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?