gerd - Gastroesophageal Gastroesophageal Reflux Disease...

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Unformatted text preview: Gastroesophageal Gastroesophageal Reflux Disease Reflux Howard J. McGowan, Maj, USAF, MC Objectives Objectives Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manisfestations Diagnostic Evaluation Treatment Complications Definition Definition American College of Gastroenterology (ACG) • Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus • Often chronic and relapsing • May see complications of GERD in patients who lack typical symptoms Physiologic vs Pathologic Physiologic Physiologic GERD • • • • Postprandial Short lived Asymptomatic No nocturnal sx Pathologic GERD • • • Symptoms Mucosal injury Nocturnal sx Epidemiology Epidemiology About 44% of the US adult population have heartburn at least once a month 14% of Americans have symptoms weekly 7% have symptoms daily Pathophysiology Pathophysiology Primary barrier to gastroesophageal reflux is the lower esophageal sphincter LES normally works in conjunction with the diaphragm If barrier disrupted, acid goes from stomach to esophagus Clinical Manisfestations Most common symptoms • Heartburn—retrosternal burning discomfort • Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions Clinical Manisfestations Clinical • Dysphagia—difficulty swallowing • Other symptoms include: Chest pain, water brash, globus sensation, odynophagia, nausea • Extraesophageal manifestations Asthma, laryngitis, chronic cough Diagnostic Evaluation Diagnostic • If classic symptoms of heartburn and regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be made clinically and treatment can be initiated Alarms Alarms • Alarm Signs/Symptoms Dysphagia Early satiety GI bleeding Odynophagia Vomiting Weight loss Iron deficiency anemia Trial of Medications Trial H2RA or PPI • • Expect response in 2­4 weeks If no response Change from H2RA to PPI Maximize dose of PPI Trial of Medications Trial If PPI response inadequate despite maximal dosage • Confirm diagnosis EGD 24 hour pH monitor Esophagogastrodudenoscopy Esophagogastrodudenoscopy Endoscopy (with biopsy if needed) • In patients with alarm signs/symptoms • Those who fail a medication trial • Those who require long­term tx Lacks sensitivity for identifying pathologic reflux Absence of endoscopic features does not exclude a GERD diagnosis Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD pH pH 24­hour pH monitoring • Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes • Trans­nasal catheter or a wireless, capsule shaped device Patient with heartburn Iniate tx with H2RA or PPI H2RA taken BID Good response Yes Frequent relapses No On demand tx PPI taken QD No Yes Good response Yes No Maintenance therapy with lowest effective dose Yes Symptoms persist Increase to max dose QD or BID Good response No Consider EGD if risk factors present (> 45, white, male and > 5 yrs of sx) Confirm diagnosis EGD, ph monitor GERD vs Dyspepsia GERD Distinguish from Dyspepsia • Ulcer­like symptoms­burning, epigastric pain • Dysmotility like symptoms­nausea, bloating, early satiety, anorexia Distinct clinical entity In addition to antisecretory meds and an EGD need to consider an evaluation for Helicobacter pylori Treatment Treatment Goals of therapy • • • Symptomatic relief Heal esophagitis Avoid complications Better Living Better Lifestyle modifications • • • • • • • • • Avoid large meals Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermint Decrease fat intake Avoid lying down within 3­4 hours after a meal Elevate head of bed 4­8 inches Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS) Avoid clothing that is tight around the waist Lose weight Stop smoking Treatment Treatment Antacids • Over the counter acid suppressants and antacids appropriate initial therapy • Approx 1/3 of patients with heartburn­related symptoms use at least twice weekly • More effective than placebo in relieving GERD symptoms Treatment Treatment Histamine H2­Receptor Antagonists • More effective than placebo and antacids for relieving heartburn in patients with GERD • Faster healing of erosive esophagitis when compared with placebo • Can use regularly or on­demand Treatment Treatment AGENT EQUIVALENT DOSAGE DOSAGES Cimetadine 400mg twice daily 400­800mg twice daily Tagamet Famotidine 20mg twice daily 20­40mg twice daily Pepcid Nizatidine 150mg twice daily 150mg twice daily Axid Ranitidine 150mg twice daily 150mg twice daily zantac Treatment Treatment Proton Pump Inhibitors • Better control of symptoms with PPIs vs H2RAs and better remission rates • Faster healing of erosive esophagitis with PPIs vs H2RAs Treatment Treatment AGENT EQUIVALENT DOSAGE DOSAGES Esomeprazole 40mg daily 20­40mg daily Nexium Omeprazole 20mg daily 20mg daily Prilosec Lansoprazole 30mg daily 15­10md daily Prevacid Pantoprazole 40mg daily 40mg daily Protonix Rabeprazole 20mg daily 20mg daily Aciphex Treatment Treatment H2RAs vs PPIs • 12 week freedom from symptoms 48% vs 77% • 12 week healing rate 52% vs 84% • Speed of healing 6%/wk vs 12%/wk Treatment Treatment Antireflux surgery Failed medical management Patient preference GERD complications Medical complications attributable to a large hiatal hernia • Atypical symptoms with reflux documented on 24­hour pH monitoring • • • • Treatment Treatment Antireflux surgery candidates • • • EGD proven esophagitis Normal esophageal motility Partial response to acid suppression Treatment Treatment Antireflux surgery • Tenets of surgery Reduce hiatal hernia Repair diaphragm Strengthen GE junction Strengthen antireflux barrier via gastric wrap 75­90% effective at alleviating symptoms of heartburn and regurgitation Treatment Treatment Postsurgery 10% have solid food dysphagia 2­3% have permanent symptoms 7­10% have gas, bloating, diarrhea, nausea, early satiety • Within 3­5 years 52% of patients back on antireflux medications • • • Treatment Treatment Endoscopic treatment • • • Relatively new No definite indications Select well­informed patients with well­documented GERD responsive to PPI therapy may benefit Three categories • Radiofrequency application to increase LES reflux barrier • Endoscopic sewing devices • Injection of a nonresorbable polymer into LES area Complications Complications Erosive esophagitis Stricture Barrett’s esophagus Complications Complications Erosive esophagitis • • Responsible for 40­60% of GERD symptoms Severity of symptoms often fail to match severity of erosive esophagitis Complications Complications Esophageal stricture • Result of healing of erosive esophagitis • May need dilation Complications Complications Barrett’s Esophagus • Columnar metaplasia of the esophagus • Associated with the development of adenocarcinoma Complications Complications Barrett’s Esophagus • Acid damages lining of esophagus and causes chronic esophagitis • Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells • This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma Complications Complications • Patient’s who need EGD Alarm symptoms Poor therapeutic response Long symptom duration • “Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice • Many patients with Barrett’s are asymptomatic Complications Complications Barrett’s Esophagus Manage in same manner as GERD EGD every 3 years in patient’s without dysplasia • In patients with dysplasia annual to shorter interval surveillance • • Summary Summary Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manisfestations Diagnostic Evaluation Treatment Complications ?QUESTIONS? ?QUESTIONS? ...
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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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