Fantry_GERD_September7_2nd - Gastroesophageal Reflux...

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Unformatted text preview: Gastroesophageal Reflux Disease (GERD) • Any symptoms or esophageal mucosal damage Any that results from reflux of gastric acid into the esophagus esophagus • Classic GERD symptoms – Heartburn (pyrosis): substernal burning discomfort – Regurgitation: bitter, acidic fluid in the mouth Regurgitation: when lying down or bending over when High Prevalence of Gastroesophageal High Reflux Symptoms 60% 50% 40% 30% 20% 10% 0% 59% 19.8% Weekly Monthly Frequency of heartburn and/or regurgitation Locke et al. Gastroenterology 1997;112:1148. Important Reasons to Diagnose and Treat GERD GERD • Negative impact on health-related quality of life 1 • Risk factor for esophageal adenocarcinoma2 1. 2. Revicki et al. Am J Med 1998;104:252. Lagergren et al. N Engl J Med 1999;340:825. Clinical Presentations of GERD Clinical • Classic GERD Classic • Extraesophageal/Atypical GERD • Complicated GERD Extraesophageal Manifestations of GERD of Pulmonary Asthma Aspiration pneumonia Chronic bronchitis Pulmonary fibrosis Other Chest pain Chest Dental erosion Dental ENT Hoarseness Laryngitis Pharyngitis Chronic cough Globus sensation Dysphonia Sinusitis Subglottic stenosis Laryngeal cancer Potential Oral and Laryngopharyngeal Signs Associated with GERD Associated • Edema and hyperemia of Edema larynx larynx • Vocal cord erythema, Vocal polyps, granulomas, ulcers ulcers • Hyperemia and lymphoid Hyperemia hyperplasia of posterior pharynx • Interarytenyoid changes • Dental erosion • Subglottic stenosis • Laryngeal cancer Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344. Pathophysiology of Extraesophageal GERD GERD Symptoms of Complicated GERD Symptoms • Dysphagia – Difficulty swallowing: food sticks or hangs up • Odynophagia – Retrosternal pain with swallowing • Bleeding When to Perform Diagnostic Tests When • • • • • • Uncertain diagnosis Atypical symptoms Symptoms associated with complications Inadequate response to therapy Inadequate Recurrent symptoms Prior to anti-reflux surgery Diagnostic Tests for GERD Diagnostic • • • • Barium swallow Endoscopy Ambulatory pH monitoring Esophageal manometry Barium Swallow Barium • Useful first diagnostic test for Useful patients with dysphagia patients – – – – Stricture (location, length) Mass (location, length) Bird’s beak Hiatal hernia (size, type) • Limitations Limitations – Detailed mucosal exam for erosive Detailed esophagitis, Barrett’s esophagus esophagitis, Endoscopy Endoscopy • Indications for endoscopy Indications – – – – Alarm symptoms Empiric therapy failure Preoperative evaluation Detection of Barrett’s Detection esophagus esophagus Ambulatory 24 hr. pH Monitoring Ambulatory • Physiologic study • Quantify reflux in Quantify proximal/distal esophagus esophagus – % time pH < 4 – DeMeester score • Symptom correlation Ambulatory 24 hr. pH Monitoring Ambulatory Normal GERD Wireless, Catheter-Free Esophageal pH Monitoring Potential Advantages • Improved patient comfort and acceptance comfort • Continued normal work, activities and diet study activities • Longer reporting periods possible (48 hours) possible • Maintain constant probe position relative to SCJ position Esophageal Manometry Esophageal Limited role in GERD Limited • Assess LES pressure, Assess location and relaxation location – Assist placement of 24 hr. Assist pH catheter pH • Assess peristalsis – Prior to antireflux surgery Prior Treatment Goals for GERD Treatment • • • • Eliminate symptoms Heal esophagitis Manage or prevent complications Maintain remission Lifestyle Modifications are Cornerstone of GERD Therapy Cornerstone • • • • • Elevate head of bed 4-6 inches Elevate Avoid eating within 2-3 hours of bedtime Lose weight if overweight Stop smoking Modify diet – Eat more frequent but smaller meals – Avoid fatty/fried food, peppermint, chocolate, Avoid alcohol, carbonated beverages, coffee and tea alcohol, • OTC medications prn Acid Suppression Therapy for GERD Acid H2-Receptor Antagonists (H2RAs) (H Cimetidine (Tagamet®) Ranitidine (Zantac®) Famotidine (Pepcid®) Nizatidine (Axid®) Proton Pump Inhibitors Proton (PPIs) (PPIs) Omeprazole (Prilosec®) Lansoprazole (Prevacid®) Rabeprazole (Aciphex®) Pantoprazole (Protonix®) Esomeprazole (Nexium ®) Esomeprazole Effectiveness of Medical Therapies for GERD GERD Treatment Response Lifestyle modifications/antacids 20 % H2-receptor antagonists 50 % Single-dose PPI Single-dose 80 % 80 Increased-dose PPI up to 100 % Treatment Modifications for Persistent Symptoms Persistent • Improve compliance • Optimize pharmacokinetics – Adjust timing of medication to 15 – 30 minutes Adjust before meals (as opposed to bedtime) before – Allows for high blood level to interact with Allows parietal cell proton pump activated by the meal parietal • Consider switching to a different PPI Consider GERD is a Chronic Relapsing Condition GERD • Esophagitis relapses quickly after cessation Esophagitis of therapy of – > 50 % relapse within 2 months – > 80 % relapse within 6 months • Effective maintenance therapy is imperative Complications of GERD Complications • Erosive/ulcerative esophagitis • Esophageal (peptic) stricture • Barrett’s esophagus • Adenocarcinoma Erosive Esophagitis Erosive Peptic Stricture Peptic Barium Swallow Endoscopy Esophageal Stricture: Dilating Devices Esophageal TTS Balloon Dilation of a Peptic Stricture TTS Barrett’s Esophagus Barrett’s Esophageal Cancer Esophageal Barium Swallow Endoscopy When to Discuss Anti-Reflux Surgery with Patients Surgery • Intractable GERD – rare – – – Difficult to manage strictures Severe bleeding from esophagitis Non-healing ulcers • GERD requiring long-term PPI-BID in a GERD healthy young patient • Persistent regurgitation/aspiration symptoms • Not Barrett’s esophagus alone Endoscopic GERD Therapy • Endoscopic antireflux therapies – Radiofrequency energy delivered to the LES • Stretta procedure – Suture ligation of the cardia • Endoscopic plication – Submucosal implantation of inert material in Submucosal the region of the lower esophageal sphincter the • Enteryx ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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