Zee ppt gerd
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This ppt was presented in ENT deptt of NMCH patna by Dr ZEESHAN AHMAD and appreciated a lot
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Zee ppt gerd
- 1. Gastro esophageal Reflux Disease My room My mess ENT Central emergency
- 2. Gasroesophageal reflux disease (GERD)
- 16. Pathophysiology of Extraesophageal GERD
- 26. Ambulatory 24 hr. pH Monitoring Normal GERD
- 30. Patient with heartburn Iniate tx with H2RA or PPI H2RA taken BID Good response Frequent relapses On demand tx PPI taken QD Good response Maintenance therapy with lowest effective dose Symptoms persist Consider EGD if risk factors present ( > 45, white, male and > 5 yrs of sx) Increase to max dose QD or BID Good response Confirm diagnosis EGD, ph monitor No Yes Yes No Yes Yes No No
- 34. 1. Orr WC, et al. Gastroenterology . 1984;86:814-819. 2. Orr WC, et al. Am J Gastroenterol . 2000;95:37-42. 3. Orr WC, et al. Am J Gastroenterol . 1994;89:509-512. 4. Kjellén G, Tibbling L. Scand J Gastroenterol . 1978;13:283-288. Sleep May Impair Esophageal Acid Clearance Gravity-Mediated Drainage 4 Esophageal Acid Clearance 1–3 Salivary Flow and Swallowing 1 Asleep Awake Factors FACTORS THAT MAY CONTRIBUTE TO INCREASED ESOPHAGEAL ACID EXPOSURE DURING SLEEP
- 41. NOT ALL PROTON PUMPS ARE ACTIVE AT ANY GIVEN TIME 1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. Unstimulated proton pumps Active proton pumps Unstimulated proton pumps in cytoplasmic tubules 1. Blair JA, et al. J Clin Invest. 1987;79:582-587. 2. Sachs G. Pharmacotherapy . 1997;17:22-37. H 2 = Histamine ACh = Acetylcholine Proton pumps become activated in response to food 1 Inactive Parietal Cell After activation, the parietal cell undergoes a series of changes, allowing proton pumps to reach the surface of the parietal cell 1 Active Parietal Cell Only active proton pumps can secrete acid 1 However, not all pumps become activated 1,2 ATPase ATPase MOA Gastrin H 2 ACh H+ H+ H+ H+ K+ K+ K+ K+
- 42. PPIs ONLY BIND TO ACTIVE PROTON PUMPS Acid is required to convert a PPI into its active form 1 1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. PPIs only bind to active proton pumps 1 Unstimulated proton pumps remain MOA PPI PPI PPI PPI
- 48. (Nissen’s)
- 56. Peptic Stricture Barium Swallow Endoscopy
- 57. Esophageal Stricture: Dilating Devices
- 58. TTS Balloon Dilation of a Peptic Stricture
- 64. Esophageal Cancer Barium Swallow Endoscopy
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
- --gerd related chest pain may mimic angina—squeezing/burning, substernal, radiates to back, neck, jaw, arms. Minutes to hours. After meals, awakens patient from sleep, exacerbated by emotional stress --water brash—hypersalivation—heartburn and regurg of sour fluid or tasteless saliva into mouth --globus—lump in throat irrespective of swallowing --odynophagia—esophageal ulcer --nausea—infrequent --hrt burn 70-85%//regurg 60%//dysphagi 15-20%//angina 33%//asthma 15-20%
- --heartburn +/- regurgitation high specificity, low sensitivity
- --need further eval if any present—egd--
- Once established h&p dx and no alarm symptoms can proceed with dx/therapeutic trial of tx.
- --if started with or changed to --prilo 40 qd x 14d as specific/sensitive as pH monitor --remember only works on active pumps. Take 30-60 min prior to eating
- --if trial of med did not work or if alarm symptoms or long term 5yrs need egd 1a evidence—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia --50-70% of patient’s with gerd will have a neg egd.
- A number of physiologic factors may contribute to increased esophageal acid exposure during sleep The esophageal response to acid was studied in 14 subjects without GERD while awake and during sleep (<30% awake) 1 Acid caused a greater swallowing rate in awake subjects; this swallowing rate in response to acid decreased during the sleep period Calculated esophageal acid clearance was also found to be impaired compared to the awake condition, taking 180% longer to clear acid when asleep Another study evaluated the effects of different body positions on esophageal acid clearance in 21 healthy subjects 2 Gravity-mediated drainage was found to be more difficult to achieve in a supine position, as a greater number of swallows were needed to achieve a normal esophageal pH in the supine position compared to the upright position 1. Orr WC, et al. Gastroenterology . 1984;86:814-819. 2. Kjellén G, Tibbling L. Scand J Gastroenterol . 1978;13:283-288.
- --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
- This animation depicts proton pump activation following stimulation with food. The ingestion of food causes a series of biochemical events that ultimately allow proton pumps to reach the surface of the cell and secrete acid 1,2 Only active proton pumps can secrete acid; however not all pumps are stimulated at a given time; some pumps remain unstimulated 2-4 References: 1. Del Valle J, et al. Gastric secretion. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:266-307. 2. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. 3. Sachs G. Pharmacotherapy . 1997;17:22-37. 4. Blair JA, et al. J Clin Invest. 1987;79:582-587.
- PPIs are only activated in an acidic environment and PPIs only bind to and inhibit active proton pumps PPIs covalently bind to the H + /K + ATPase (proton pump) to inhibit the final step of gastric acid production Reference: Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376.
- Gastric acidity is a mechanism of protection against bacterial overgrowth, and PPI use reduces gastric acidity 1-3 In a controlled prospective study, 47 outpatients with peptic disease were examined by endoscopy before and after treatment with a 4-week course of a PPI or an H 2 RA 4 Before treatment only 8% of patients had gastric or duodenal bacterial overgrowth. After treatment 53% of patients treated with a PPI had overgrowth and 17% of those using the H 2 RA had overgrowth 4 Patients treated with the PPI had the highest gastric pH which positively correlated with bacterial count (r=.68; P <0.001) 4 A systematic literature review (11 papers evaluating 126,999 patients on PPI therapy) showed a positive association between PPI use and the risk of developing Clostridium difficile infection 1 A combination cohort and case-control analysis of hospitalized patients (n=1187) linked PPI use with an increased risk of C difficile diarrhea 2 One cohort analysis also observed increased community-acquired pneumonia rates associated with PPI use (adjusted relative risk of current PPI use compared to those who stopped taking PPI=1.89) 3 The study population consisted of 364,638 subjects of whom 5551 developed a first occurrence of pneumonia A more recent study from the General Practice Research Database in the United Kingdom found that current, long-term PPI use did not increase risk of community-acquired pneumonia; however, recently starting PPI therapy (2, 7, or 14 days prior to index date) was found to increase risk 5 The study evaluated case patients (n=80,066) who received an incident diagnosis of community acquired pneumonia and matched controls (n=799,881) “ When we stratified the current PPI recipient group on the basis of duration of exposure before the index date, PPI use for fewer than 30 days was associated with moderately increased risk for CAP. Among current PPI recipients with longer periods of PPI exposure, risk for CAP did not increase. A close examination of the group with current PPI use for fewer than 30 days revealed that new PPI therapy started within the 30 days before the index date accounted for all of the increased risk for CAP in this group. In addition, increases in risk for CAP were progressively larger among recipients who started PPI or histamine-2–receptor antagonist therapy within 14, 7, or even 2 days before the index date.” 5 From Sarkar M, et al. Ann Intern Med. 2008;149:391-398. References: 1. Leonard J, et al. Am J Gastroenterol . 2007;102:2047-2056. 2. Dial S, et al. CMAJ . 2004;171:33-38. 3. Laheij RJF, et al. JAMA . 2004;292:1955-1960. 4. Thorens J, et al. Gut . 1996;39:54-59. 5. Sarkar M, et al. Ann Intern Med. 2008;14
- 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
- --dysphagia, odynophagia, early satiety, gi bleed, anemia, vomit, wt loss
- --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
- 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
- --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
- --alarm symptoms—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia