This presentation is about peptic ulcer disease , including:Pathomorphology,etiology,symptoms,complications,diagnosis and pharmacotherapy,asurgical intervention and prevention...
GERD is most common gastric problem in community affecting large number of people. Diagnosis and management is very simple with understanding.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
Gastroesophageal reflux disease is a chronic disorder that involves weakness and inappropriate relaxation of the lower esophageal sphincter allowing the contents of the stomach to flow up into the esophagus.
This presentation is about peptic ulcer disease , including:Pathomorphology,etiology,symptoms,complications,diagnosis and pharmacotherapy,asurgical intervention and prevention...
GERD is most common gastric problem in community affecting large number of people. Diagnosis and management is very simple with understanding.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
Gastroesophageal reflux disease is a chronic disorder that involves weakness and inappropriate relaxation of the lower esophageal sphincter allowing the contents of the stomach to flow up into the esophagus.
Gastroesophageal Reflux Disease (GERD) is a common disorder that has undergone many paradigm changes in the last 15 years. We discuss the current paradigms in the pathophysiology, diagnosis and management of GERD.
Gastroesophageal Reflux Disease (GERD) is a common disorder that has undergone many paradigm changes in the last 15 years. We discuss the current paradigms in the pathophysiology, diagnosis and management of GERD.
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.
Acid peptic disease /dental courses /certified fixed orthodontic courses by I...Indian dental academy
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Marcellus Simadibrata Kolopaking MD PhD
Department of Medical Education
Division Gastroenterology Department of Internal Medicine
Faculty of Medicine University Indonesia
Dr.Cipto Mangunkusumo Hospital Jakarta
Gastrointestinal Diseases
Group 5:
Leticia Bernal Leon
Daydig Rodriguez
Maria Rodriguez
Karina Silveira
Instructor:
Dr. Alain Llanes Rojas, DNP, APRN, FNP-BC
Miami Regional University
Diagnosis, Symptoms & Illness Management
MSN5600
Gastroesophageal Reflux
Gastroesophageal reflux that does not cause symptoms is known as physiologic reflux. In nonerosive reflux disease (NERD), individuals have symptoms of reflux disease but no visible or minimal esophageal mucosal injury
Gastroesophageal reflux disease (GERD) is the reflux of acid and pepsin or bile salts from the stomach to the esophagus that causes esophagitis. The severity of the esophagitis depends on the composition of the gastric contents and esophageal mucosa exposure time.
Definition & Classification
Gastroesophageal Reflux
Causes
GERD can be caused by abnormalities or alterations in
1. Lower esophageal sphincter function
2. Esophageal motility
3. Gastric motility or emptying
Esophageal function studies include the following:
Determination of the lower esophageal sphincter (LES) pressure (manometry)
Graphic recording of esophageal swallowing waves, or swallowing pattern (manometry)
Detection of reflux of gastric acid back into the esophagus (acid reflux)
Detection of the ability of the esophagus to clear acid (acid clearing)
An attempt to reproduce symptoms of heartburn (Bernstein test)
Gastroesophageal Reflux
Risk Factors
Obesity
Hiatal hernia
Use of drugs or chemicals that relax the LES (anticholinergics, nitrates, calcium channel blockers, nicotine)
Cigarette smoke.
Trigger Factors
Coughing
Vomiting
Straining at stool
Asthma
Chronic cough
Sinusitis.
Gastroesophageal Reflux
Common Symptoms
Heartburn that occurs 30 to 60 minutes after meals and when the patient bends over or lies down.
Regurgitation of sour or bitter gastric contents
Belching, and fullness of the stomach
Upper abdominal pain within 1 hour of eating.
Atypical Symptoms
chronic cough
asthma attacks
chronic laryngitis
sinusitis
discomfort during swallowing.
Noncardiac chest pain.
Dysphagia
Gastroesophageal Reflux
Clinical manifestations are related to mucosal injury from acid regurgitation and the frequency and duration of reflux events.
The symptoms worsen if the individual lies down or if intraabdominal pressure increases because of coughing, vomiting, or straining at stool.
Uncomplicated GERD that is responsive to first-line therapy does not require an endoscopy.
Patients who do not respond to therapy and those with suspected complications should undergo an endoscopic examination
Management & Evaluation
Differential diagnosis
Gastritis
Peptic ulcer
Gastric cancer
Cholelithiasis
Angina pectoris.
Gastroesophageal Reflux
Diagnosis of GERD is based on the history and clinical manifestations.
An upper endoscopy with biopsy is the standard diagnostic procedure for GERD. It confirms the diagnosis and documents the type and extent of tissue damage.
Esophageal endoscopy: shows hyperemia ...
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.
Gastroesophageal reflux disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and complications.
Controversy: the role of immunomodulator in allergic caseSuharti Wairagya
dipresentasikan oleh Erwanto BW Teguh HK
Divisi Alergi Imunologi Klinik Departemen 1. Penyakit Dalam FKUI/RSCM Bagian Penyakit Dalam SMF non Bedah RS. dr. H. Marzoeki Mahdi Bogor
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Recent management of gerd from consensus to clinical application dr taulin agustinus
1. RECENT MANAGEMENT OF GERD: From Consensus To Clinical Application
Dr.Agus Taolin, SpPD
2. “GERD is a condition which develops when the refluxof stomach content causes troublesome symptoms and / or complications”
Esophageal
Syndromes
Extra-esophageal
Syndromes
Symptomatic
Syndromes
Typical Reflux
Syndrome
Reflux Chest
Pain Syndrome
Syndromes
with Esophageal
Injury
Reflux Esophagitis
Reflux Stricture
Barrett’s Esophagus
Adenocarcinoma
Established
Associations
Reflux Cough
Reflux Laryngitis
Reflux Asthma
Reflux Dental Eros.
Proposed
Associations
Pharyngitis
Sinusitis
Idiopathic
Pulmonary Fibrosis
Recurrent Otitis
Media
Vakil N et al. Am J Gastroenterol 2006; in press
The Montréal definition of GERD
INTRODUCTION
4. Most common GERD symptom in Asia
Acid regurgitation -87%
Feeling of acidity in the stomach-45%
Angina-like chest pain-35%
Heartburn-30%
Dyspepsia-29%
Dysphagia-6.5%
Wong BCY et al. Aliment Pharmacol Ther.2003TypicalAtypical
NCCP -14.5%
Chronic cough -13%
Laryngeal disorder-10%
Asthma-4.8%
5. Social and medical impact of GERD in TaiwanLiu et al. Aliment Pharmacol Ther 2005Heartburn sufferers in Taiwan
•Have more atypical GERD symptoms.
•More medical consultation.
•Increased frequency of absenteeism.
•More sleep disturbance. Heartburn consulters in Taiwan
•Co-existing globus.
•Higher costs for antacid, PPI, sedatives, tranquilizers, and antidepressants.
7. Figure 1. Prevalence of Reflux esophagitis 1997 VS 2002
5.7
25.81
0 5 10 15 20 25 30 35
% of case
1997 2002
Ari F. Syam et al. 2005.
8. Impaired
mucosal
defence
de Caestecker, BMJ 2001; 323:736–9.
Johanson, Am J Med 2000; 108(Suppl 4A): S99–103.
peristaltic
Hiatus hernia
Impaired LES
–transient LES
relaxations (TLESR)
– hypotensive LES
H+
Pepsin
Bile and
pancreatic
enzymes
esophageal
clearance of acid
(lying flat, alcohol,
coffee)
acid output
(smoking, coffee)
H. pylori
intragastric pressure
(obesity, lying flat)
bile reflux
gastric emptying (fat)
Pathophysiology of GERD
salivary HCO3
9. Environmental Risk Factors for Gastroesophageal Reflux Disease
Risk Factor
Mechanism of Risk
Smoking
Weakened LES? (small risk)
Alcohol
Mucosal damage ? (small risk)
Medications
Weakening of LES, mucosal damage
Meals and specific foods
Gastric distension, weakening of LES, irritation of esophageal mucosa
Helicobacter pylori
Beneficial influence as corpus gastritis reduces acid output
Naso-gastric tubes
Conduit for acid reflux in supine patients
Abdominal trauma
Disruption of diaphragm?
LES = lower esophageal sphincter
Fass, 2004
10. Medical Conditions Associated withGastroesophageal Reflux Disease
Associated Condition
Mechanism of Risk
Obesity
Increased intra-abdominal pressure
Diabetes mellitus
Delayed gastric emptying
Zollinger-Ellison syndrome
Increased acid output
Pregnancy
Increased intra-abdominal pressure, weakened LES
Myotomy in achalasia
Destroyed LES
CRST syndrome
Impaired peristalsis
Sicca syndrome
Impaired esophageal clearance
Psychiatric disease
Impaired esophageal motility
Mental retardation of childhood
Impaired esophageal motility
LES = lower esophageal sphincter
Fass, 2004
11. The role of H. pylori infection in the pathogenesis of GERD:
•There is little evidence that H. pylori infection has pathogenic role in GERD.
•Virulent strain (Cag A positive) inverse relationship.
•Depends on anatomical distribution of gastritis (antral predominant gastritis or corpus predominant gastritis) and pre- existing GERD
13. DIAGNOSIS
1. Upper GI endoscopy
–Upper GI endoscopy is the gold standard of the diagnosis of GERD mucosal break
–To assess macroscopic changes in the esophageal mucosa. Biopsy sample is taken in patient with suspected malignancy/Barret’s esophagus
–Some patient with characteristic symptom of GERD may exist without any mucosal break NERD
16. Alarm symptoms (e.g. dysphagia, weight
loss, bleeding, abdominal mass, age >40
years)
Diagnostic problems (e.g. atypical
symptoms)
No response to empirical treatment in
patient with characteristic symptoms
By patient request, or referred from other
clinician
Endoscopy are considered
to be performed in patients with :
17. 2. Esophageal radiography with barium swallow
• Only performed in patient with esophageal stenosis secondary to peptic esophagitis resulting in dysphagia
3. 24 hours pH monitoring
To monitor episodes of esophageal acidification by placement of a pH microelectrode in the distal esophagus
(The newest technique : BRAVO)
18. 4. Esophageal Manometry
This test may sometimes useful when a barium swallow and endoscopy have been normal
5. Acid Suppression Test / PPI Test
As the empirical treatment to evaluate
the symptoms of GERD after taking
high dose of PPI
19.
20. Acid Suppression/PPI test
•ThisPPItestisnowwidelyusedtodiagnoseGERDpatientsespeciallyinprimarycaresetting eventhoughsomereports(Kahrilasetal. 2005andametaanalysisstudybyNumansetal.2004.)confirmedthatPPItesthasahighsensitivitybutlowspecificity.
•The test is positive when 50% -75% symptoms improvement is observed after 1-2 weeks treatment
21. Rabeprazole 20 mg twice daily as a diagnostic test for GERD
PPI
Dose
Days
Sen (%)
Spe (%)
Rabeprazole
20 mg twice daily
7
83
45
Esomeprazole
40 mg once daily &
20 mg twice daily
14
79 -86
24 -65
Omeprazole
20 mg twice daily
7
71 -81
55
Lansoprazole
60 mg daily
7
85
73
Johnsson F et al. Scand J Gastroenterol 1998
Johnsson F et al. Scand J Gastroenterol 2003
Juul-Hansen P et al. Scand J Gastroenterol 2001
Stanislas Bruley des Varannes et al. World J Gastroenterol 2006
22. BEsevereERD*NERD + mild ERD+
New concept based on ProGERD 2005No complicationsNegligible progression
>85% Potentially serious complications
<15% Focus of treatment: Symptoms Symptoms & lesions
+Grade A and B according to the LA classification
*Grade C and D according to the LA classification
Labenz & Morgner-Miehlke 2006Evolving concepts of the progression of GERD: implications for clinical management
24. Goals in the management of GERD
•Provide complete (sufficient) relief from heartburn and other symptoms
•Heal underlying esophagitis
•Maintain symptomatic and endoscopic remission
•Treat or, ideally, prevent complications
Dent et al 1999
25. Reduce weight
Stop smoking
Avoid reflux-promoting agents (e.g. alcohol, coffee, some foods) (not evidence based)
Elevate head
of bed
Consider alternatives to reflux-promoting drugs (e.g. theophylline, anticholinergics)
Modifications
Eat small meals,
no late meals, reduce fat
Lifestyle modifications for the management of GERD
26. Drugs
•GERD motility disorder
•The Fact acid suppression therapy more effective than prokinetic drugs
•PPIis the drug of choice
29. Symptom-based
diagnosis
Risk
assessment
Empirical
therapy
up to 95% in primary care
NERD
RE
~35%
CRD
~5%
~60% Endoscopy
Alarm
symptoms
Reflux
esophagitis
Complicated reflux disease
Labenz & Malfertheiner 2005GERD: initial management
30. 1. Antacid
•The mainstay for rapid, save, effective relief of symptoms without significant healing effect
•Dose: 15 mL qid
2. H2-Receptor Antagonist( Ranitidine, Famotidine, Nizatidine)
•As an acid suppressor (and increase the chance for lesions to heal) should be used in double dose than those used for treatment of duodenal ulcer
Only effective in mild GERD
3. Prokinetic agentDomperidoneCisapride
31. 4. Proton pump inhibitor
•Drug of choicein the treatment of GERD
•Very effective (clinically and endoscopically) in symptoms relief and healing of severe grade esophagitis and GERD refractory to H2RA:
•Dose for GERD:
-Omeprazole: 2 x 20 mg
-Lanzoprazole: 2 x 30 mg
-Pantoprazole: 2 x 40 mg
-Rabeprazole: 2 x 10 mg
-Esomeprazole: 2 x 40 mg
6-8 weeks maintenance/on demand therapy
•Combination with prokinetic drugs enhance effectivity
32. Dose for NERD:
-Omeprazole: 1 x 20 mg
-Lanzoprazole: 1 x 30 mg
-Pantoprazole: 1 x 40 mg
-Rabeprazole: 1 x 10 mg
-Esomeprazole: 1 x 40 mg
•>4 weeks on demand therapy
33. Algorithm of the management of GERD in primary care (National Consensus in the Management of GERD in Indonesia, Indonesian Society of Gastroenterology,2004)
Typical GERD Symptoms
*Heartburn
*Regurgitation
Alarm symptom present
Age >40 years
Alarm symptoms absent
Symptoms persist
Maintain therapy 4 weeks
Empirical treatment/PPI test
Endoscopy
Symptoms respond
On-demand therapy
Frequent relapses
34. Algorithm of the management of GERD (National Consensus in the Management of GERD in Indonesia, Indonesian Society of Gastroenterology2004)
Typical GERD Symptoms
*Heartburn
*Regurgitation
Uninvestigated
Investigated
Mild esophagitis
NERD
Empirical Treatment
/ PPI Test
Initial Treatment
Maintenance Therapy
On demand therapy
PPI test (1-2 weeks)
Sensitivity: 68-80%
Symptoms recurrent or persist
Moderate & Severe Esophagitis
Recurrent Symptom
Alarm Symptoms
Age > 40 years
35. Wong et al. J Gastroenterol Hepatol 2004For mild GERD symptom
•Treat before testFor severe GERD symptom
•Gastroenterologist -test before treat
•Primary care physician -treat before test
•ENT doctor -treat before test
Most doctors heard of PPI testing but only 33-52%of them
had used it before.
Clinical practice pattern in Asia
36. Pharmacokinetic and acid
inhibition profiles
Efficacy
Indications and formulations
Potential for drug interactions
Tolerability/safety
Choosing a PPI to manage GERD:
factors to consider
37. In vitro chemical activation rates of PPIs vary with pH
Kromer W et al. Differences in pH –Dependent Activation Rates of Subtituted Benzimidazoles and Biological in vitro Correlates.
Pharmacology 1998; 56 : 57 -70
38. During night-time, mean percent time pH > 3 &
pH > 4 was significantly higher on a single dose
of rabeprazole 20 mg than esomeprazole 40 mg
0
5
10
15
20
25
30
35
40
45
50
Intragastric pH > 3 Intragastric pH > 4
Mean Percent (%) Time
Rabeprazole 20 mg
Esomeprazole 40 mg
Warrington S et al. Eur J Clin Pharmacol 2006; 62: 685 - 691
N = 24 Helicobacter pylori – negative healthy volunteers
P = NS:
• Mean AUC0-24 h
• Mean % time pH > 3
• Mean % time pH > 4
*P < 0.05 *P < 0.05
39. 51
37.7
24.9
11.2
35.7
23.9
14.2
5.8
0
10
20
30
40
50
60
70
80
90
100
pH > 3 pH > 4 pH > 5 pH > 6
pH Threshold
% of Time
Oral RAB 20
IV PAN 40
D Armstrong et al. Aliment Pharmacol Ther 2007; 25 (2): 185 - 196
Day 1 - Oral Pariet 20 mg is significantly more
effective than IV pantoprazole 40 mg in % time
pH > 3, 4, 5 & 6 over 24 hours
Complete 24-Hour Recording (0 - 24 hours)
P < 0.05 for All
N = 33 Helicobacter pylori - negative volunteers
RAB - rabeprazole
PAN - pantoprazole
95% confidence intervals are represented by vertical lines
40. ? x2 daily PPI + H2RA
x2 daily PPI
x1 daily PPI
x1 daily ½ PPI
Prokinetic + H2RA
Prokinetic*
Antacids + lifestyle
Antacids
Lifestyle
H2RA*
OR
*no clear dose-response established
Highest efficacy
Lowest efficacy
Recommended
Should be
abandoned
Current
guidelinesMainstream options for therapy of GERD
after Dent et al 2002
41. 0
20
40
60
Patients free from heartburn%
0
1–2
3–4
6–8
Weeks of treatment
H2-receptorantagonistsMeta-analysis n=2198
PPIs
P<0.0001
80Speed of symptom resolution in patients with reflux esophagitis
Chiba et al 1997
42. P<0.0005
0
20
40
60
80
Esophagitis cases healed, %
0
2
4
6
8
10
12
Time (weeks)
PPIs
H2-receptorantagonists
Placebo
100
Meta-analysis: n=7635
83.6
51.9
28.2
Chiba et al 1997Speed of healing of reflux esophagitis
43. More patients had satisfactory relief of day – time
heartburn & regurgitation with Pariet 10mg
than with esomeprazole 20mg
79.4%
71.4%
75.7%
60.5%
71.1%
85.7% 86.0%
92.5%
55%
65%
75%
85%
95%
1 2 3 4 (wk)
Patients achieving symptom relief (%)
Esomeprazole 20mg/d n=52 Rabeprazole 10mg/d n=52
p = 0.045
Fock KM, Rabeprazole vs Esomeprazole in non erosive gastro – oesophageal reflux disease: A Randomized, double blind study
In Urban Asia. World Journal of Gastroenterology, 2005 ; 11 (20): 3011 - 3170
44. Superior reduction in severe heartburn with
Pariet 20mg than high dose Omeprazole 40mg,
within 3 days
4.7%
10.3%
0%
2%
4%
6%
8%
10%
12%
Rabeprazole 20mg Omeprazole 40mg
Patients
n = 230 patients
Report of severe daytime heartburn during the first 3 days
( post hoc analysis )
Holtman G. et al. A Randomized, double – blind, comparative study of standard-dose and high dose omeprazole in
gastro – oesophageal reflux disease. Aliment Pharmacol Ther 2002; 16 : 479 - 485
45. Rabeprazole 10 mg was statistically superior to
omeprazole 20 mg in partial pain relief rate on
Day 1 & acid regurgitation relief rate on Day 7
0
20
40
60
80
100
120
D1 (Partial Pain) D7 (Acid Regurgitation)
Relief Rate (%)
Rabeprazole 10 mg (N = 108)
Omeprazole 20 mg (N = 103)
P = NS:
Abdominal Bloatness Relief Rate
Belching Relief Rate
Active Duodenal Ulcer
*P < 0.05
*P < 0.05
Lin S et al. Zhonghua Nei Ke Za Zhi 2002; 41 (9): 589-91
46. Rabeprazole provided effective relief of daytime & nighttime heartburn
& regurgitation in a majority of patients suffering from erosive GERD
who reported ineffective relief with prior OME or LAN therapy
65.6
82.2
75.5
81
77.8
82.3
76.8
84.4
63.5
77.2
66.2
74.8
66.4 66 66.7
72.3
0
10
20
30
40
50
60
70
80
90
100
At Day 7 At Week 4 At Day 7 At Week 4
Complete Relief With Rabeprazole (%)
Daytime Heartburn
Nighttime Heartburn
24-Hour Heartburn
Regurgitation
N = 290 previously on omeprazole OME
N = 210 previously on lansoprazole LAN Fitzgerald S et al. Gastroenterology 2001; 120 (5) Suppl 1: A441
Prior Omeprazole Prior Lansoprazole
47. A high percentage achieve heartburn relief * – Future of Acid Suppression Therapy (FAST) Study
M. Robinson et al. Aliment Pharmacol Ther 2002; 16: 445-454
* Patients with moderate or severe symptoms at baseline who achieve mild or no symptoms
48. PPIs –Meals & Time of Dosing
Rabeprazole
Pantoprazole
Lansoprazole
Omeprazole
Esomeprazole
Meal
No effect on bioavailability
↓absorption up to 2 hours or longer
Cmax& AUC
↓50 -70% if given 30 minutes after food compared to fasting conditions
Cmax↓25% when 20 mg when administered with applesauce, unlike 40 mg
AUC ↓43-53% after food intake compared to fasting conditions
Time of Dosing
No effect on bioavailability
No effect on bioavailability
Before meals
Before meals
1 hour before meals
US FDA Approved Package Insert
49. PPIs –Drug Interactions
Rabeprazole
Pantoprazole
Lansoprazole
Omeprazole
Esomeprazole
Non-pH dependent interaction with
None
None
Sucralfate
Theophylline
Phenytoin Diazepam Warfarin Disulfram Cyclosporin
Benzodiazepines
Diazepam
pH-dependent interaction with
Ketoconazole Digoxin
US FDA Approved Package Insert
50. Use of PPIs in Pregnancy
B -Animal studies showed no fetal risk but no controlled clinical study; or
animals studies showed no adverse effects but not seen in clinical study. If there is a clinical need for a Category B drug, it is considered safe
C -Animal studies showed teratogenic or embryocidal effects but no clinical study; or no animal study available. Drugs in this category should be given only when the potential benefit justifies the potential risks to the fetus
Drug
FDA Pregnancy Category
Rabeprazole
B
Pantoprazole
B
Lansoprazole
B
Esomeprazole
B
Omeprazole
C
US FDA Approved Package Insert
51. Management of Complication
•Long term complication:
-Stricture
-Barrett’s esophagus
carcinoma
•Stricture of the esophagus
-Diameter <13 mm dilatation
Failed
surgery
52. Wani S et al. Aliment Pharmacol Ther 2005; 22 (7): 627 - 633
The majority of Barrett’s oesophagus patients (73.9%)
can achieve normalization of oesophageal acid exposure
on rabeprazole 20 mg twice daily therapy
(median total % time pH < 4 = 0.2%)
73.9
26.1
0
10
20
30
40
50
60
70
80
90
100
Total Barrett's Esophagus Patients
(%)
Normal pH*
Abnormal pH*
N = 46
*Patients with intra-oesophageal pH < 4 for longer than 4.2% of the
total monitoring period were considered to have an ABNORMAL result
53. •fundoplication•The best candidates for fundoflication are those with . . –Esophagitis documented by endoscopy, –Need for continuous PPI therapy–Abnormal pH monitoring studies, –Normal esophageal motility studies, –Responders to PPI therapy with persistent volume regurgitation
Surgical treatment
56. SUMMARY
•GERD is common in western population low prevalence in Asia –Africa countries. In Indonesia seems to be increased
•Characteristic symptoms of GERD is heartburn Disphagia, nausea, regurgitation
•Early endoscopy is recommended in all patients presenting with reflux symptoms
57. •PPI test is widely used as the empirical treatment of GERD, especially in primary care setting
•PPIs are the drug of choice for the initial management and long term care of all patients with GERD. Treatment should always be started with a highly effective PPI
•Anti reflux surgery should be reserved for (a few) carefully selected patients
•Endoscopic treatment are currently experimental
SUMMARY