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![Diagnostic Studies
• Esophagogastroduodenoscopy (EGD) (or,
upper gastrointestinal [GI] endoscopy) with
biopsy,
• 24-hour ambulatory pH study,
• Manometry,
• Barium contrast study,
• Gastric emptying study.](https://image.slidesharecdn.com/gerdrefluxoesophagitis-230514164922-73d90401/85/GERD-Reflux-Oesophagitis-pptx-31-320.jpg)
Uploaded byPradeep Pande
GERD Reflux Oesophagitis.pptx
The document provides tips for using a PowerPoint presentation on gastroesophageal reflux disease (GERD). It suggests: 1. Using blank slides to elicit what students already know about each topic before presenting new information 2. Repeating this process of blank slide then information slide three times for active learning 3. The presentation can be used for self-study as well by reviewing the notes and bibliography The presentation covers learning objectives and sections on introduction/history, etiology, pathophysiology, clinical features, investigations, management, and multiple choice questions. It provides detailed information on each topic in an engaging format designed for teaching.
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GERD Reflux Oesophagitis.pptx
- 1. Tips on usingmy ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.
- 2.
- 3. Learning Objectives:GORD/GERD 1. Introduction& History 2. Relevant Anatomy, Physiology 3. Aetiology 4. Pathophysiology 5. Pathology 6. Classification 7. Clinical Features 8. Investigations 9. Management 10. Prevention 11. Guidelines 12. Take home messages
- 4.
- 5. Introduction • Gastroesophageal refluxdisease (GERD), is defined as a condition in which the stomach contents reflux into the esophagus or beyond (oral cavity, larynx, or the lungs), causing troublesome symptoms and complications. • Reflux esophagitis is defined as inflammation of the esophageal mucosa secondary to gastroesophageal reflux disease.
- 6. Aetiology • Idiopathic • Congenital/Genetic • Nutritional Deficiency/excess • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative / lifestyle • Iatrogenic • Psychosomatic • Poisoning/ Toxins/ Drug induced
- 7. Aetiology • Idiopathic • Congenital/Genetic • Nutritional Deficiency/excess • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative / lifestyle • Iatrogenic • Psychosomatic • Poisoning/ Toxins/ Drug induced
- 8. Etiology • Reflux ofgastric contents into the esophagus due to weak lower esophageal sphincter (LES) function, • Impaired esophageal clearance – Esophageal dysmotility – Presence of hiatal hernia, – Impairment in the tone of the lower esophageal sphincter (LES), – Transient LES relaxation, – Poor gastric emptying
- 9. Etiology • Obesity • Smoking •Alcohol, • Caffeine • Lack of physical activity • Anxiety/depression • Stress • Eating habits (large meals, eating before bed) • Diabetes • Age 50 years or older • Connective tissue disorders Scleroderma • High dietary fat • Drugs • Microbiome alteration • Pregnancy • Tobacco chewing • Nonalcoholic fatty liver disease. • Zollinger-Ellison syndrome causing increased acid secretion
- 10. Etiology:Drugs induced • Angiotensin- convertingenzyme inhibitors • Anticholinergics • Calcium channel blockers • Narcotics • Nitrates • Progesterone • Sedatives or tranquilizers (eg, benzodiazepines) • Statins • Theophylline • Tricyclic antidepressants (eg, amitriptyline) •
- 11. Etiology • Protective roleof H.Pylori remains controversial.
- 12.
- 13. Pathophysiology Mechanism of LES –Intrinsicdistal esophageal muscles – tonically contracted. –Angle of His –Muscular Sling fibers of the gastric cardia. –Diaphragmatic crura. –Transmitted pressure of the abdominal cavity. –Phreno-esophageal membrane
- 14. Pathophysiology • Reflux occursin healthy individuals also cleared by- 1. Clearance by esophageal peristaltic movement 2. Neutralization of the small acidic residue by weakly alkaline swallowed saliva.
- 15. Pathophysiology • Pepsin” inthe reflux contents • Strong acid (pH < 2), however, can cause mucosal damage independent of the presence of pepsin. • The presence of bile in reflux
- 16. Pathophysiology • Transient relaxationof the lower esophageal sphincter or a low resting lower esophageal sphincter pressure • Presence of a hiatus hernia • Increased intra-abdominal fat, as is the case in obesity, and increased intra-abdominal pressure, such as in pregnancy and patients with ascites • Impairment of the normal defense mechanisms, including esophageal peristalsis (dysregulation of esophageal peristalsis) • Impairment of saliva production due to several causes, including chronic inflammation of the salivary glands • Impairment of esophageal mural defense mechanisms.
- 17.
- 18. Clinical Features • Demography •Symptoms • Signs • Prognosis • Complications
- 19.
- 20. Demography • 10-20% ofhealthy adult Americans experienced symptomatic GERD at least once a month. Severe disease in6%. • 5%in Asians. • White individuals have higher prevalence of severe grades of esophagitis • Reflux esophagitis is equally prevalent among men and women.However, the predominance of esophagitis and Barrett esophagitis in men compared to women is 3:1 and 10:1, respectively. • Incidence of gerd increased in the autumn and winter • Incidence of reflux esophagitis has doubled over a period of 10 years. • Gastroesophageal reflux exists universally in preterm infants.
- 21.
- 22. Symptoms Esophageal and Extraesophageal •Esophageal – Heartburn – Acid dyspepsia – Regurgitation – Chest pain. • Exraesophageal symptoms-
- 23. Symptoms • Exraesophageal symptoms- –Chronic Cough – Dental erosions,, – Asthma – Throat pain – Aspiration pneumonia, – Globus sensation – Hoarseness due to pharyngitis, laryngitis, or sinus problems.
- 24. Symptoms • However, somepatients with severe esophagitis or Barrett esophagus may be symptom-free and have no heartburn
- 25.
- 26. Complications • Upper gastrointestinalbleeding, • Anemia, • Stricture, • Barrett esophagus • Dysplasia • Malignancy
- 27. Alarming Signs &Symptoms • Dysphagia • Early satiety • GI bleeding • Odynophagia • Vomiting • Weight loss • Iron deficiency anemia
- 28. Investigations • Laboratory Studies –Routine – Special • Imaging Studies • Tissue diagnosis – Cytology • FNAC – Histology – Germ line Testing and Molecular Analysis • Diagnostic Laparotomy.
- 29. Diagnostic Studies Imaging Studies •X-Ray • USG • CT • Angiography • MRI • Endoscopy • Nuclear scan
- 30. Diagnostic Studies Imaging Studies •X-Ray –Barium swallow • USG • CT • Angiography • MRI • Endoscopy • Nuclear scan
- 31. Diagnostic Studies • Esophagogastroduodenoscopy(EGD) (or, upper gastrointestinal [GI] endoscopy) with biopsy, • 24-hour ambulatory pH study, • Manometry, • Barium contrast study, • Gastric emptying study.
- 32. Diagnostic Studies • Accordingto the diagnostic guidelines established by American College of Gastroenterology (ACG) for GERD, if a patient’s history is typical for uncomplicated GERD, an initial trial of empirical therapy is appropriate, without further investigation.
- 33. Classification • Based onendoscopic and histopathologic appearance, GERD is classified into three different phenotypes: 1. Non-erosive reflux disease (NERD), 2. Erosive esophagitis (EE) 3. Barrett esophagus (BE)
- 34.
- 35. Grades of Esophagitis TheSavary-Miller grading system • Grade 1: single or multiple erosions on a single fold. ... • Grade 2: multiple erosions affecting multiple folds. ... • Grade 3: multiple circumferential erosions. • Grade 4: ulcer, stenosis or oesophageal shortening. • Grade 5: Barrett's epithelium.
- 36. Diagnostic Studies • Theendoscopic findings in gastroesophageal reflux disease (GERD) range from normal esophageal mucosa to erosions and ulcerations
- 37. Pathology Microscopy • Squamous (basal)cell hyperplasia, elongation of vascular papillae, presence of intraepithelial inflammatory cells, dilated intercellular spaces (intercellular edema), ballooning degeneration of squamous cells (due to accumulation of intracellular plasma proteins), vascular lakes (dilated small blood vessels in superficial lamina propria/vascular papillae), acanthosis, mucosal erosions and ulcerations
- 38. Barrett's epithelium. • Replacementof squamous epithelium with gastric columnar epithelium
- 39.
- 40. Differential Diagnosis • Coronaryartery disease • Infectious esophagitis • Eosinophilic esophagitis • Peptic ulcer disease • Biliary colic • Esophageal motor disorders • Esophageal stricture • Esophageal cancer • Dyspepsia • Dysphagia • Rumination syndrome • Radiation and chemotherapy-induced esophagitis
- 41.
- 42. Complications • Barrett esophagus, •Dysplasia, • Malignancy
- 43.
- 44. Management • The treatmentis based on- 1 Lifestyle modification 2 Control of gastric acid secretion through • A. Medical therapy with- – Antacids – PPIs B.Surgical treatment with corrective antireflux surgery
- 45.
- 46. Lifestyle Modifications • Losingweight (if overweight) • Avoiding alcohol, chocolate, citrus juice, and tomato-based products peppermint, coffee, and possibly the onion • Avoiding large meals • Waiting 3 hours after a meal before lying down • Elevating the head of the bed by 8 inches
- 47.
- 48. Minimally invasive Therapy Laparoscopicfundoplication • Complete mobilization of the fundus of the stomach with division of the short gastric vessels • Reduction of the hiatal hernia • Narrowing of the esophageal hiatus • Creation of a 360° fundoplication over a large intraesophageal dilator (Nissen fundoplication)
- 49. Operative Therapy • Indicationsfor fundoplication include the following: – Patients with symptoms that are not completely controlled by PPI therapy – Barrett esophagus – extraesophageal manifestations Young patients – Poor patient compliance with regard to medications – Postmenopausal women with osteoporosis – Patients with cardiac conduction defects – Cost of medical therapy
- 50. Myths • Heartburn chestpain should not be first managed as GERD. First angina must be excluded.
- 51.
- 52.
- 53. Take home messages •Gastroesophageal reflux disease (GERD) is a common clinical problem, affecting millions of people worldwide. • Patients are recognized by both classic and atypical symptoms. • Acid suppressive therapy provides symptomatic relief and prevents complications in many individuals with GERD. • Fundoplication is surgical treatment.
- 54. MCQs • A diagnosisof gastroesophageal reflux disease implies that a patient has which of the following functional abnormalities? A.Compression of the esophagus from a double aortic arch B.Cricopharyngeal incoordination C.Denervation of esophageal muscle D.Lower esophageal sphincter incompetence
- 55. MCQs • A diagnosisof gastroesophageal reflux disease implies that a patient has which of the following functional abnormalities? A.Compression of the esophagus from a double aortic arch B.Cricopharyngeal incoordination C.Denervation of esophageal muscle D.Lower esophageal sphincter incompetence
- 56. MCQs • A patientwho has symptoms of gastroesophageal reflux disease (GERD) is prescribed a trial of proton pump inhibitors. One month later the symptoms have not improved despite treatment, and findings on endoscopy are unremarkable. Which of the following is the most appropriate next step in management? • A.Barium swallow x-ray study • B.Esophageal manometry • C.Repeat endoscopy in one month • D.24-hour pH testing
- 57. MCQs • A patientwho has symptoms of gastroesophageal reflux disease (GERD) is prescribed a trial of proton pump inhibitors. One month later the symptoms have not improved despite treatment, and findings on endoscopy are unremarkable. Which of the following is the most appropriate next step in management? • A.Barium swallow x-ray study • B.Esophageal manometry • C.Repeat endoscopy in one month • D.24-hour pH testing
- 58. MCQs • Which ofthese is considered an "alarm symptom" suggestive of complicated GERD? A. Excessive belching/flatulence B. Epigastric pain C. Nausea D. Odynophagia
- 59. MCQs • Which ofthese is considered an "alarm symptom" suggestive of complicated GERD? A. Excessive belching/flatulence B. Epigastric pain C. Nausea D. Odynophagia
- 60. MCQs • which ismost accurate regarding the workup for GERD? A. Barium radiography is routinely recommended in the diagnosis of GERD B. A presumptive diagnosis of GERD can be made and empirical proton pump inhibitor (PPI) therapy initiated in the setting of typical symptoms of heartburn and regurgitation without additional studies C. Upper endoscopy is required for diagnosis of GERD in all patients D. Specific diagnosis of GERD can only be made with biopsies obtained from the distal esophagus
- 61. MCQs • which ismost accurate regarding the workup for GERD? A. Barium radiography is routinely recommended in the diagnosis of GERD B. A presumptive diagnosis of GERD can be made and empirical proton pump inhibitor (PPI) therapy initiated in the setting of typical symptoms of heartburn and regurgitation without additional studies C. Upper endoscopy is required for diagnosis of GERD in all patients D. Specific diagnosis of GERD can only be made with biopsies obtained from the distal esophagus
- 62. MCQs • Which ofthese is most commonly recognized as an "alarm symptom" that suggests potentially serious complications associated with GERD? A. Dysphagia B. Constipation C. Epigastric pain D. Foul-smelling gas
- 63. MCQs • Which ofthese is most commonly recognized as an "alarm symptom" that suggests potentially serious complications associated with GERD? A. Dysphagia B. Constipation C. Epigastric pain D. Foul-smelling gas
- 64. MCQs • Which ofthese is best established as a risk factor for GERD? A. Epilepsy B. Diabetes C. Male sex D. Use of beta-blockers
- 65. MCQs • Which ofthese is best established as a risk factor for GERD? A. Epilepsy B. Diabetes C. Male sex D. Use of beta-blockers
- 66. MCQs • Which ofthese medications is most likely to increase acid reflux and worsen GERD symptoms? A. Metformin B. Levothyroxine C. Amitriptyline D. Warfarin
- 67. MCQs • Which ofthese medications is most likely to increase acid reflux and worsen GERD symptoms? A. Metformin B. Levothyroxine C. Amitriptyline D. Warfarin
- 68. MCQs • In additionto upper gastrointestinal (GI) endoscopy, which of these is most routinely a part of the workup for GERD? A. Nuclear medicine gastric emptying study B. CT C. Manometry D. Ultrasonography
- 69. MCQs • In additionto upper gastrointestinal (GI) endoscopy, which of these is most routinely a part of the workup for GERD? A. Nuclear medicine gastric emptying study B. CT C. Manometry D. Ultrasonography
- 70. MCQs • Which ismost accurate about GERD treatment? A. Lifestyle changes remain the cornerstone of GERD management B. PPIs are now preferred to histamine 2–receptor antagonists as first-line therapy for most patients with mild to moderate GERD symptoms and grade I-II esophagitis C. Chocolate has been found to be beneficial when included in the diet of patients with GERD D. Cardiac conduction defects are a contraindication to surgical intervention for GERD
- 71. MCQs • Which ismost accurate about GERD treatment? A. Lifestyle changes remain the cornerstone of GERD management B. PPIs are now preferred to histamine 2–receptor antagonists as first-line therapy for most patients with mild to moderate GERD symptoms and grade I-II esophagitis C. Chocolate has been found to be beneficial when included in the diet of patients with GERD D. Cardiac conduction defects are a contraindication to surgical intervention for GERD
- 72. Get this pptin mobile 1. Download Microsoft PowerPoint from play store. 2. Open Google assistant 3. Open Google lens. 4. Scan qr code from next slide.
- 73. Get this pptin mobile
- 74. Get my pptcollection • https://t.me/surgerypresentation • https://www.slideshare.net/drpradeeppande/e dit_my_uploads • https://www.dropbox.com/sh/x600md3cvj85 woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl=0 • https://www.facebook.com/doctorpradeeppan de/?ref=pages_you_manage • https://t.me/+eqNYT21gmWZjMjI9