No PPI without Endoscopy + Biopsy of - Falk · PDF filePrague Criteria, Gastro 2006; 131:...

No PPI without Endoscopy + Biopsy ofSquamo-columnar Junction!!

NERD, ERD and GERD: which diagnostic

tools are available and when are they needed?

Martin RieglerVienna, Austria

Falk Symposium, Portoroz

June 15, 2007

It is all about us!

GERD: the stage!

LES

Esophagus

Stomach

LES

Esophagus

Stomach

GERD: the stage!

Cause Effect

Cause Effect

+ PPI!!!

?

Esophageal Adeno CA - Risk Factors

• Barrett Esophagus, Low Grade Dysplasia!

• GERD

• Obesity

• age > 50 years

• white males

Diagnostic tool:

1). Sensitive for Reflux!2). Indicator for Carcinoma Risk!

Diagnostic tool:

1). Sensitive for Reflux!2). Indicator for Carcinoma Risk!

CLE

Columnar Lined Esophagus - History

Barrett 1950: intrathoracic stomach

Allison & Johnstone1953: Esophagus lined with gastric mucous membrane

Barrett 1957: Columnar lined esophagus

Columnar Lined Esophagus (CLE)

• Induced by Reflux!

• Squamous Becomes Columnar!

• Cancer Risk (0.2%-2.0%/year).

Definition of Columnar Lined Esophagus

• Endoscopy

•Anatomy

• Histopathology

normal

Definition of Columnar Lined Esophagus

• Endoscopy

•Anatomy

• Histopathology

CLE

Definition of Columnar Lined Esophagus

•Endoscopy

• Anatomy

•Histopathology

submucosal glands

CLE

Paull-Chandrasoma Classification of CLE

•Endoscopy

• Anatomy

• Histopathology

Cardiac Mucosa Oxyntocardiac Mucosa

Intestinal Metaplasia

Pathogenesis of Columnar Lined Esophagus

Transient LES Relaxations!

Pathogenesis of Columnar Lined Esophagus

Reflux

Cardiac MucosaSquamous

Parietal Goblet

IM=BarrettOCM

geneticswitch?

Barrett Esophagus:

Intestinal Metaplasia in Cardiac Mucosa!

Years

0 15105

CLE

6

LGD HGD

13

CAIM

From CLE to Carcinoma

IM: annual incidence 0.2-2.0%

Barrett-Epidemiology

Normal Population: 0.5%-1.6%

symptomatic GERD: 5%-25% no GERD Symptoms: 25%

Endoscopy: Yes!

Biopsies?

Biopsy Protocol at the EndoscopicEsophago-gastric Junction!

Text

Level 0 = rise of Endoscopic „Gastric Folds“

Text

Biopsy Protocol at the EndoscopicEsophago-gastric Junction!

Level 0 = rise of Endoscopic „Gastric Folds“

Histopathology

(n=114 GERD Pat.)

• CLE = 100 %

• CLE + intestinal Metaplasia = 22.8%

• IM at „normal Junction“ = 17.2%

• LGD = 5/114 = 4.4% (2 at „normal“Junction)

Correlation: Esophagitis & Hernia

(n=114 GERD Pat.)

• Correlation Esophagitis & IM: p = 0.398

• Correlation Hiatal Hernia & IM: p = 0.405

Text

Where Does the Stomach Start?Oxyntic Mucosa!

?

Biopsy Protocol at the EndoscopicEsophago-gastric Junction!

Text

?Where Does the Stomach Start?

Oxyntic Mucosa!

Biopsy Protocol at the EndoscopicEsophago-gastric Junction!

• 102 GERD Pat (42:60 m:w); 50 (18-80) years

Biopsies: n=1998

-1.0 cm -0.5 cm 0 cm +0.5 cm

Biopsy Protocol at the EndoscopicEsophago-gastric Junction!

Endoscopy vs. Histology at the „Junction“

(n= 102 GERD Pat.)

CLE=CM, OCM, IM (18.6%!!)OM=Oxyntic Mucosa = Normal Gastric Mucosa!Squam=Squamous Epithelium

Level OM CLE IM Squam no Bx

> +1.0 0 2% 2% 3% 93%

+1.0 0 3% 4% 26% 67%

+0.5 0 33% 5% 57% 5%

0 1% 84% 12% 2% 1%

-0.5 18% 67% 9% 0 6%

-1.0 71% 23% 4% 0 2%

The „True“ Junction!

Level 0 histologic „Junction“!

CLE + IM Distribution:

n=19/102 = 18.6%

Esophagus (squamous)

Stomach (oxyntic mucosa)

dilated esophagus + CLE

End Stage Dilated Esophagus

Esophagus (squamous)

Stomach (oxyntic mucosa)

dilated esophagus + CLE

End Stage Dilated Esophagus & IM!

IM

Esophagus (squamous)

Stomach (oxyntic mucosa)

dilated esophagus + CLE

End Stage Dilated Esophagus & Adeno CA!

IM

CA

NERD!

Histology: Squamous - CLE - OM!

OM

CM

Squamous

Micro-CLE = „NERD!“

Endoscopy cannot:

1). assess esophagogastric junction!

2). exclude CLE ± IM!

Endoscopic „landmarks“

Squamocolumnar Junction

End of Tubular Esophagus

+1.0 cm

+0.5 cm

level 0

-0.5 cm

-1.0 cmPrague Criteria,Gastro 2006; 131: 1392.

Squamocolumnar JunctionMaximalCircular

End of Tubular Esophagus=level 0!

Prague Criteria,Gastro 2006; 131: 1392.

EGD REPORT:

Diaphragm

Endoscopy in GERD:

4 Bx Squamocolumnar Junction

no IM IM (15-25%)

EGD + Bxin 3-5 years

Multilevel Bx

IMLGDHGD

EGD + Bxin 3a

„act“

OLD DEFINITIONS:

CLE Symptoms EndoscopicEsophagitis

GERD yes yes yes/no

ERD yes yes yes

NERD yes yes no

CONTROLS no no

NOVEL DEFINITIONS:

CLE=Reflux

Symptoms EndoscopicEsophagitis

GERD yes yes yes/no

ERD yes yes yes

NERD yes yes no

? yes no no

NOVEL DEFINITIONS:

DISEASE

abnormal morphology

cancer risk!

symptoms+impaired life quality

ABNORMALITY

abnormal morphology

no cancer risk!

no symptoms

NOVEL MANAGEMENT:

DISEASEABNORMAL

CLEwithout

IM and Symptoms

CLEwith IM

and/or Symptoms

TREATEGD in 3-5 years

FUNCTION TEST!

ESOPHAGEAL MANOMETRY:

PULL THROUGH: normal LES

ESOPHAGEAL MANOMETRY:

PULL THROUGH: impaired LES

ESOPHAGEAL MANOMETRY:

normal impaired motility

ESOPHAGEAL FUNCTION TEST:

Impedance: acidic reflux!

ESOPHAGEAL FUNCTION TEST:

Impedance: non acidic reflux!

ESOPHAGEAL FUNCTION TEST:

Manometry±Impedance

pH Monitoring±Impedance

WHEN:

Before and After Fundoplication!

pH probe placement!Exclude Motility Disorder!

ESOPHAGEAL FUNCTION TEST:

MANOMETRY+/-IMPEDANCE

MOTILITY TRANSPORT

ACHALASIA, SPASM, NUTCRACKER,

IMPAIRED MOTILITY

BODY LES

ACHALASIA, HYPER-HYPOTENSIVE LES

ESOPHAGEAL FUNCTION TEST:

pH MONITORING + IMPEDANCE

ANY REFLUXpH - INDEPENDENT

ACID REFLUXpH - DEPENDENT

+PPI THERAPY

ESOPHAGEAL FUNCTION TEST:

GERD symptoms:

pH Monitoring

abnormal

GERD confirmed

normal

ImpedancepH monitoring

normal

abnormal

do not operate!

TREAT!

Outlook:

High Resolution Manometry!High Resolution Endoscopy!

„NOVEL“ TOOLS FOR GERD!

• HISTOPATHOLOGY!

• Paull Chandrasoma Classification!

• FUNCTION TESTS, Imaging (NBI, HR-Endoscopy)!

• Interdisciplinary approach (GI, Surgery, Pathology)!

Fundoplication on Barrett‘s

author year regression progression

Gurski RR 200328/77 (36.4%)

8/77 (10.3%)

Zaninotto G

2005 6/35 (17%) 5/35 (14%)

CLE & successful Nissen Fundoplication

Parrilla P. et al., Ann Surg 2003, 237: 291

Selective bilateral Vagotomy, Nissen Fundoplikation & Antrum Resektion + Y-

Roux Gastrojejunostomie (Bile Diversion)

Prä OP (n=78) NASOK Post OP

SSBE (n=31) 40 Mo IM (n=11; 36%)

40 Mo CM (n=20; 64%)=Regression!

75 Mo 4/20 von CM in OCM!

LSBE (n=42) 44 Mo IM (n=16; 38%)

44 Mo CM (n=26; 62%)=Regression!

89 Mo 5/26 CM in OCM!

108 Mo LGD (n=1)

extra LSBE (n=5) 96 Mo IM (n=5; 100%)

CLE-length no change!

Csendes A. Surgery 2006; 139: 46-53.