness </li></ul></ul><ul><ul><li>Laryngitis </li></ul></ul><ul><ul><li>Pharyngitis </li></ul></ul><ul><ul><li>Chronic cough </li></ul></ul><ul><ul><li>Globus sensation </li></ul></ul><ul><ul><li>Dysphonia </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul><ul><ul><li>Subglottic stenosis </li></ul></ul><ul><ul><li>Laryngeal cancer </li></ul></ul>
    17. 21. Potential Oral & Laryngopharyngeal Signs Associated with GERD <ul><li>Edema /hyperemia of larynx </li></ul><ul><li>Vocal cord erythema, polyps, granulomas, ulcers </li></ul><ul><li>Hyperemia & lymphoid hyperplasia of posterior pharynx </li></ul><ul><li>Interarytenyoid changes </li></ul><ul><li>Dental erosion </li></ul><ul><li>Subglottic stenosis </li></ul><ul><li>Laryngeal cancer </li></ul>Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.
    18. 22. Pathophysiology of Extraesophageal GERD
    19. 23. Complications: 1. Oesophagitis <ul><li>A range of endoscopic findings, from mild redness to severe. With bleeding, ulceration &stricture formation. </li></ul><ul><li>There is a poor correlation between symptoms, histological &endoscopic findings. </li></ul><ul><li>Significant GERD may be present despite normal endoscopy / normal oesophageal histology. </li></ul>
    20. 24. Complications: Oesophagitis
    21. 25. Complications:2.Barrett's oesophagus <ul><li>‘ Columnar lined oesophagus'-CLO, is a pre-malignant glandular intestinal metaplasia of the lower oeso, in which the normal squamous lining is replaced by columnar mucosa. </li></ul><ul><li>Occurs as an adaptive response to chronic GERD,found in 10% undergoing gastroscopy for reflux symptoms. </li></ul><ul><li>CLO is the major risk factor for oesophageal adenocarcinoma, with a lifetime cancer risk of 10%, more closely related to the severity& duration of reflux rather than the CLO per se. </li></ul><ul><li>The cancer incidence is estimated at 1/200 patient years (0.5% /year), being low& > 95% with CLO die of causes other than oesophageal cancer. </li></ul><ul><li>Prevalence is increasing, more in men (especially white) &> 50. </li></ul><ul><li>It is weakly associated with smoking but not alcohol. </li></ul><ul><li>E-cadherin polymorphisms, p53 mutations, TGF-β, EGF receptors, COX-2& TNF-α may play roles. </li></ul>
    22. 26. Barrett Diagnosis:diagnosis <ul><li>Requires multiple systematic biopsies to maximise the chance of detecting intestinal metaplasia /or dysplasia. </li></ul>
    23. 27. Barret:Management <ul><li>Neither PPI nor antireflux surgery will stop progression or induce regression of CLO& treatment is only indicated for symptoms of reflux or complications such as stricture. </li></ul><ul><li>Endoscopic ablation therapy or photodynamic therapy can induce regression but 'buried islands' of glandular mucosa may persist underneath the squamous epithelium& cancer risk is not eliminated. </li></ul><ul><li>At present these therapies remain experimental but show promise; they are also used in patients with high-grade dysplasia (HGD) or early malignancy who are not suitable for surgery. </li></ul>
    24. 28. Barret: Management <ul><li>Regular endoscopic surveillance can detect dysplasia& malignancy at an early stage & improve 2-year survival but, because most CLO is undetected until cancer develops, surveillance strategies are unlikely to influence the overall mortality rate of oesophageal cancer. </li></ul><ul><li>Surveillance is expensive &cost-effectiveness conflicting. </li></ul><ul><li>Surveillance is currently recommended every 2-3 years for those without dysplasia & at 6-12-monthly intervals for those with low-grade dysplasia. </li></ul><ul><li>Oesophagectomy is widely recommended for those with HGD as the resected specimen harbours cancer in up to 40%. </li></ul><ul><li>Recent data suggest that HGD often remains stable & may not progress to cancer, at least in the medium term. </li></ul><ul><li>Close follow-up with biopsies every 3 months is an alternative strategy for those with HGD. </li></ul>
    25. 29. Complications:3. IDA <ul><li>Occurs as a consequence of chronic, insidious blood loss from long-standing oesophagitis. </li></ul><ul><li>Almost all such patients have a large hiatus hernia& bleeding can occur from subtle erosions in the neck of the sac ('Cameron lesions </li></ul>
    26. 30. Complications: 4.Benign oesophageal stricture <ul><li>Develop as a consequence of long-standing oesophagitis. </li></ul><ul><li>Most elderly & have poor oesophageal peristaltic activity. </li></ul><ul><li>Present with dysphagia which is worse for solids than liquids. </li></ul><ul><li>Bolus obstruction following ingestion of meat causes absolute dysphagia. </li></ul><ul><li>A history of heartburn is common but not invariable;as in many elderly patients. </li></ul><ul><li>Diagnosis is made by endoscopy, with biopsies to exclude Cancer. </li></ul><ul><li>Endoscopic balloon dilatation or bouginage is helpful. </li></ul><ul><li>Subsequently, long-term therapy with a PPI at full dose should be started to reduce the risk of recurrent oesophagitis & stricture formation. </li></ul>
    27. 31. GERD:Investigations <ul><li>Young patients with typical symptoms, without worrying features such as dysphagia, weight loss or anaemia, can be treated empirically without investigation. </li></ul><ul><li>Investigation is advisable if patients present in middle or late age, if symptoms are atypical or if a complication is suspected. </li></ul><ul><li>Endoscopy is the investigation of choice, performed to exclude other upper GI diseases & identify complications. </li></ul><ul><li>A normal endoscopy in a patient with compatible symptoms should not preclude treatment for GERD. </li></ul><ul><li>Twenty-four-hour pH monitoring is indicated if, despite endoscopy, the diagnosis is not clear. </li></ul><ul><li>A pH of < 4 for > 6-7% of the study time is diagnostic of GERD. </li></ul>
    28. 33. When to Perform Diagnostic Tests <ul><li>Uncertain diagnosis </li></ul><ul><li>Atypical symptoms </li></ul><ul><li>Symptoms associated with complications </li></ul><ul><li>Inadequate response to therapy </li></ul><ul><li>Recurrent symptoms </li></ul><ul><li>Prior to anti-reflux surgery </li></ul>
    29. 34. Diagnostic Tests for GERD <ul><li>Barium swallow </li></ul><ul><li>Endoscopy </li></ul><ul><li>Ambulatory pH monitoring </li></ul><ul><li>Esophageal manometry </li></ul>
    30. 35. Barium Swallow <ul><li>Useful first diagnostic test for patients with dysphagia </li></ul><ul><ul><li>Stricture (location, length) </li></ul></ul><ul><ul><li>Mass (location, length) </li></ul></ul><ul><ul><li>Bird’s beak </li></ul></ul><ul><ul><li>Hiatal hernia (size, type) </li></ul></ul><ul><li>Limitations </li></ul><ul><ul><li>Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus </li></ul></ul>
    31. 36. Endoscopy <ul><li>Indications for endoscopy </li></ul><ul><ul><li>Alarm symptoms </li></ul></ul><ul><ul><li>Empiric therapy failure </li></ul></ul><ul><ul><li>Preoperative evaluation </li></ul></ul><ul><ul><li>Detection of Barrett’s esophagus </li></ul></ul><ul><ul><li>Detect grade: LA grading classification system for GERD. </li></ul></ul>
    32. 37. The LA Classification system – Grade A reflux esophagitis Stomach Grade A : One (or more) mucosal break, no longer than 5 mm, that does not extend between the tops of two mucosal folds.
    33. 38. The LA Classification system – Grade B reflux esophagitis Stomach Grade B : One (or more) mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds.
    34. 39. The LA Classification system – Grade C reflux esophagitis Stomach Grade C : One (or more) mucosal break that is continuous between the tops of two or more mucosal folds, but which involves less than 75% of the circumference.
    35. 40. The LA Classification system – Grade D reflux esophagitis Stomach Grade D : One (or more) mucosal break that involves at least 75% of the esophageal circumference.
    36. 41. Ambulatory 24 hr. pH Monitoring <ul><li>Physiologic study </li></ul><ul><li>Quantify reflux in proximal/distal esophagus </li></ul><ul><ul><li>% time pH < 4 </li></ul></ul><ul><ul><li>DeMeester score </li></ul></ul><ul><li>Symptom correlation </li></ul>
    37. 42. Ambulatory 24 hr. pH Monitoring Normal GERD
    38. 43. Wireless, Catheter-Free Esophageal pH Monitoring <ul><li>Improved patient comfort / acceptance </li></ul><ul><li>Continued normal work, activities&diet study </li></ul><ul><li>Longer reporting periods possible (48 hours) </li></ul><ul><li>Maintain constant probe position . </li></ul>Potential Advantages
    39. 44. Esophageal Manometry <ul><li>Assess LES pressure, location / relaxation </li></ul><ul><ul><li>Assist placement of 24 hr. pH catheter </li></ul></ul><ul><li>Assess peristalsis </li></ul><ul><ul><li>Prior to antireflux surgery </li></ul></ul>Limited role in GERD
    40. 45. Treatment Goals for GERD <ul><li>Eliminate symptoms </li></ul><ul><li>Heal esophagitis </li></ul><ul><li>Manage or prevent complications </li></ul><ul><li>Maintain remission </li></ul>
    41. 46. Management: Life-style <ul><li>Weight loss </li></ul><ul><li>Avoidance of dietary items that worsen symptoms. </li></ul><ul><li>Elevation of the bed head in those who experience nocturnal symptoms </li></ul><ul><li>Avoidance of late meals </li></ul><ul><li>Modify diet </li></ul><ul><ul><li>Eat more frequent but smaller meals </li></ul></ul><ul><ul><li>Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and tea. </li></ul></ul><ul><li>Avoid eating within 2-3 hours of bedtime. </li></ul><ul><li>Giving up smoking. </li></ul>
    42. 47. Management: antacids <ul><li>Proprietary antacids &alginates also provide symptomatic benefit. </li></ul><ul><li>H2-receptor antagonist drugs also help symptoms without healing oesophagitis. </li></ul><ul><li>PPI are the treatment of choice for severe symptoms &for complicated reflux disease </li></ul><ul><li>PPI are better than H2Bs in healing oesophagitis& relieving symptoms. </li></ul><ul><li>Symptoms almost invariably resolve& oesophagitis heals in the majority of patients. </li></ul><ul><li>Recurrence of symptoms is common when therapy is stopped& some require life-long treatment at the lowest acceptable dose. </li></ul>
    43. 48. Effectiveness of Medical Therapies for GERD Treatment Response Lifestyle modifications/antacids 20 % H 2 -receptor antagonists 50 % Single-dose PPI 80 % Increased-dose PPI up to 100 %
    44. 49. Treatment Modifications for Persistent Symptoms <ul><li>Improve compliance </li></ul><ul><li>Optimize pharmacokinetics </li></ul><ul><ul><li>Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime) </li></ul></ul><ul><ul><li>Allows for high blood level to interact with parietal cell proton pump activated by the meal </li></ul></ul><ul><li>Consider switching to a different PPI as esmo or rebeprazol. </li></ul>
    45. 50. GERD is a Chronic Relapsing Condition <ul><li>Esophagitis relapses quickly after cessation of therapy </li></ul><ul><ul><li>> 50 % relapse within 2 months </li></ul></ul><ul><ul><li>> 80 % relapse within 6 months </li></ul></ul><ul><li>Effective maintenance therapy is imperative </li></ul>
    46. 51. GERD IN OLD AGE <ul><li>Prevalence: higher. </li></ul><ul><li>Severity of symptoms: does not correlate with the degree of mucosal inflammation. </li></ul><ul><li>Complications: late complications as peptic strictures or bleeding from oesophagitis are more common. </li></ul><ul><li>Recurrent pneumonia: consider aspiration from occult GERD. </li></ul>
    47. 53. Erosive Esophagitis
    48. 54. Peptic Stricture Barium Swallow Endoscopy
    49. 55. Esophageal Stricture: Dilating Devices
    50. 56. TTS Balloon Dilation of a Peptic Stricture
    51. 57. Barrett’s Esophagus
    52. 58. Esophageal Cancer Barium Swallow Endoscopy
    53. 60. When to Discuss Anti-Reflux Surgery with Patients <ul><li>Intractable GERD – rare </li></ul><ul><ul><li>Difficult to manage strictures </li></ul></ul><ul><ul><li>Severe bleeding from esophagitis </li></ul></ul><ul><ul><li>Non-healing ulcers </li></ul></ul><ul><li>GERD requiring long-term PPI-BID in a healthy young patient </li></ul><ul><li>Persistent regurgitation/aspiration symptoms </li></ul><ul><li>Not Barrett’s esophagus alone </li></ul>
    54. 61. Endoscopic GERD Therapy <ul><li>Endoscopic antireflux therapies </li></ul><ul><ul><li>Radiofrequency energy delivered to the LES </li></ul></ul><ul><ul><ul><li>Stretta procedure </li></ul></ul></ul><ul><ul><li>Suture ligation of the cardia </li></ul></ul><ul><ul><ul><li>Endoscopic plication </li></ul></ul></ul><ul><ul><li>Submucosal implantation of inert material in the region of the lower esophageal sphincter </li></ul></ul><ul><ul><ul><li>Enteryx </li></ul></ul></ul>
    55. 62. Time is cruel: