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Gastroesophageal Reflux Disease PowerPoint Presentation

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Description : Check out this medical presentation on Digestive System, which is titled "Gastroesophageal Reflux Disease", to know about Gastroesophageal Reflux Disease (GERD), Epidemiology of GERD, Pathophysiology of GERD, Clinical Manifestations, Diagnostic Evaluation, Treatment, and Complications.

Tags : Digestive System,Gastroesophageal Reflux Disease, GERD, Epidemiology, Pathophysiology, Clinical Manifestations, Diagnostic Evaluation, Treatment, Complications

Published on : Jul 10, 2021 | Views : 6899 | Downloads : 54

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Slide 1-

Gastroesophageal Reflux Disease Arthur Harris, M.D. GI Division, Jacobi Medical Center/NCBH Assistant Professor of Medicine, AECOM
Slide 2-

Objectives Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manifestations Diagnostic Evaluation Treatment Complications
Slide 3-

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
Slide 4-

Physiologic vs Pathologic Physiologic GERD Post-prandial Short-lived Often asymptomatic TLSER’s No nocturnal sx Pathologic GERD Symptoms Mucosal injury Nocturnal sx
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Slide 6-

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
Slide 7-

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
Slide 8-

Clinical Manifestations Most common symptoms Heartburn—retrosternal burning discomfort Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions
Slide 9-

Clinical Manifestations Dysphagia—difficulty swallowing Other symptoms include: Chest pain, water brash, globus sensation, odynophagia, nausea Extraesophageal manifestations Asthma, laryngitis, chronic cough
Slide 10-

Diagnostic Evaluation 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
Slide 11-

Potential Oral and Laryngopharyngeal Signs Associated with GERD Edema and hyperemia of larynx Vocal cord erythema, polyps, granulomas, ulcers Hyperemia and lymphoid hyperplasia of posterior pharynx Interarytenyoid changes Dental erosion Subglottic stenosis Laryngeal cancer
Slide 12-

Alarms Alarm Signs/Symptoms Dysphagia Early satiety GI bleeding Odynophagia Vomiting Weight loss Iron deficiency anemia
Slide 13-

Trial of Medications H2RA or PPI Expect response in 2-4 weeks If no response Change from H2RA to PPI Maximize dose of PPI
Slide 14-

Trial of Medications If PPI response inadequate despite maximal dosage Confirm diagnosis EGD 24 hour pH monitoring
Slide 15-

Esophagogastrodudenoscopy Endoscopy (with biopsy if needed) In patients with alarm signs/symptoms Those who fail medication trial Those who require long-term Rx Lacks sensitivity for identifying pathologic reflux Absence of endoscopic features does not exclude a GERD diagnosis Allows for detection, stratification, and management of esophageal manifestations or complications of GERD
Slide 16-

Ambulatory pH Testing 24-hour pH monitoring Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes Trans-nasal catheter or a wireless, capsule shaped device
Slide 17-

Ambulatory 24 hour pH Monitoring -1 Physiologic study Quantify reflux in proximal/distal esophagus % time pH < 4 DeMeester score Symptom correlation
Slide 18-

Ambulatory 24 hour pH Monitoring -2 Normal GERD
Slide 19-

Wireless, Catheter-Free Esophageal pH Monitoring Potential Advantages ●Improved patient comfort and acceptance ●Continued normal work, activities and diet during study ●Longer reporting periods possible (up to 48 hours) ●Maintain constant probe position relative to SCJ
Slide 20-

Esophageal Manometry Limited role in GERD Assess LES pressure, location and relaxation Assist placement of 24 hour pH catheter Assess peristalsis Prior to anti-reflux surgery
Slide 21-

Patient with heartburn Initiate Rx with H2RA or PPI H2RA taken BID Good response Frequent relapses On demand Rx 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
Slide 22-

GERD vs Dyspepsia Distinguish from Dyspepsia Ulcer-like symptoms-burning, epigastric pain Dysmotility like symptoms-nausea, bloating, early satiety, anorexia Distinct clinical entity In addition to anti-secretory meds and an EGD, need to consider testing for Helicobacter pylori
Slide 23-

Treatment Goals of therapy Symptomatic relief Heal esophagitis Avoid complications
Slide 24-

Better Living Lifestyle modifications Avoid large meals Avoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate, onions, garlic, peppermint Decrease fat intake Avoid lying down within 3-4 hours after a meal Elevate head of bed 4-8 inches Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAID’s) Avoid clothing that is tight around the waist Lose weight Stop smoking
Slide 25-

Treatment Antacids O-T-C acid suppressants and antacids may be appropriate initial therapy Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly More effective than placebo in relieving GERD symptoms
Slide 26-

Treatment Histamine H2-Receptor 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 on-demand
Slide 27-

Treatment AGENT EQUIVALENT DOSAGE DOSAGES Cimetadine 400mg twice daily 400-800mg twice daily Tagamet Famotidine 20mg twice daily 20-40mg twice daily Pepcid Nizatidine 150mg twice daily 150mg twice daily Axid Ranitidine 150mg twice daily 150mg twice daily Zantac
Slide 28-

Treatment Proton Pump Inhibitors Better control of symptoms with PPI’s vs H2RAs and better remission rates Faster healing of erosive esophagitis with PPIs vs H2RAs
Slide 29-

Treatment AGENT EQUIVALENT DOSAGE DOSAGES Esomeprazole 40mg daily 20-40mg daily Nexium Omeprazole 20mg daily 20mg daily Prilosec Lansoprazole 30mg daily 15-30mg daily Prevacid Pantoprazole 40mg daily 40mg daily Protonix Rabeprazole 20mg daily 20mg daily Aciphex
Slide 30-

Treatment H2RAs vs PPI’s 12 week freedom from symptoms 48% vs 77% 12 week esophagitis healing rate 52% vs 84% Speed of healing 6%/wk vs 12%/wk
Slide 31-

Treatment Modifications for Persistent Symptoms Improve compliance Optimize pharmacokinetics Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime) Allows for high blood level to interact with parietal cell proton pump activated by the meal Consider switching to a different PPI
Slide 32-

Treatment Anti-reflux surgery - Indications Failed medical management Patient preference GERD complications Medical complications attributable to a large hiatal hernia Atypical symptoms with pathologic reflux documented on 24-hour pH monitoring
Slide 33-

Treatment Anti-reflux surgery candidates EGD proven esophagitis ?Normal esophageal motility Incomplete response to acid suppression
Slide 34-

Treatment Anti-reflux surgery (laparoscopic) Tenets of surgery Reduce hiatal hernia Repair diaphragm Strengthen GE junction Strengthen anti-reflux barrier via gastric wrap 75-90% effective at alleviating symptoms of heartburn and regurgitation
Slide 35-

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Slide 36-

Treatment Post-surgery 10% have solid food dysphagia 2-3% have permanent symptoms 7-10% have gas, bloating, diarrhea, nausea, early satiety Within 3-5 years, up to 52% of patients back on anti-reflux medications
Slide 37-

Treatment Endoscopic treatment Relatively new No clearly established indications Well-informed patients with well-documented GERD responsive to PPI therapy may benefit Three categories Radiofrequency application to increase LES reflux barrier Endoscopic sewing devices Injection of a non-resorbable polymer into LES region
Slide 38-

Complications Erosive esophagitis Stricture Barrett’s esophagus
Slide 39-

Complications Erosive esophagitis Responsible for 40-60% of GERD symptoms Severity of symptoms often fail to match severity of erosive esophagitis
Slide 40-

Complications Esophageal stricture Occurs as a result of healing of erosive esophagitis May need dilation
Slide 41-

Peptic Stricture Barium swallow Endoscopy
Slide 42-

Complications Barrett’s Esophagus Columnar metaplasia of the esophagus Associated with the development of adenocarcinoma
Slide 43-

Complications Barrett’s Esophagus Acid damages lining of esophagus and causes chronic esophagitis Damaged area heals in a metaplastic process with abnormal columnar cells replacing squamous cells This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma
Slide 44-

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
Slide 45-

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 even shorter interval surveillance is recommended
Slide 46-

Summary Definition of GERD Epidemiology of GERD Pathophysiology of GERD Clinical Manifestations Diagnostic Evaluation Treatment Complications
Slide 47-

?QUESTIONS?