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Description : Clinical And Endoscopic Diagnostic Assessment of Gerd And Complications.

Tags : gerd,endoscopic diagnostic assessment,gerd and complications,heartburn,spectrum disease,gastroesophageal reflux disease,systems for esophagitis,complications of GERD

Published on : Sep 06, 2022 | Views : 1405 | Downloads : 13

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Slide 1-

Prof.Dr.Ahmet Dobrucalı CLINICAL AND ENDOSCOPIC DIAGNOSTIC ASSESSMENT OF GERD AND COMPLICATIONS İÜ.Cerrahpaşa Tıp Fakültesi Gastroenteroloji Bilim Dalı
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20% 9-17% 2-5% 2-5% 12-15% ? -2% Heartburn prevalence in the World Dent J. Gut 1999
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Frequency of heartburn in the United States heartburn population P&G MRD#US972782, data in Sponsor’s file. http://www.fda.gov/ohrms/dockets/ac/02/briefing/3861b1_01_ProctorGamble-Zeneca.htm
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Asymptomatic Barretts Occasionally symptomatic Not seen by M.D. Frequently symptomatic Seen by M.D. Persistent symptoms and complications (<10%) Kennedy T.Aliment Pharmacol Ther 2000 GERD Iceberg
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GERD and QOL Dimenas T.Scan J Gastroenterıl 1993 Phychological well-being score (NL=104)
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The clinical spectrum of GERD Typical Heartburn Regurgitation Atypical Chest pain Dysphagia Cough Asthma Laryngitis Physiological reflux Symptomatic GERD Complicated esophagitis Esophagitis Complications Ulceration Hemorrhage Stricture Barrett Adeno ca. With erosive esophagitis Without esophagitis (Requires abnormal pH-metry)
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Heartburn can be defined by the presence of substernal discomfort or pain, usually burning in quality, that starts at the epigastrium and radiates towards the mouth - Heartburn generally is worse following meals and with reclining or lying down - It is relieved by antacids or other therapies that inhibit gastric acid secretion Heartburn
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Severity of heartburn in patients with and without esophagitis Smout L. Aliment Pharmacol Therap 1997
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Incidence of regurgitation and heartburn are unrelated to grade of esophagitis Carisson E,Gastroenterol 1996
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(NERD) Non-erosive reflux disease is characterised by the presence of GERD symptoms but without endoscopically visible breaks (60-70%) or Symptomatic reflux disease (S-GERD) Positive pH monitoring or (MII+pH) Negative pH monitoring or (MII+pH) Microscopic erosive reflux disease Presence of high symptom index No symptom index GERD Hypersensitive esophagus? Functional heartburn? Non acid related stimuli? Minor acid reflux? (pH>4) (E-GERD) Erosive reflux disease (M-GERD) (Metaplasic reflux disease) Barrett GERD Fass R,Ofman JJ. Am J Gastroenterol 2002.
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Chracteristic response of the esophagus in patients with GERD Fox M, BMJ 2006
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(NERD) Non-erosive reflux disease is characterised by the presence of GERD symptoms but without endoscopically visible breaks (50-65%) or Symptomatic reflux disease (S-GERD) Positive pH monitoring or (MII+pH) Negative pH monitoring or (MII+pH) Microscopic erosive reflux disease Presence of high symtom index No symptom index GERD Hypersensitive esophagus? Functional heartburn? Non acid related stimuli? Minor acid reflux? (pH>4) (E-GERD) Erosive reflux disease (M-GERD) (Metaplasic reflux disease) Barrett GERD Fass R,Ofman JJ. Am J Gastroenterol 2002.
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Is GERD a single spectrum disease? 33 patients with NERD confirmed by positive pH monitoring 3% is symptom free Symptoms are moderate or severe in 67% 17 patients underwent repeat endoscopy 94% (16) have erosive esophagitis After 10 years After 5 years Pace F. Dig Liver Dis 2004
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Atypical and extraesophageal manifestations of GERD Chest pain Epigastric pain Nausea Oral Dental eresions Atypical Extraesophageal Pharyngolaryngeal Hoarseness Globus sensation Sore throat Vocal cord irritation Vocal cord granulomas/polyps Posterior laryngitis Pulmonary Chronic cough Asthma Aspiration Pulmonary fibrosis Recurrent pneumonia Other Sleep abnormalities Asthma Sleep apnea ?
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CHEST PAIN IN GERD MOTILITY DISORDERS ? REFLUX VISCERAL HYPERSENSITIVITY ? PHYSICOLOGICAL FACTORS ? Non-cardiac chest pain
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Classical symptoms of angina pectoris versus those arising from esophageal causes Esophageal chest pain usually; Produces pressure like squeezing or burning Can radiate to neck,jaw,back or arms May be sharp and severe Resolves or abates often spontaneously when treated with antacids or nitrates Features in the history that help to distinguish esophageal pain from cardiac pain; Aytipical response to exercise Pain that continued as a background ache Retrosternal pain without lateral radiation Pain that disturbed sleep Presence of certain esophageal symptoms (eg. heartburn, regurgitation, dysphagia)
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Atypical and extraesophageal manifestations of GERD Chest pain Epigastric pain Nausea Oral Dental eresions Atypical Extraesophageal Pharyngolaryngeal Hoarseness Globus sensation Sore throat Vocal cord irritation Vocal cord granulomas/polyps Posterior laryngitis Pulmonary Chronic cough Asthma Aspiration Pulmonary fibrosis Recurrent pneumonia Other Sleep abnormalities Asthma Sleep apnea ?
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Reflux related pulmonary disease Reflux penetrates UES, and eventually the pulmonary system, leading to asthma symptoms. It might be a vasovagal reflex, where acidification of the distal esophagus is sufficient to trigger bronchospasm without having acid penetrating the UES. Dumot et al. Contemporary Internal Medicine 1997
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Prevalence of abnormal acid exposure in adult asthmatics Sontag, Gastroesophageal Reflux Disease and Airway Disease,New York 1999
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Clues to GERD related asthma Adult onset Nonallergic Poorly responsive to medical therapy Nocturnal cough Increase in symptoms after meals, in the supine position. Simpson et al.et al.Arch Int Med 1995
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Asthma symptom score in responders to PPI therapy Harding SM. Am J Med 1996.
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Relationship between GERD symptoms and laryngeal lesions Hoarsenes (55-80%) Globus and thoroat clearing (40-58%) Persistent cough (20-52%) Chronic laryngitis (40-60%) Laryngeal carcinoma (25-50%) Laryngeal stenosis (40-75%) *Gaynor L.. Am J Gastroenterol 1991 **Koufman M.Laryngoscope 1991
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Normal or nearly normal chest X-ray No smoking or exposure to environmental irritants, No use of ACE inhibitors Failure of cough to treatment of asthma Failure of cough to improve with treatment of postnasal drip syndrome Patients with a clinical profile highly suggestive of silent GERD as a cause of their cough are characterized by the following findings;
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Reflux laryngitis Bilateral erythema of medial arythenoid walls Red streaks on the vocal cords
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Effect of omeprazole on oropharyngeal symptoms Wo JM. Am J Gastroenterol 1997 *p<0.005, **p<0.05 compared to baseline
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Possible GERD symptoms No GER (40%) Non-acid GER symptoms (40%) Acid GER with symptoms (20%) Ambulatory MII-pH monitoring on Rx Persistent symptoms Success Trial of PPI Rx Shay S. Gastroenterology 2003
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Invasive tests, when? Barium esophagogram -Dysphagia 24 h. esophageal pH monitoring -PPI failure (on medication) -Pre-antireflux surgery Endoscopy - Alarm symptoms Dysphagia,weight loss odynophagia,anorexia bleeding - Exclude Barrett’s esophagus Dysphagia - Patients requiring chronic therapy 24 h. Impedance-pH monitoring Acid perfusion test (Bernstein)
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Hiatal hernia 96% of patients with long-segment (>3cm) Barrett’s esophagus 72% of patients with short-segment (<3cm) Barrett’s esophagus 71% of patients with erosive esophagitis 30% of patients with NERD Hiatal hernia
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Los Angeles (LA) New Savary-Miller Hetzel MUSE (Metaplasia,Ulcer, Stricture,Erosions) Classification systems for esophagitis
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Grade 1: Single erosion or exudate; taking only 1 longidutinal fold Grade 2: Noncircular multiple erosions or exudative lesions taking more than 1 longidutinal fold, with or without confluence Grade 3: Circular erosive or exudative lesion Grade 4: Chronic lesions; Ulcers, strictures or short esophagus, isolated or associated with grades 1-3 Grade 5: Barrett’s esophagus alone or associated with lesions grade 1-3 New Savary-Miller endoscopic grading system Stomach Stomach Stomach Stomach Stomach Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
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Stomach Stomach Stomach Stomach Grade A: >1 mucosal break <5mm long confined to the mucosal folds Grade B: >1 mucosal break >5mm long confined to the the mucosal folds but not continious between the tops of 2 folds Grade C: Mucosal breaks continious between the tops of 2 or more folds involving <75% of the esophageal circumference Grade D: Mucosal breaks involving >75% of the esophageal circumference Grade A Grade B Grade C Grade D LA classification of esophagitis Lundell et al Gut 1999 The International Working Group for the Classification of Oesophagitis (IWGCO)
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Hetzel classification of esophagitis Grade 0: Normal Grade 1: Edema, hyperemia and/ or friability of the mucosa Grade 2: Superficial erosions involving <10% of the mucosal surface of last 5mm of the esophageal squamous mucosa Grade 3: Superficial erosions / ulcerations involving 10% to 50% of the mucosal surface of the distal esophagus Grade 4: Deep peptic ulcerations anywhere in the esophagus or confluent erosion >50% of the distal esophagus
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Basal layer Squamous epithelium Papillary extensions Squamous epithelium Muscularis mucosa Submucosa Lamina propria Circular muscle layer Longidutinal muscle layer
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Basal layer Squamous epithelium Papillary extentions Bazal cell hyperplasia and elongation of rete pegs Normal GERD
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Tobey N. Gastroenterolgy 1996
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MUSE classification of esophagitis
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Complications of GERD Erosive or ulcerative (2-7%) esophagitis Peptic stricture (1-23%) Barrett’s esophagus (10-15%) Bleeding (<2%) Anemia Dysphagia Esophageal cancer Extraesophageal complications Chronic cough Asthma Sleep disturbances Hoarseness Larynx ca?
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Peptic stricture Uncomplicated reflux-related esophageal strictures are; - Typically located at the squamocolumnar mucosal junction and are less than 1cm in lenght. - A long history of heartburn with intermittent dysphagia over a period of months to years without weight loss
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Barium radiography in peptic stricture These patients are typically older and have long-standing GERD symptoms and severity of reflux symptoms decrease gradually with development of esophageal stricture Once a true stricture has been confirmed, the challenge is to determine the etiology as benign or malignant by endoscopy, biopsy and cytologic examination.
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Development of reflux symptoms at an earlier age Increased duration of reflux symptoms Increased severity of nocturnal reflux sypmtoms Increased complications of GERD (esophagitis, ulceration, stricture and bleeding) Barrett’s esophagus
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Barrett’s esophagus Displacing of squamocolumnar junction proximal to gastroesophageal junction Intestinal metaplasia characterized by acid mucin containing goblet cells using combined H&E-alcian blue pH 2.5 stain is detected by performing a biopsy
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Endoscopic recognition of Barrett’s esophagus requires; Squamocolumnar junction Gastroesophageal junction Diaphragmatic hiatus
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Top of lineer gastric fold Diaphragmatic hiatus Mucosal folds best demonstrated by partial deflation of the esophagus
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Palisade vessels The longidutinal esophageal palisade vessels, present in the mucosal layer of the lower esophagus, disappear into the submucosal layer at the GEJ
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Long segment and short segment Barrett’s esophagus < 3cm >3cm Long segment BE Short segment BE
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Chromoendoscopy Lugol’s iodine Methylen blue
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Maximal extent of columnar metaplasia Gastroesophageal junction (Tops of gastric mucosal folds) Circumferential extent of columnar metaplasia Prague C2 M5 Prague criteria C&M 5cm 2cm 3cm IWGCO (Working Group for the Classification of Reflux Eesophagitis ) Barrett
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New endoscopic techniques in the disagnosis of intestinal metaplasia Magnification endoscopy Autofluorescence endoscopy Narrow band imaging (NBI)
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Ridge / villous pattern Circular pattern Regular and orderly thin caliber vessels Irregular and distorded pattern (normal) Increased density of irregular,dilated and corkscrew type vessels (abnormal) Sharma P,Gastrointestinal Endoscopy, 2006 A C D E B
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Irregular / distorted pattern of villus for the presence of high grade dyasplasia Sensitivity 100% Specificity 98.7% Positive predictive value 95% Abnormal vascularity for the presence of high grade dyasplasia Sensitivity 93.5% Specificity 86.7% Positive predictive value 94.7% Sharma P,Gastrointestinal Endoscopy, 2006
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