Download Free Medical Gastroesophageal Reflux Disease PowerPoint Presentation

Gastroesophageal Reflux Disease PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Heartburn symptoms off/on for many years but increasing in severity and frequency in last 6-12 months.

Tags : gastroesophageal reflux disease,reflux disease,heartburn symptoms,problem of GERD,pathophysiology,evaluation of GERD

Published on : Sep 06, 2022 | Views : 1734 | Downloads : 3

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

GERD:An Old Problem with New Approaches Jason Phillips, MD
Slide 2-

Case HPI: 44 y/o M with heartburn Heartburn symptoms off/on for many years but increasing in severity and frequency in last 6-12 months Symptoms are described as: Sternal ‘burning’ with acid taste in mouth Occurs most frequently at night most days of the week Last hours Partially relieved with Mylanta
Slide 3-

Case Exacerbated by: Supine positions after meal Large meals Food triggers: pasta, greasy food, coffee, alcohol Denies weight loss, dysphagia, melena, hematemesis
Slide 4-

Case PMH: Obesity Meds: Mylanta NKDA SH: smokes 1ppd x 10+years, drinks 2-4 glasses of wine per night FH: No h/o esophageal Ca
Slide 5-

Case PE: BP 140/86 P 96 Afeb Wt 275 lbs (BMI 36) Gen: obese, NAD Exam essentially normal
Slide 6-

Case Pt was seen by his PCP and diagnosed with GERD. Prescribed a PPI to take once a day. Advised pt to lose weight and quit smoking Follow-up in 4-6 weeks
Slide 7-

Case At 5 weeks, he called his PCP and complained he was still having daily episodes of heartburn though ‘the medicine helped a little’ PCP’s 3 options: Increase PPI to BID Change PPI Referral to GI
Slide 8-

Case PPI was increased to BID and the patient continued to have reflux symptoms Therefore, the pt was referred to GI for further evaluation
Slide 9-

Case GI visit: Additional history Pts symptoms sounded like typical reflux-like symptoms Symptoms mostly occurred from 8-10 PM after his dinner at 7 PM Large evening meals most days Had not tried avoiding typical food triggers Had not lost weight or stopped smoking
Slide 10-

Case GI visit: Additional history He was taking his PPI 30 minutes after meals (during dessert) twice per day as recommended His symptoms overall improved by ~50% but as mentioned, he continued to have daily symptoms
Slide 11-

Case GI visit: Additional history Reflux events also increased during the day during stressful moments at work
Slide 12-

Case Possible diagnoses Inadequately treated GERD vs functional heartburn Malignancy Esophageal spasm Peptic ulcer disease Angina
Slide 13-

Case EGD while still taking medications: normal esophagus with no evidence of esophagitis or Barrett’s esophagus Normal stomach and duodenum
Slide 14-

Case Does he have non-erosive acid reflux that is inadequately treated with his current PPI or is this functional heartburn?
Slide 15-

Case To distinguish, I arranged for the patient to have a 24 pH probe while still taking his BID PPI Bravo wireless 24 hour pH probe
Slide 16-

ppt slide no 16 content not found
Slide 17-

ppt slide no 17 content not found
Slide 18-

ppt slide no 18 content not found
Slide 19-

Case Diagnosed with acid reflux Recommendations BID PPI – taken 30 minutes BEFORE meals Additional nocturnal H2 blocker Behavioral modifications Earlier dinner, smaller portions Avoidance of trigger foods Quit smoking Lose weight
Slide 20-

GERD Incidence Complaints of heartburn 40% of Americans complain of monthly heartburn 20% complain of weekly heartburn 7% complain of daily heartburn Prevalence of GERD is increasing over the 30 years
Slide 21-

Problem of GERD Difficult to define Physiologic vs pathologic acid reflux Physiologic  postprandial, short lived, asymptomatic, rarely during sleep Pathologic  symptoms, often include nocturnal episodes
Slide 22-

Symptoms Heartburn Epigastric pain Regurgitation Dysphagia Chest pain Nausea Odynophagia Globus sensation Supraesophageal symptoms
Slide 23-

Symptoms Patient’s descriptions can be difficult to interpret: “Its not heartburn its… “…bile coming up into my throat.” “…intense pain in my stomach.” “…its not pain, its heaviness in my chest.” “…pain in the back of my throat when I awake.”
Slide 24-

Pathophysiology 80% of reflux symptoms occur as a result of transient LES relaxation Other motility defects LES incompetence Gastroparesis Esophageal body dymotility Anatomic defects: Hiatal hernia
Slide 25-

Diagnosis Symptoms  empiric PPI Uncomplicated symptoms (no alarm signs – weight loss, GI bleeding, dysphagia) Age < 65 years No esophagotoxic medications (e.g, bisphophonates) 6 weeks trial
Slide 26-

Diagnosis: Empiric treatment Sensitivity ~75% Specificity ~80% Using 50% improvement as the therapeutic endpoint Schindlbeck et al…Arch Int Med 155:1808-12, 1995 Fass et al…Arch Int Med 159:2161-8, 1999
Slide 27-

Evaluation of GERD In patients who have ‘red flags’ or fail 6 weeks of a PPI  EGD EGD: signs of esophagitis Barrett’s esophagus Hiatal hernias Exclusion of cancer and other diagnoses (PUD)
Slide 28-

Evaluation of GERD
Slide 29-

Evaluation of GERD PillCam may offer a non-invasive method to look for evidence of esophagitis or Barrett’s esophagus
Slide 30-

ppt slide no 30 content not found
Slide 31-

ppt slide no 31 content not found
Slide 32-

PillCam Identified 97% (32/33) of the cases of Barrett’s esophagus when confirmed by traditional endoscopy Agreed 99% (72/73) of the time in excluding Barrett’s esophagus confirmed by traditional EGD Identified 89% (33/37) of the cases of esophagitis Agreed 99% (68/69) of the cases of ‘no evidence of esophagitis’ Eliakim et al… Preliminary results. ACG 2004.
Slide 33-

Evaluation 75% of community based EGD for evaluation of GERD have NO evidence of mucosal injury 50% of patients with endoscopy negative reflux disease have abnormal esophageal acid exposure In these cases, other tests are needed
Slide 34-

Ambulatory pH monitor Considered to be the most sensitive test for diagnosing reflux Traditional  transnasal catheter with probe situated 5 cm above LES Bravo pH system  wireless technology
Slide 35-

ppt slide no 35 content not found
Slide 36-

ppt slide no 36 content not found
Slide 37-

Treatment PPI are standard medical therapy Daily PPI generally has a 80% healing rate for moderate to severe esophagitis and relief of symptoms in up to 90% of patients Overall, all PPI are equally effective in treating symptoms. However, there is some variability in response from patient to patient
Slide 38-

Treatment Proper timing of PPI administration is critical for efficacy 30 minutes before breakfast or other large meal In select patients, a second dose can be added before the evening meal
Slide 39-

Surgical Treatment Indications Esophagitis Stricture Barrett’s metaplasia Medication failure Purpose of surgery  restoration the LES
Slide 40-

ppt slide no 40 content not found
Slide 41-

Surgical Treatment Most studies indicate that the majority of patients are symptom-free (70-95%) Recent studies suggest that after 5 years, up to 1/3 of patients required PPI to control symptoms. At 10 years, up to 50% require PPIs Side-effects: gas-bloat symptoms, diarrhea, dysphagia
Slide 42-

Endoscopic Treatments In development with ongoing studies Most try to improve LES function in some manner Not quite ready for prime time in community practice
Slide 43-

Stretta procedure
Slide 44-

Stretta procedure Decrease in symptom score Decreased PPI No effect on LESP No effect on acid exposure Some serious thermal injury complications
Slide 45-

Enteryx injection
Slide 46-

Enteryx injection Decreased in heartburn symptoms Decreased 24 hour acid exposure Decreased need for PPI No improvement in severity of esophagitis at EGD Long term safety issues not known
Slide 47-

Endoscopic suturing
Slide 48-

Endoscopic suturing Decreased heartburn symptoms PPI eliminated in 74% of patients at 6 months Decreased esophageal acid exposure; however, only 30% completely normalized Long term follow-up needed
Slide 49-

Questions?