1. GERD and Peptic ulcer disease
August 29, 2011

2. Peptic Physiology

3. Peptic Physiology Intrinsic factor Hydrochloric acid
Stimulated by gastrin, ach, H+
Mucus
Bicarbonate
Pepsinogen
Stimulated by gastrin
Primarily in antrum

4. Gastroesophageal Reflux Disease

5. 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

6. Physiologic vs Pathologic
Physiologic GERD
Postprandial
Short lived
Asymptomatic
No nocturnal sx
Pathologic GERD
Symptoms
Mucosal injury
Nocturnal sx
--distinction between normal and GERD is blurred because some degree of reflux is physiologic is all folks
Physiologic—postprandially, short lived, asymptomatic, not during sleep
Pathologic—symptoms or mucosal injury and often with nocturnal symptoms

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
--At level of diaphragmatic hiatus—main deterrant to reflux
--disruption due to –review slide--multifactorial

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
Dysphagia—difficulty swallowing
Other symptoms include:
Chest pain, globus sensation, odynophagia, nausea
Extraesophageal manifestations
Asthma, laryngitis, chronic cough
--gerd related chest pain may mimic angina—squeezing/burning, substernal, radiates to back, neck, jaw, arms. Minutes to hours. After meals, awakens patient from sleep, exacerbated by emotional stress
--water brash—hypersalivation—heartburn and regurg of sour fluid or tasteless saliva into mouth
--globus—lump in throat irrespective of swallowing
--odynophagia—esophageal ulcer
--nausea—infrequent
--hrt burn 70-85%//regurg 60%//dysphagi 15-20%//angina 33%//asthma 15-20%

9. 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
--heartburn +/- regurgitation high specificity, low sensitivity

10. Alarms Dysphagia Early satiety GI bleeding Odynophagia Vomiting
Weight loss
Iron deficiency anemia
--need further eval if any present—egd--

11. Trial of Medications H2RA or PPI Expect response in 2-4 weeks
If no response
Change from H2RA to PPI
Maximize dose of PPI
Once established h&p dx and no alarm symptoms can proceed with dx/therapeutic trial of tx.

12. Trial of Medications If PPI response inadequate despite maximal dosage
Confirm diagnosis
EGD
24 hour pH monitor
--if started with or changed to
--prilo 40 qd x 14d as specific/sensitive as pH monitor
--remember only works on active pumps. Take min prior to eating

13. EGD Endoscopy (with biopsy if needed)
In patients with alarm signs/symptoms
Those who fail a medication trial
Those who require long-term tx
Absence of endoscopic features does not exclude a GERD diagnosis
Allows for detection, stratification, and management of esophageal manifestations or complications of GERD
--if trial of med did not work or if alarm symptoms or long term 5yrs need egd 1a evidence—dysphagia/early satiety/gi bleed/odynophagia/vomiting/wt loss/anemia
% of patient’s with gerd will have a neg egd.

14. 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
--Transnasal catheter or a wireless capsule shaped device affixed to distal esophagus
--cather positioned 5cm above manometrically defined upper limit of les
--capsul attached 6cm proximal to endoscopically defined squamocolumnar jxn
--if mucosal changes—have dx and do not need 24hph.

15. Patient with heartburn
Initiate tx with H2RA or PPI
H2RA taken
BID
PPI taken QD No
Good response No
Good response
Yes
Yes
Yes
Increase to
max dose QD
or BID
Maintenance therapy
with lowest effective dose
Frequent relapses No
Yes
On demand tx
Symptoms persist
Good response No
Consider EGD if
risk factors present
(> 45, white, male
and > 5 yrs of sx)
Confirm diagnosis
EGD, ph monitor

16. Treatment Goals of therapy Symptomatic relief Heal esophagitis
Avoid complications

17. 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, NSAIDS)
Avoid clothing that is tight around the waist
Lose weight
Stop smoking

18. Medical Treatment Antacids
Over the counter acid suppressants and antacids 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
--Tums, rolaids, maalox
--$1 billion in yearly expenditures
--aluminum/calcium—constipation
Mag--diarrhea

19. Medical 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

20. Medical Treatment AGENT EQUIVALENT DOSAGE DOSAGES
Cimetadine mg twice daily mg twice daily
Tagamet
Famotidine mg twice daily mg twice daily
Pepcid
Nizatidine mg twice daily mg twice daily
Axid
Ranitidine mg twice daily mg twice daily
zantac
--otc dose uniformly half of standard lowest prescription dose
--similar clinical efficacy

21. Medical Treatment Proton Pump Inhibitors
Better control of symptoms with PPIs vs H2RAs and better remission rates
Faster healing of erosive esophagitis with PPIs vs H2RAs

22. Treatment AGENT EQUIVALENT DOSAGE DOSAGES
Esomeprazole mg daily mg daily
Nexium
Omeprazole mg daily mg daily
Prilosec
Lansoprazole mg daily md daily
Prevacid
Pantoprazole mg daily mg daily
Protonix
Rabeprazole mg daily mg daily
Aciphex
--no significant differences in symptomatic tx of GERD or healing of erosive esophagitis 1a evidence
--works only on active pumps—take 30-60min prior to meals
--long-term tx generally benefits outweigh risks

23. Treatment Antireflux surgery Failed medical management
Patient preference
GERD complications
Medical complications attributable to a large hiatal hernia
Atypical symptoms with reflux documented on 24-hour pH monitoring
candidacy
--esophagitis—by egd
--need normal manometry/motility
--partial response to acid suppression
--reduce hh, repair diaphragm, strengthen ge jxn—antireflux barrier
% effective at alleviating hrtburn/regurg
--better at helping with hrtburn/regurg than atypical sx

24. Treatment Antireflux surgery candidates EGD proven esophagitis
Normal esophageal motility
Partial response to acid suppression

25. Treatment Antireflux surgery Tenets of surgery Reduce hiatal hernia
Repair diaphragm
Strengthen GE junction
Strengthen antireflux barrier via gastric wrap
75-90% effective at alleviating symptoms of heartburn and regurgitation

26. Nissen Fundoplication

27. Upper GI Study

28. Treatment Endoscopic treatment Three categories Relatively new
No definite indications
Select 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 nonabsorbable polymer into LES area

29. Complications Erosive esophagitis Stricture Barrett’s esophagus
--dysphagia, odynophagia, early satiety, gi bleed, anemia, vomit, wt loss

30. Complications Erosive esophagitis
Responsible for 40-60% of GERD symptoms
Severity of symptoms often fail to match severity of erosive esophagitis
--black arrow squamo-columnar jxn—Z-line
--Z-line has undulating smooth contours
--green arrow—gastric columnar epithelium above round black sphincter
--red arow—pink white esophageal squamous epithelium
--ulcerations in 2-7%

31. Complications Esophageal stricture
Result of healing of erosive esophagitis
May need dilation
4-20% of patients

32. Complications Barrett’s Esophagus Columnar metaplasia of the esophagus
Associated with the development of adenocarcinoma
--1950—Norman Barrett %
--black arrow squamo-columnar jxn—Z-line
--Z-line has undulating smooth contours
--green arrow—gastric columnar epithelium above round black sphincter
--red arow—pink white esophageal squamous epithelium
--RFs—male, smoker, age, obese

33. Complications Barrett’s Esophagus
Acid damages lining of esophagus and causes chronic esophagitis
Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells
This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma
Adenoca with barretts 0.5%/yr without barretts 0.07%/yr

34. 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 shorter interval surveillance
Many patients with Barrett’s are asymptomatic

35. Complications Esophageal dysplasia/cancer Cancer High-grade dysplasia
Esophagectomy
High-grade dysplasia
Esophagectomy or ablation
Low-grade dysplasia
Treat GERD
EGD surviellence 35

36. Peptic Ulcer Disease

37. Peptic Ulcer Disease
Symptoms
Pain
Bleeding
Perforation
Obstruction

38. Peptic Ulcer Disease

39. 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

40. Duodenal Ulcer Eridicate H pylori Surgery for complications
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

41. Duodenal Ulcer

42. 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

43. Gastric Ulcer Types Type I Type II Type III Most common Lesser curve
H pylori
Type II
Pre pyloric
Associated with duodenal ulcers
Type III
Antrum
NSAIDs

44. Gastric Ulcer Need to rule out malignancy Treatment EGD Biopsy
Stop NSAIDs
PPI
Treat H pylori
Repeat EGD to check for healing
Surgery
Malignancy
Bleeding
Perforation
Obstruction

45. Questions?