gerd and peptic ulcer disease august 29, 2011. peptic physiology
TRANSCRIPT
GERD and GERD and Peptic ulcer diseasePeptic ulcer disease
August 29, 2011August 29, 2011
Peptic Physiology
Peptic Physiology
•Pepsinogen•Stimulated by gastrin•Primarily in antrum
•Intrinsic factor•Hydrochloric acid•Stimulated by gastrin, ach, H+
•Mucus•Bicarbonate
Gastroesophageal Reflux Disease
EpidemiologyEpidemiology
About 44% of the US adult population About 44% of the US adult population have heartburn at least once a monthhave heartburn at least once a month
14% of Americans have symptoms weekly14% of Americans have symptoms weekly 7% have symptoms daily7% have symptoms daily
Physiologic vs PathologicPhysiologic vs Pathologic
Physiologic GERDPhysiologic GERD PostprandialPostprandial Short livedShort lived AsymptomaticAsymptomatic No nocturnal sxNo nocturnal sx
Pathologic GERDPathologic GERD SymptomsSymptoms Mucosal injuryMucosal injury Nocturnal sxNocturnal sx
PathophysiologyPathophysiology
Primary barrier to Primary barrier to gastroesophageal reflux gastroesophageal reflux is the lower esophageal is the lower esophageal sphinctersphincter
LES normally works in LES normally works in conjunction with the conjunction with the diaphragmdiaphragm
If barrier disrupted, acid If barrier disrupted, acid goes from stomach to goes from stomach to esophagusesophagus
Clinical Manifestations Clinical Manifestations Most common symptomsMost common symptoms
Heartburn—retrosternal burning Heartburn—retrosternal burning discomfortdiscomfort
Regurgitation—effortless return of Regurgitation—effortless return of gastric contents into the pharynx gastric contents into the pharynx without nausea, retching, or without nausea, retching, or abdominal contractionsabdominal contractions
Dysphagia—difficulty swallowingDysphagia—difficulty swallowing Other symptoms include:Other symptoms include:
Chest pain, globus sensation, Chest pain, globus sensation, odynophagia, nauseaodynophagia, nausea
Extraesophageal manifestationsExtraesophageal manifestations Asthma, laryngitis, chronic coughAsthma, laryngitis, chronic cough
Diagnostic EvaluationDiagnostic Evaluation
If classic symptoms of heartburn and If classic symptoms of heartburn and regurgitation exist in the absence of “alarm regurgitation exist in the absence of “alarm symptoms” the diagnosis of GERD can be symptoms” the diagnosis of GERD can be made clinically and treatment can be initiatedmade clinically and treatment can be initiated
AlarmsAlarms
DysphagiaDysphagia Early satietyEarly satiety GI bleedingGI bleeding OdynophagiaOdynophagia VomitingVomiting Weight lossWeight loss Iron deficiency Iron deficiency
anemiaanemia
Trial of MedicationsTrial of Medications
H2RA or PPIH2RA or PPIExpect response in 2-4 weeksExpect response in 2-4 weeks If no responseIf no response
Change from H2RA to PPIChange from H2RA to PPI Maximize dose of PPIMaximize dose of PPI
Trial of MedicationsTrial of Medications
If PPI response inadequate despite If PPI response inadequate despite maximal dosage maximal dosage Confirm diagnosisConfirm diagnosis
EGDEGD 24 hour pH monitor24 hour pH monitor
EGDEGD Endoscopy (with biopsy if Endoscopy (with biopsy if
needed)needed) In patients with alarm In patients with alarm
signs/symptomssigns/symptoms Those who fail a medication trialThose who fail a medication trial Those who require long-term txThose who require long-term tx
Absence of endoscopic features Absence of endoscopic features does not exclude a GERD does not exclude a GERD diagnosisdiagnosis
Allows for detection, Allows for detection, stratification, and management stratification, and management of esophageal manifestations or of esophageal manifestations or complications of GERDcomplications of GERD
24-hour pH monitoring24-hour pH monitoringAccepted standard for establishing or Accepted standard for establishing or
excluding presence of GERD for those excluding presence of GERD for those patients who do not have mucosal changespatients who do not have mucosal changes
Trans-nasal catheter or a wireless, capsule Trans-nasal catheter or a wireless, capsule shaped deviceshaped device
Patient with heartburn
Initiate tx with H2RA or PPI
H2RA taken BID
Good response
Frequent relapses
On demand tx
PPI taken QD
Good response
Maintenance therapywith lowest effective dose
Symptoms persist
Consider EGD if risk factors present(> 45, white, maleand > 5 yrs of sx)
Increase tomax dose QD or BID
Good response
Confirm diagnosisEGD, ph monitor
No
Yes YesNo
Yes
Yes
No
No
TreatmentTreatment
Goals of therapyGoals of therapySymptomatic reliefSymptomatic reliefHeal esophagitisHeal esophagitisAvoid complicationsAvoid complications
Lifestyle modificationsLifestyle modifications Avoid large mealsAvoid large meals Avoid acidic foods (citrus/tomato), alcohol, caffeine, Avoid acidic foods (citrus/tomato), alcohol, caffeine,
chocolate, onions, garlic, peppermintchocolate, onions, garlic, peppermint Decrease fat intakeDecrease fat intake Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches Avoid meds that may potentiate GERD (CCB, alpha agonists, Avoid meds that may potentiate GERD (CCB, alpha agonists,
theophylline, nitrates, sedatives, NSAIDS)theophylline, nitrates, sedatives, NSAIDS) Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist Lose weightLose weight Stop smokingStop smoking
Medical TreatmentMedical Treatment AntacidsAntacids
Over the counter acid Over the counter acid suppressants and antacids suppressants and antacids appropriate initial therapyappropriate initial therapy
Approx 1/3 of patients with Approx 1/3 of patients with heartburn-related symptoms heartburn-related symptoms use at least twice weeklyuse at least twice weekly
More effective than placebo in More effective than placebo in relieving GERD symptomsrelieving GERD symptoms
Medical TreatmentMedical Treatment
Histamine H2-Receptor AntagonistsHistamine H2-Receptor AntagonistsMore effective than placebo and antacids for More effective than placebo and antacids for
relieving heartburn in patients with GERDrelieving heartburn in patients with GERDFaster healing of erosive esophagitis when Faster healing of erosive esophagitis when
compared with placebocompared with placeboCan use regularly or on-demandCan use regularly or on-demand
Medical TreatmentMedical Treatment
AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESCimetadine 400mg twice daily 400-800mg twice dailyCimetadine 400mg twice daily 400-800mg twice dailyTagametTagamet
Famotidine 20mg twice daily 20-40mg twice dailyFamotidine 20mg twice daily 20-40mg twice dailyPepcidPepcid
Nizatidine 150mg twice daily 150mg twice dailyNizatidine 150mg twice daily 150mg twice dailyAxidAxid
Ranitidine 150mg twice daily 150mg twice dailyRanitidine 150mg twice daily 150mg twice dailyzantaczantac
Medical TreatmentMedical Treatment
Proton Pump InhibitorsProton Pump InhibitorsBetter control of symptoms with PPIs vs Better control of symptoms with PPIs vs
H2RAs and better remission ratesH2RAs and better remission ratesFaster healing of erosive esophagitis with Faster healing of erosive esophagitis with
PPIs vs H2RAsPPIs vs H2RAs
TreatmentTreatment
AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESEsomeprazole 40mg daily 20-40mg dailyEsomeprazole 40mg daily 20-40mg dailyNexiumNexium
Omeprazole 20mg daily 20mg dailyOmeprazole 20mg daily 20mg dailyPrilosecPrilosec
Lansoprazole 30mg daily 15-10md dailyLansoprazole 30mg daily 15-10md dailyPrevacidPrevacid
Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg dailyProtonixProtonix
Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg dailyAciphexAciphex
TreatmentTreatment
Antireflux surgeryAntireflux surgeryFailed medical managementFailed medical managementPatient preferencePatient preferenceGERD complicationsGERD complicationsMedical complications attributable to a large Medical complications attributable to a large
hiatal herniahiatal herniaAtypical symptoms with reflux documented on Atypical symptoms with reflux documented on
24-hour pH monitoring24-hour pH monitoring
TreatmentTreatment
Antireflux surgery candidatesAntireflux surgery candidatesEGD proven esophagitisEGD proven esophagitisNormal esophageal motilityNormal esophageal motilityPartial response to acid suppressionPartial response to acid suppression
TreatmentTreatment
Antireflux surgeryAntireflux surgeryTenets of surgeryTenets of surgery
Reduce hiatal herniaReduce hiatal hernia Repair diaphragmRepair diaphragm Strengthen GE junctionStrengthen GE junction Strengthen antireflux barrier via gastric wrapStrengthen antireflux barrier via gastric wrap 75-90% effective at alleviating symptoms of 75-90% effective at alleviating symptoms of
heartburn and regurgitationheartburn and regurgitation
Nissen FundoplicationNissen Fundoplication
Upper GI StudyUpper GI Study
TreatmentTreatment
Endoscopic treatmentEndoscopic treatment Relatively newRelatively new No definite indicationsNo definite indications Select well-informed patients with well-documented Select well-informed patients with well-documented
GERD responsive to PPI therapy may benefitGERD responsive to PPI therapy may benefit
Three categoriesThree categories Radiofrequency application to increase LES reflux barrierRadiofrequency application to increase LES reflux barrier Endoscopic sewing devicesEndoscopic sewing devices Injection of a nonabsorbable polymer into LES areaInjection of a nonabsorbable polymer into LES area
ComplicationsComplications
Erosive esophagitisErosive esophagitis StrictureStricture Barrett’s esophagusBarrett’s esophagus
ComplicationsComplications
Erosive esophagitisErosive esophagitisResponsible for 40-60% of GERD symptomsResponsible for 40-60% of GERD symptomsSeverity of symptoms often fail to match Severity of symptoms often fail to match
severity of erosive esophagitisseverity of erosive esophagitis
ComplicationsComplications Esophageal Esophageal
stricturestrictureResult of healing Result of healing
of erosive of erosive esophagitisesophagitis
May need dilationMay need dilation
ComplicationsComplications
Barrett’s EsophagusBarrett’s EsophagusColumnar metaplasia of Columnar metaplasia of
the esophagusthe esophagusAssociated with the Associated with the
development of development of adenocarcinomaadenocarcinoma
ComplicationsComplications Barrett’s EsophagusBarrett’s Esophagus
Acid damages lining of Acid damages lining of esophagus and causes esophagus and causes chronic esophagitischronic esophagitis
Damaged area heals in a Damaged area heals in a metaplastic process and metaplastic process and abnormal columnar cells abnormal columnar cells replace squamous cellsreplace squamous cells
This specialized intestinal This specialized intestinal metaplasia can progress metaplasia can progress to dysplasia and to dysplasia and adenocarcinomaadenocarcinoma
ComplicationsComplications
Barrett’s EsophagusBarrett’s EsophagusManage in same manner as GERDManage in same manner as GERDEGD every 3 years in patient’s without EGD every 3 years in patient’s without
dysplasiadysplasia In patients with dysplasia annual to shorter In patients with dysplasia annual to shorter
interval surveillanceinterval surveillanceMany patients with Barrett’s are asymptomaticMany patients with Barrett’s are asymptomatic
ComplicationsComplications
Esophageal dysplasia/cancerEsophageal dysplasia/cancer Cancer Cancer
EsophagectomyEsophagectomy
High-grade dysplasiaHigh-grade dysplasia Esophagectomy or ablationEsophagectomy or ablation
Low-grade dysplasiaLow-grade dysplasia Treat GERDTreat GERD EGD surviellenceEGD surviellence
Peptic Ulcer Disease
Peptic Ulcer Disease
SymptomsPainBleedingPerforationObstruction
Peptic Ulcer Disease
Duodenal Ulcer
Usually within 2 cm of the pylorus Pain cyclical
1-2 hours after breakfast, lunch and at night Etiology
H pylori - 90%NSAIDs – 10% Increased vulnerablity of mucosa to acid and
pepsin
Duodenal Ulcer
Eridicate H pylori Triple therapy
PPI – twice daily for 2 weeks Amoxicillin - 1g twice daily for 2 weeks Clarithromycin – 500mg twice daily for 2 weeks
Surgery for complications Bleeding Perforation Obstruction
Duodenal Ulcer
Zolliger-Ellison Syndrome (Gastrinoma) Very rare
MEN-1 Tumor of islet cell
Produce gastrin – lab levels extreme Typically in wall of duodenum or pancreas
Gastrinoma Triangle Ulcers
Usually multiple In 2nd-3rd portion of duodenum
Treatment PPI Surgical resection
Gastric Ulcer
Types Type I
Most common Lesser curve H pylori
Type II Pre pyloric Associated with duodenal ulcers
Type III Antrum NSAIDs
Gastric Ulcer
Need to rule out malignancy EGD Biopsy
Treatment Stop NSAIDs PPI Treat H pylori Repeat EGD to check for healing Surgery
Malignancy Bleeding Perforation Obstruction
Questions?