GERD is a day to day common problem, which is on the increase due to so many obvious reasons. It needs to be addressed to the public and the medical fraternity for proper management and treatment.
Gastro esophageal Reflux Disease (GERD) and its managementDr. Ankit Gaur
In this presentation I have tried to explain in brief about gastro esophageal Reflux Disease (GERD), its etiology, risk factors, diagnosis, and its management via pharmacotherapy.
Ulcerative colitis (UC) is an inflammatory bowel disease. It causes irritation, inflammation, and ulcers in the lining of your large intestine (also called your colon). There's no cure, and people usually have symptoms off and on for life
Gastro esophageal Reflux Disease (GERD) and its managementDr. Ankit Gaur
In this presentation I have tried to explain in brief about gastro esophageal Reflux Disease (GERD), its etiology, risk factors, diagnosis, and its management via pharmacotherapy.
Ulcerative colitis (UC) is an inflammatory bowel disease. It causes irritation, inflammation, and ulcers in the lining of your large intestine (also called your colon). There's no cure, and people usually have symptoms off and on for life
GERD is the commonest GI problem afflicting the mankind. The cause is lax LES which is just opposite to Achalasia cadia. That is why GERD is also known as Chalasia cardia.
GERD is the commonest GI problem afflicting the mankind. The cause is lax LES which is just opposite to Achalasia cadia. That is why GERD is also known as Chalasia cardia.
As we enter in the Modern day, we are witnessing dawn of the new trend in which closed body operating procedures are more often being performed through minimal access. This development is the consequence of vision and work of many dedicated individuals. They include early pioneers of endoscopy who planted the seed and lastly the current pioneers who pushed and expanded these frontiers to give rise the birth of modern laparoscopy. Therapeutic laparoscopic surgery was introduced into the surgical practice recently and within a short span of time, it has become established as defacto standard for the treatment of chronic cholelithiasis and many advanced laparoscopic procedures can be performed safely. Laparoscopic surgery, what we should witness today, may be the culmination of over a hundred years of painstaking efforts from the number of pioneers within the fields of optics, instrumentation and video laparoscopic camera. Few advances in medicine occur in isolation. The innate human curiosity to peer within the body cavities can be traced back to ancient times. However, due to primitive technology and crude instruments, several ambitions were not realized. It is probably safe to say that first laparoscopy would not have been performed had it not been for the efforts of many physicians in 1800s to develop endoscope. The device developed by Theodore Stein in mid 1880 contains all the aspects of the current endoscopic documentation system. There was a crude endoscope and a high intensity light source. Illumination was made by continuously feeding a magnesium wire into an ignition chamber utilizing a clockwise mechanism. Light from this combustion was reflected to the tube utilizing a mirror. Finally the look was focused on to some photographic plate through coupling optics.
Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation. Severe constipation includes obstipation (failure to pass stools or gas) and fecal impaction, which can progress to bowel obstruction and become life-threatening.
Constipation is a symptom with many causes. These causes are of two types: obstructed defecation and colonic slow transit (or hypo mobility). About 50 percent of people evaluated for constipation at tertiary referral hospitals have obstructed defecation. This type of constipation has mechanical and functional causes. Causes of colonic slow transit constipation include diet, hormonal disorders such as hypothyroidism, side effects of medications, and rarely heavy metal toxicity. Because constipation is a symptom, not a disease, effective treatment of constipation may require first determining the cause. Treatments include changes in dietary habits, laxatives, enemas, biofeedback, and in particular situations surgery may be required.
Constipation is common; in the general population rates of constipation varies from 2–30 percent. In elderly people living in care homes the rate of constipation is 50–75 percent.[4] In the United States expenditures on medications for constipation are greater than US$250 million per year.
The definition of constipation includes the following:
infrequent bowel movements (typically three times or fewer per week)
difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools; straining in this context is a strong effort to push out stool often by holding one's breath and by pushing the respective muscles in the abdominal area hard), or
the sensation of incomplete bowel evacuation.
The Rome III criteria are widely used to diagnose chronic constipation, and are helpful in separating cases of chronic functional constipation from less-serious instances.
Another definition states that less than three bowel movements per week and straining on more than 75% of occasions represents constipation in clinical surveys.
Laparoscopic Urologic surgery, is a part of the curriculum of Minimal Access Surgery, and requires lot of skills and patience. All new surgeons carrying out Basic Laparoscopic surgery should aim at also doing Lap. Urological surgeries, which has a steep learning curve, but with with excellent outcomes.
New Treatments for GERD and Barrett's EsophagusSummit Health
Learn the symptoms of Gastroesophageal Reflux Disease (GERD) and Barrett’s esophagus, and when they may warrant further medical attention. Hear the latest in treatment methods, including radio frequency ablation and endoscopic ultrasound.
Its an overview about Gastro-Esophageal Reflux Disease, mainly focused on Clinical features, Role of Investigation, Diagnostic Criteria, Management plan.
It was mainly prepared for a scientific seminer. It may help others as well.
Really putting such patients first means: 4 ensuring that such patients have continuity of care with a healthcare professional whom the patient knows and trusts; longer appointments as required;shared decision making and an agreed care plan; and easy access to care.
The presence of haematuria may be the sole symptom of an underlying disease, either benign or malignant. It is one of the most common presentations of patients with urinary tract diseases and of patients referred for urinary imaging. Painless visible haematuria (VH) is the commonest presentation of bladder cancer.
CBDSs are one of the medical conditions leading to surgical intervention. They may occur in 3%–14.7% of all patients for whom cholecystectomies are preformed. When patients present with CBD, the one important question that should be answered: what is the best modality of treatment under the giving conditions? There are competing technologies and approaches for diagnosing CBDS with regard to diagnostic performance characteristics, technical success, safety, and cost effectiveness. Management of CBDS usually requires two separate teams: the gastroenterologist and the surgical team. One of the main factors in the management is initially the detection of CBDS, before, during, or after cholecystectomy. The main options for treatment are pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST), laparoscopic or open surgical bile duct clearance. There are other options for the treat- ment of CBDS such as electrohydraulic lithotripsy (EHL), extracorporeal shockwave lithotripsy (ESWL), dissolving solutions, and laser lithotripsy. It is unlikely that one option
will be appropriate for all clinical circumstances in all centers. Variables such as disease status, patient demographics, availability of endoscopic, radiological and surgical expertise, and healthcare economics will all have significant influence on practice
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
Ageing, also spelled aging, is the process of becoming older. The term refers especially to human beings, many animals, and fungi, whereas for example bacteria, perennial plants and some simple animals are potentially immortal. In the broader sense, ageing can refer to single cells within an organism which have ceased dividing (cellular senescence) or to the population of a species (population ageing).
In humans, ageing represents the accumulation of changes in a human being over time,[1] encompassing physical, psychological, and social change. Reaction time, for example, may slow with age, while knowledge of world events and wisdom may expand. Ageing is among the greatest known risk factors for most human diseases:[2] of the roughly 150,000 people who die each day across the globe, about two thirds die from age-related causes.
The causes of ageing are uncertain; current theories are assigned to the damage concept, whereby the accumulation of damage (such as DNA oxidation) may cause biological systems to fail, or to the programmed ageing concept, whereby internal processes (such as DNA methylation) may cause ageing. Programmed ageing should not be confused with programmed cell death (apoptosis).
The Ideal Suture Material
Can be used in any tissue
Easy to handle
Good knot security
Minimal tissue reaction
Unfriendly to bacteria
Strong yet small
Won’t tear through tissues
Cheap
USES:
To bring tissue edges together and speed wound healing (=tissue apposition)
Orthopedic surgery to help stabilize joints
Repair ligaments
Ligate vessels or tis
Robotic Surgery means computer/ Robotic assisted surgery.
It was developed to overcome the limitations of MAS and to enhance the capabilities of surgeons performing open Surgery History of Robotic surgery
The first robot to assist in surgery was the Arthrobot, which was developed and used for the first time in Vancouver in 1983.[43] Intimately involved were biomedical engineer, Dr. James McEwen, Geof Auchinleck, a UBC engineering physics grad, and Dr. Brian Day as well as a team of engineering students. The robot was used in an orthopaedic surgical procedure on 12 March 1984, at the UBC Hospital in Vancouver.
Over 60 arthroscopic surgical procedures were performed in the first 12 months, and a 1985 National Geographic video on industrial robots, The Robotics Revolution, featured the device. Other related robotic devices developed at the same time included a surgical scrub nurse robot, which handed operative instruments on voice command, and a medical laboratory robotic arm. A YouTube video entitled Arthrobot illustrates some of these in operation .
Pancreatitis is a dreaded condition associated with development of acute and sudden inflammation of the pancreas.
Pancreatic enzymes are released in the abdomen and cause inflammation by the damage from digestion of normal body structures, especially fat in the abdomen.
Mortality ranges from 3 percent in patients with interstitial edematous pancreatitis to 17 percent in patients who develop pancreatic necrosis.
Every upcoming surgeon practising minimal access surgery should know the basics of urology , so that he or she can put his or her,s capabilities as a surgeon
Common symptoms of depression:
Lost of interest in the things that were previously pleasurable
Depressed and Sadness
Hopelessness
Other may Include:
Anxiety
Increased feeling of guilt
Irritability
Impatience
Sleep disturbances
Tearfulness
Difficulty concentrating
Appetite changes (loss/gain)
Increased Isolation
Somatic Pain
Substance abuse
This presentation was delivered at Puri on 10th january 2015
on the occasion of annual Rotary District Conference along with IMA Puri. It highlights on metabolic syndrome and its surgical solution.
What is MIS?
A minimally invasive medical procedure is defined as one that is carried out by entering the body through the skin or through a body cavity or anatomical opening, but with the smallest damage possible to these struct uresIncludes laparoscopic, endoscopic, and other approaches.
Why MIS?
Decreased patient pain
Decreased patient recovery period
Possible decrease in inflammatory response in the patient which may prove to have a better outcome in oncologic operations.
Distant future
In the distant future, there will be a para- digm shift with the development of non-inva- sive surgical techniques in combination with nanotechnologies and a new era in the devel- opment of surgery, and subsequently in surgi- cal techniques, will be opened.
Nanotechnology is an umbrella term for materials and devices that operate at the nanoskill (1 billionth of a meter). In terms of scale, a nanometer is approximately one 1/8000 of a human hair or 10 times the diam- eter of a hydrogen atom. The size of the device can vary but starts from a ten thou- sand-logic element system that will occupy a cube of no more than one hundred nanome- ters. This is a volume slightly larger than 0.001 cubic microns. This would be sufficient to hold a small computer. For example, if red blood cells are approximately eight microns in diameter, the 100 nanomicroprocessor will be 80 times smaller than a red blood cell. Devices this size could easily fit into the circulatory system and could even conceivably enter indi- vidual cells.
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.There are different kinds of hernia, each requiring a specific management or treatment.
SIGNS AND SYMPTOMS
By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.
Hernias may or may not present with either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ.
Hernias are not tears in the tissue but are openings in the adipose tissue. It is possible for a hernia to come and go, but in most cases a pain will persist.
Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.
Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation. Strangulated hernias are always painful and pain is followed by tenderness. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink.
In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.
CAUSES OF HERNIA
Causes of hiatal hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, and incorrect posture.
Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination (constipation, enlarged prostate).
It has not changed the nature of disease
The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise
If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach
The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound.
We actually do not know what is there stored for us, but we believe that laparoscopy is trending towards advancement and nano and robotic technology is going to replace in future.
3D cameras have come into existence and various newer technologies are being invented.
SHANTI MEMORIAL HOSPITAL IS A MULTISPECIALITY MEDICAL CENTRE ESTD. IN APRIL 1991 & IS SITUATED IN THE HEART OF THE CITY OF CUTTACK.
IT IS A PRIVATE LIMITED HOSPITAL.
STARTED WITH A TEAM OF LIKE MINDED MEDICAL PROFESSIONALS WITH A MISSION TO PROVIDE HEALTHCARE FOR THE NEEDY AT AN AFFORDABLE COST WE BELIEVE THAT A PERSON CAN BE BEST CURED IN A COMFORTABLE HOMELY ATMOSPHERE & WE STRIVE TO CREATE AN AMBIENCE WHERE THE PATIENT FEELS MORE AT HOME THAN AT HOSPITAL.
OUR VISION FOR THE FUTURE IS TO KEEP OURSELVES IN TO THE BEST OF THE HEALTHCARE INNOVATIONS, AND PROVIDE HIGHEST QUALITY HEALTHCARE FOR THE MASSES.
HEAL PATIENTS & KILL THE DISEASE WITHIN.
WE ENSURE HOPE & GIVE HAPPINESS TO OUR PATIENTS
We are Committed to maintain the highest Standard of Care and treatment with Special emphasis to patient Safety and Satisfaction. We Constantly Strive improving Quality Indices & make it our Hallmark of practices .
Established in 1991, since the last 22 years SMH has become the state of the art hospital.
This has occurred almost entirely due to the golden motto of our institution : “ Service through Excellence”- the ONE FAMILY TRADITION followed by all staff members at the hospital.
KEY PROFILE OF OUR HOSPITAL
The hospital has 100 beds and has recognition from the Local Council.
The metamorphosis from 25 beds in 1991 to the present has been a slow but a progressive one.
We Believe in Quality & Personalised care & affordibility of our patients.
Since the last 2 years we have seen tremendous improvements in methods of communication and counselling of critically ill patients.
The critical care dept. is at par the best in the state.
OUR STRENGTHS
World class physicians
Competing through quality
Working as a team
Winning the Trust of public
Adopt to the local needs
Financial transparency
Quality through education & training.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
2. Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease
(GERD)(GERD)
• Any symptoms or esophageal mucosal damageAny symptoms or esophageal mucosal damage
that results from reflux of gastric acid into thethat results from reflux of gastric acid into the
esophagusesophagus
• Classic GERD symptomsClassic GERD symptoms
– Heartburn (pyrosis): substernal burning discomfortHeartburn (pyrosis): substernal burning discomfort
– Regurgitation: bitter, acidic fluid in the mouthRegurgitation: bitter, acidic fluid in the mouth
when lying down or bending overwhen lying down or bending over
3.
4. ObjectivesObjectives
• Definition of GERDDefinition of GERD
• Epidemiology of GERDEpidemiology of GERD
• Pathophysiology of GERDPathophysiology of GERD
• Clinical ManisfestationsClinical Manisfestations
• Diagnostic EvaluationDiagnostic Evaluation
• TreatmentTreatment
• ComplicationsComplications
5. DefinitionDefinition
– American College ofAmerican College of
Gastroenterology (ACG)Gastroenterology (ACG)
– Symptoms OR mucosal damageSymptoms OR mucosal damage
produced by the abnormal reflux ofproduced by the abnormal reflux of
gastric contents into the esophagusgastric contents into the esophagus
– Often chronic and relapsingOften chronic and relapsing
– May see complications of GERD inMay see complications of GERD in
patients who lack typicalpatients who lack typical
symptomssymptoms
6.
7.
8. Physiologic vs PathologicPhysiologic vs Pathologic
• Physiologic GERDPhysiologic GERD
– PostprandialPostprandial
– Short livedShort lived
– AsymptomaticAsymptomatic
– No nocturnal sxNo nocturnal sx
• Pathologic GERDPathologic GERD
– SymptomsSymptoms
– Mucosal injuryMucosal injury
– Nocturnal sxNocturnal sx
9. Locke et al. Gastroenterology 1997;112:1148.Locke et al. Gastroenterology 1997;112:1148.
High Prevalence of GastroesophagealHigh Prevalence of Gastroesophageal
Reflux SymptomsReflux Symptoms
19.8%
59%
0%
10%
20%
30%
40%
50%
60%
Weekly Monthly
Frequency of heartburn and/or
regurgitation
10.
11. Important Reasons to Diagnose and TreatImportant Reasons to Diagnose and Treat
GERDGERD
• Negative impact on health-related quality of lifeNegative impact on health-related quality of life11
• Risk factor for esophageal adenocarcinomaRisk factor for esophageal adenocarcinoma22
1.1. Revicki et al. Am J Med 1998;104:252.Revicki et al. Am J Med 1998;104:252.
2.2. Lagergren et al. N Engl J Med 1999;340:825.Lagergren et al. N Engl J Med 1999;340:825.
12.
13. PathophysiologyPathophysiology
• Primary barrier toPrimary barrier to
gastroesophageal reflux isgastroesophageal reflux is
the lower esophagealthe lower esophageal
sphinctersphincter
• LES normally works inLES normally works in
conjunction with theconjunction with the
diaphragmdiaphragm
• If barrier disrupted, acidIf barrier disrupted, acid
goes from stomach togoes from stomach to
esophagusesophagus
14.
15. Clinical Presentations of GERDClinical Presentations of GERD
• Classic GERDClassic GERD
• Extraesophageal/Atypical GERDExtraesophageal/Atypical GERD
• Complicated GERDComplicated GERD
20. Symptoms of Complicated GERDSymptoms of Complicated GERD
• DysphagiaDysphagia
– Difficulty swallowing: food sticks or hangsDifficulty swallowing: food sticks or hangs
upup
• OdynophagiaOdynophagia
– Retrosternal pain with swallowingRetrosternal pain with swallowing
• BleedingBleeding
21.
22. When to Perform Diagnostic TestsWhen to Perform Diagnostic Tests
• Uncertain diagnosisUncertain diagnosis
• Atypical symptomsAtypical symptoms
• Symptoms associated with complicationsSymptoms associated with complications
• Inadequate response to therapyInadequate response to therapy
• Recurrent symptomsRecurrent symptoms
• Prior to anti-reflux surgeryPrior to anti-reflux surgery
28. Wireless, Catheter-Free Esophageal pH Monitoring
• Improved patientImproved patient
comfort and acceptancecomfort and acceptance
• Continued normal work,Continued normal work,
activities and diet studyactivities and diet study
• Longer reporting periodsLonger reporting periods
possible (48 hours)possible (48 hours)
• Maintain constant probeMaintain constant probe
position relative to SCJposition relative to SCJ
Potential AdvantagesPotential Advantages
29. Esophageal ManometryEsophageal Manometry
• Assess LES pressure,Assess LES pressure,
location and relaxationlocation and relaxation
– Assist placement of 24 hr.Assist placement of 24 hr.
pH catheterpH catheter
• Assess peristalsisAssess peristalsis
– Prior to antireflux surgeryPrior to antireflux surgery
Limited role in GERDLimited role in GERD
30. GERD vs DyspepsiaGERD vs Dyspepsia
• Distinguish from DyspepsiaDistinguish from Dyspepsia
– Ulcer-like symptoms-burning, epigastric painUlcer-like symptoms-burning, epigastric pain
– Dysmotility like symptoms-nausea, bloating,Dysmotility like symptoms-nausea, bloating,
early satiety, anorexiaearly satiety, anorexia
• Distinct clinical entityDistinct clinical entity
• In addition to antisecretory meds and anIn addition to antisecretory meds and an
EGD need to consider an evaluation forEGD need to consider an evaluation for
Helicobacter pyloriHelicobacter pylori
31. Treatment Goals for GERDTreatment Goals for GERD
• Eliminate symptomsEliminate symptoms
• Heal esophagitisHeal esophagitis
• Manage or prevent complicationsManage or prevent complications
• Maintain remissionMaintain remission
32. Lifestyle Modifications areLifestyle Modifications are
Cornerstone of GERD TherapyCornerstone of GERD Therapy
• Elevate head of bed 4-6 inchesElevate head of bed 4-6 inches
• Avoid eating within 2-3 hours of bedtimeAvoid eating within 2-3 hours of bedtime
• Lose weight if overweightLose weight if overweight
• Stop smokingStop smoking
• Modify dietModify diet
– Eat more frequent but smaller mealsEat more frequent but smaller meals
– Avoid fatty/fried food, peppermint, chocolate,Avoid fatty/fried food, peppermint, chocolate,
alcohol, carbonated beverages, coffee and teaalcohol, carbonated beverages, coffee and tea
• OTC medications prnOTC medications prn
33. Better LivingBetter Living
• Lifestyle modificationsLifestyle modifications
– Avoid large mealsAvoid large meals
– Avoid acidic foods (citrus/tomato), alcohol, caffiene,Avoid acidic foods (citrus/tomato), alcohol, caffiene,
chocolate, onions, garlic, peppermintchocolate, onions, garlic, peppermint
– Decrease fat intakeDecrease fat intake
– Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal
– Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches
– Avoid meds that may potentiate GERD (CCB, alphaAvoid meds that may potentiate GERD (CCB, alpha
agonists, theophylline, nitrates, sedatives, NSAIDS)agonists, theophylline, nitrates, sedatives, NSAIDS)
– Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist
– Lose weightLose weight
– Stop smokingStop smoking
35. Better LivingBetter Living
• Lifestyle modificationsLifestyle modifications
– Avoid large mealsAvoid large meals
– Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic,Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic,
peppermintpeppermint
– Decrease fat intakeDecrease fat intake
– Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal
– Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches
– Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates,Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates,
sedatives, NSAIDS)sedatives, NSAIDS)
– Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist
– Lose weightLose weight
– Stop smokingStop smoking
36. TreatmentTreatment
• AntacidsAntacids
– Over the counter acidOver the counter acid
suppressants and antacidssuppressants and antacids
appropriate initial therapyappropriate initial therapy
– Approx 1/3 of patients withApprox 1/3 of patients with
heartburn-related symptomsheartburn-related symptoms
use at least twice weeklyuse at least twice weekly
– More effective than placeboMore effective than placebo
in relieving GERD symptomsin relieving GERD symptoms
37. TreatmentTreatment
• Histamine H2-Receptor AntagonistsHistamine H2-Receptor Antagonists
– More effective than placebo and antacids forMore effective than placebo and antacids for
relieving heartburn in patients with GERDrelieving heartburn in patients with GERD
– Faster healing of erosive esophagitis whenFaster healing of erosive esophagitis when
compared with placebocompared with placebo
– Can use regularly or on-demandCan use regularly or on-demand
39. TreatmentTreatment
• Proton Pump InhibitorsProton Pump Inhibitors
– Better control of symptoms with PPIs vsBetter control of symptoms with PPIs vs
H2RAs and better remission ratesH2RAs and better remission rates
– Faster healing of erosive esophagitis with PPIsFaster healing of erosive esophagitis with PPIs
vs H2RAsvs H2RAs
41. TreatmentTreatment
• H2RAs vs PPIsH2RAs vs PPIs
– 12 week freedom from symptoms12 week freedom from symptoms
• 48% vs 77%48% vs 77%
– 12 week healing rate12 week healing rate
• 52% vs 84%52% vs 84%
– Speed of healingSpeed of healing
• 6%/wk vs 12%/wk6%/wk vs 12%/wk
42. TreatmentTreatment
• Antireflux surgeryAntireflux surgery
– Failed medical managementFailed medical management
– Patient preferencePatient preference
– GERD complicationsGERD complications
– Medical complications attributable to a largeMedical complications attributable to a large
hiatal herniahiatal hernia
– Atypical symptoms with reflux documented onAtypical symptoms with reflux documented on
24-hour pH monitoring24-hour pH monitoring
43. TreatmentTreatment
• Antireflux surgery candidatesAntireflux surgery candidates
– EGD proven esophagitisEGD proven esophagitis
– Normal esophageal motilityNormal esophageal motility
– Partial response to acid suppressionPartial response to acid suppression
44. TreatmentTreatment
• Antireflux surgeryAntireflux surgery
– Tenets of surgeryTenets of surgery
• Reduce hiatal herniaReduce hiatal hernia
• Repair diaphragmRepair diaphragm
• Strengthen GE junctionStrengthen GE junction
• Strengthen antireflux barrier via gastric wrapStrengthen antireflux barrier via gastric wrap
• 75-90% effective at alleviating symptoms of75-90% effective at alleviating symptoms of
heartburn and regurgitationheartburn and regurgitation
45. TreatmentTreatment
• PostsurgeryPostsurgery
– 10% have solid food dysphagia10% have solid food dysphagia
– 2-3% have permanent symptoms2-3% have permanent symptoms
– 7-10% have gas, bloating, diarrhea, nausea,7-10% have gas, bloating, diarrhea, nausea,
early satietyearly satiety
– Within 3-5 years 52% of patients back onWithin 3-5 years 52% of patients back on
antireflux medicationsantireflux medications
46. TreatmentTreatment
• Endoscopic treatmentEndoscopic treatment
– Relatively newRelatively new
– No definite indicationsNo definite indications
– Select well-informed patients with well-documentedSelect well-informed patients with well-documented
GERD responsive to PPI therapy may benefitGERD responsive to PPI therapy may benefit
• Three categoriesThree categories
– Radiofrequency application to increase LES refluxRadiofrequency application to increase LES reflux
barrierbarrier
– Endoscopic sewing devicesEndoscopic sewing devices
– Injection of a nonresorbable polymer into LES areaInjection of a nonresorbable polymer into LES area
47. Effectiveness of Medical Therapies forEffectiveness of Medical Therapies for
GERDGERD
TreatmentTreatment ResponseResponse
Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %
HH22-receptor antagonists-receptor antagonists 50 %50 %
Single-dose PPISingle-dose PPI 80 %80 %
Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %
48. Treatment Modifications forTreatment Modifications for
Persistent SymptomsPersistent Symptoms
• Improve complianceImprove compliance
• Optimize pharmacokineticsOptimize pharmacokinetics
– Adjust timing of medication to 15 – 30 minutesAdjust timing of medication to 15 – 30 minutes
before meals (as opposed to bedtime)before meals (as opposed to bedtime)
– Allows for high blood level to interact withAllows for high blood level to interact with
parietal cell proton pump activated by the mealparietal cell proton pump activated by the meal
• Consider switching to a different PPIConsider switching to a different PPI
49. GERD is a Chronic Relapsing ConditionGERD is a Chronic Relapsing Condition
• Esophagitis relapses quickly after cessationEsophagitis relapses quickly after cessation
of therapyof therapy
– > 50 % relapse within 2 months> 50 % relapse within 2 months
– > 80 % relapse within 6 months> 80 % relapse within 6 months
• Effective maintenance therapy is imperativeEffective maintenance therapy is imperative
57. ComplicationsComplications
• Erosive esophagitisErosive esophagitis
– Responsible for 40-60% of GERD symptomsResponsible for 40-60% of GERD symptoms
– Severity of symptoms often fail to matchSeverity of symptoms often fail to match
severity of erosive esophagitisseverity of erosive esophagitis
59. ComplicationsComplications
• Barrett’s EsophagusBarrett’s Esophagus
– Columnar metaplasia ofColumnar metaplasia of
the esophagusthe esophagus
– Associated with theAssociated with the
development ofdevelopment of
adenocarcinomaadenocarcinoma
60. ComplicationsComplications
• Barrett’s EsophagusBarrett’s Esophagus
– Acid damages lining ofAcid damages lining of
esophagus and causesesophagus and causes
chronic esophagitischronic esophagitis
– Damaged area heals in aDamaged area heals in a
metaplastic process andmetaplastic process and
abnormal columnar cellsabnormal columnar cells
replace squamous cellsreplace squamous cells
– This specializedThis specialized
intestinal metaplasia canintestinal metaplasia can
progress to dysplasia andprogress to dysplasia and
adenocarcinomaadenocarcinoma
61.
62. When to Discuss Anti-RefluxWhen to Discuss Anti-Reflux
Surgery with PatientsSurgery with Patients
• Intractable GERD – rareIntractable GERD – rare
– Difficult to manage stricturesDifficult to manage strictures
– Severe bleeding from esophagitisSevere bleeding from esophagitis
– Non-healing ulcersNon-healing ulcers
• GERD requiring long-term PPI-BID in aGERD requiring long-term PPI-BID in a
healthy young patienthealthy young patient
• Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms
• Not Barrett’s esophagus aloneNot Barrett’s esophagus alone
63. Partial fundoplication techniquesPartial fundoplication techniques
• Thal 90 deg. Ant. WrapThal 90 deg. Ant. Wrap
• Watson 120 deg ant-lat. wrapWatson 120 deg ant-lat. wrap
• Dor 150-200 deg ant. wrapDor 150-200 deg ant. wrap
• Toupet 270 deg posterior wrapToupet 270 deg posterior wrap
• Belsey Mark IV 270 deg transthoracicBelsey Mark IV 270 deg transthoracic
ant- lat wrap.ant- lat wrap.
64. Indications for partialIndications for partial
fundoplicationfundoplication
• 1.PRIMARY ESO. MOTILITY1.PRIMARY ESO. MOTILITY
DISORDERSDISORDERS
• Achalasia ( after myotomy)Achalasia ( after myotomy)
• SclerodermaScleroderma
• 2.SEC. ESOP. MOTILITY DISORDERS2.SEC. ESOP. MOTILITY DISORDERS
POOR MOTILITY SEC. TO CHRONICPOOR MOTILITY SEC. TO CHRONIC
/BARRETS ESOP/BARRETS ESOP
65. • 3. Inability to tolerate complete3. Inability to tolerate complete
fundoplicationfundoplication
• Dysphagia, gas bloatingDysphagia, gas bloating
• Chronic nauseaChronic nausea
• AerophagiaAerophagia
• Revision of obstructing360 deg wrapsRevision of obstructing360 deg wraps
66. Scores for heartburn (a) and acid regurgitationScores for heartburn (a) and acid regurgitation
(b) 12 months after an anterior or a posterior(b) 12 months after an anterior or a posterior
partial fundoplicationpartial fundoplication..
67.
68.
69.
70.
71. Endoscopic GERD TherapyEndoscopic GERD Therapy
• Endoscopic antireflux therapiesEndoscopic antireflux therapies
– Radiofrequency energy delivered to the LESRadiofrequency energy delivered to the LES
• Stretta procedureStretta procedure
– Suture ligation of the cardiaSuture ligation of the cardia
• Endoscopic plicationEndoscopic plication
– Submucosal implantation of inert material inSubmucosal implantation of inert material in
the region of the lower esophageal sphincterthe region of the lower esophageal sphincter
• EnteryxEnteryx
73. • This is how a laparoscopic fundoplication isThis is how a laparoscopic fundoplication is
performed to repair the antireflux valve inperformed to repair the antireflux valve in
patients with heartburn. It was performedpatients with heartburn. It was performed
by Dr Craig Taylor in Sydney. This type ofby Dr Craig Taylor in Sydney. This type of
anti-reflux procedure (anterioranti-reflux procedure (anterior
fundoplication) provides excellentfundoplication) provides excellent
heartburn control whilst minimising the sideheartburn control whilst minimising the side
effects that used to be common after theeffects that used to be common after the
older Nissen fundoplication, especially gasolder Nissen fundoplication, especially gas
bloating.bloating.
74. • This newer technique aims to restore theThis newer technique aims to restore the
function of the valve between stomach andfunction of the valve between stomach and
oesophagus in a more natural andoesophagus in a more natural and
anatomical way. Patients can expect to beanatomical way. Patients can expect to be
free of their heartburn and reflux and stopfree of their heartburn and reflux and stop
taking antireflux medication- for manytaking antireflux medication- for many
patients this can be quite life changing.Aspatients this can be quite life changing.As
with all surgical procedures there are risks,with all surgical procedures there are risks,
and patients need to be aware of these.and patients need to be aware of these.
75. • The procedure took approximately 1 hourThe procedure took approximately 1 hour
under a general anaesthetic, and onlyunder a general anaesthetic, and only
requires an overnight stay in hospital.requires an overnight stay in hospital.
Patients can generally return to work withinPatients can generally return to work within
a few days, and may resume all normala few days, and may resume all normal
physical activity including gym and liftingphysical activity including gym and lifting
within a monthwithin a month
Editor's Notes
--distinction between normal and GERD is blurred because some degree of reflux is physiologic is all folks Physiologic—postprandially, short lived, asymptomatic, not during sleep Pathologic—symptoms or mucosal injury and often with nocturnal symptoms
--At level of diaphragmatic hiatus—main deterrant to reflux --disruption due to –review slide--multifactorial
--Tums, rolaids, maalox --$1 billion in yearly expenditures --aluminum/calcium—constipation Mag--diarrhea
--otc dose uniformly half of standard lowest prescription dose --similar clinical efficacy
--no significant differences in symptomatic tx of GERD or healing of erosive esophagitis 1a evidence --works only on active pumps—take 30-60min prior to meals --long-term tx generally benefits outweigh risks
candidacy --esophagitis—by egd --need normal manometry/motility --partial response to acid suppression --reduce hh, repair diaphragm, strengthen ge jxn—antireflux barrier --75-90% effective at alleviating hrtburn/regurg --better at helping with hrtburn/regurg than atypical sx
Figure 11-18. Endoscopic appearance of benign strictures. Acid-septic strictures and Schatzki's rings are the most common strictures requiring dilation. Although in most instances endoscopic examination allows obvious distinction between the two, variation in air insufflation and the differences in magnification over short distances between the lower esophageal sphincter and the endoscope can make the assessment of the lower esophagus difficult in some patients. A subtle peptic stricture may be missed endoscopically, or, more precisely, may be confused with a Schatzki's ring. Contrast radiology can be a more sensitive technique for demonstrating subtle rings and strictures and for calibrating the lumen more precisely. A–C, Endoscopic photographs of several Schatzki's rings. D–G, peptic strictures. Note the esophageal pseudodiverticula proximal to the peptic stricture in panels F and G. Their presence increases the risk of unguided dilatation of the esophagus and mandates the use of a guidewire technique. H, Tight anastomotic stricture (suture at 10 o'clock) and “watermelon esophagus” viewed endoscopically. The watermelon seeds and kernel of corn provide a reference for the pinhole quality of this stricture.
Figure 11-21. Types of dilators: balloons. Balloon dilators are an additional option for the endoscopist approaching an esophageal stricture. They may be placed over a guidewire or through the scope (TTS). Theoretically, balloons have the advantage of being safer because of the radial application of force, and elimination of the shearing effect of rigid dilators. Moreover, dilation can be performed under direct visualization using the TTS balloon. Recent balloon innovations facilitating their use include longer balloons that avoid the tendency for slippage with inflation, and high-pressure balloons that should provide a truer diameter for the dilation of more resistant strictures. In the limited number of randomized studies comparing Savory-type dilators with balloon dilators, they appeared equally safe. Efficacy, as assessed by symptom improvement and luminal patency, has been variably reported in the literature favoring either technique [18], [19], [20]. A, Range of available balloons and an inflation gun. B–E, A peptic stricture before and after balloon dilation, thus demonstrating the direct visualization that is possible with the TTS technique. References: [18]. Saeed ZA, Winchester CB, Ferro PA, et al. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc 1995 41 189-195 [19]. Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie for dilation of benign oesophageal stricture? An interim report of a randomized controlled trial. Gut 1988 29 1741-1747 [20]. Shemesh E, Czerniak A, Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures. World J Surg 1990 14 518-522
--black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --ulcerations in 2-7%
4-20% of patients
--1950—Norman Barrett --10-15% --black arrow squamo-columnar jxn—Z-line --Z-line has undulating smooth contours --green arrow—gastric columnar epithelium above round black sphincter --red arow—pink white esophageal squamous epithelium --RFs—male, smoker, age, obese
Adenoca with barretts 0.5%/yr--------without barretts 0.07%/yr