1. WILLIAM J. SALYERS, JR., MD, MPH DIVISION CHIEF/MEDICAL DIRECTOR KU WICHITA GASTROENTEROLOGY ASSOCIATE PROGRAM DIRECTOR INTERNAL MEDICINE RESIDENCY Putting Out the Fire: Prevention & Treatment of Acid Reflux & Ulcers

2. Goals Discuss the causes and treatments of ulcer-related disease. Discuss the causes and treatments of GERD. Review the long-term consequences of GERD. Review the use of endoscopy in management of ulcers and complications of GERD.

3. PEPTIC ULCER DISEASE

6. What Causes an Ulcer? Ulcers occur when acid eats away the lining of the esophagus, stomach, or small intestine.

7. How Does This Happen? Medications  Pain Relievers: Ibuprofen, Aspirin, Naproxen  Bisphosphonates: Fosamax, Actonel Helicobacter pylori bacteria High Acid States: Gastrinoma

8. Does Stress Cause Ulcers?

9. Yes & No Stress alone does NOT cause ulcers. Uncontrolled high stress conditions may:  Burns  Physical trauma  Surgery

10. HELICOBACTER PYLORI

11. Helicobacter Pylori 30 – 40% of the US population is estimated to be infected with HP. The majority of individuals acquire HP during childhood.

13. What Are the Symptoms? Pain.  May be worse when your stomach is empty. Bleeding. Nausea & Vomiting. Unexplained weight loss.

14. Complications of Ulcers GI Bleeding. Perforation. Scarring.

16. Treatment Medications to suppress acid production. Medications that neutralize acid or protect the stomach lining. Antibiotics for H. pylori infection. Endoscopic therapy.

17. ENDOSCOPY

18. What is Endoscopy Examination of the gastrointestinal tract using long, thin flexible scopes.  EGD  Colonoscopy  Enteroscopy  Capsule Endoscopy Used for diagnostic and therapeutic purposes.  Colon cancer screening  Evaluation of abdominal pain  Management of swallowing difficulty  Management of bleeding

23. ACID REFLUX DISEASE

24. What is GERD? Gastroesophageal Reflux Disease. Backwash of acid into the esophagus.  Irritates the lining of the esophagus.  Occasionally caused by bile.  Due to relaxation of the lower esophageal sphincter.

26. What Are the Symptoms? Heartburn. Metal or sour taste in mouth. Chest pain. Chronic dry cough. Regurgitation of food or sour liquid. Difficulty swallowing. Lump in the throat.

27. Risk Factors Smoking. Obesity. Connective tissue disease. Hiatal hernia. High output acid disorders. Diabetes. Pregnancy.

30. Treatment Lifestyle measures.  Avoid trigger foods.  Don’t eat 3 hours before bedtime.  Keep head of bed elevated at night.  Lie on your left side at night.  Don’t smoke.  Maintain a healthy weight.  Don’t wear tight clothing. Acid suppressing medications. Anti-reflux surgery / procedures.

31. When Should You See Your Doctor? Symptoms of chest pain. Symptoms that occur > 2 x weekly.  Taking OTC acid medications > 2 x weekly. Symptoms that interfere with your daily activities. Difficulty swallowing. Unintentional weight loss. GI bleeding.

32. What Are the Complications of GERD? Peptic strictures. Esophageal ulcers. Pre-cancerous changes of the esophagus (Barrett’s). Esophageal cancer.

34. Peptic Stricture Reversible inflammation & edema irreversible scarring. Heartburn often decreases w/ worsening dysphagia. Dysphagia usually limited to solids.

36. Esophageal Cancer: Adenocarcinoma Related to heartburn & Barrett’s esophagus. Barrett’s Screening  Highest Yield – White Males > 50 w/ longstanding GERD.  Consider all pts w/ GERD > 5 yrs & all pts age > 50.

40. BARRETT’S ESOPHAGUS

43. Epidemiology Barrett’s Esophagus  Premalignant lesion assoc w/ Adenocarcinoma of esophagus & GE jct.  Increasing incidence of Esophageal AdenoCa in US over past 2 decades.  AdenoCa accounting for > 50% esophageal cancers in US.  Annual incidence of AdenoCa in BE is < 0.5% in US.  Poor 5-year survival – only 13%.  BE - Dx in 10 -15% pts w/ reflux undergoing EGD.  Prevalence reported as high as 5.6% in pts w/o chronic reflux symptoms.

46. Therapy PPI to control GERD symptoms. Nissen Fundoplication may be considered for pt’s w/ controlled GERD on PPI. PPI tx &/or surgery do not reverse BE. No role for pH monitoring.  Tx goal is symptom control, not pH level. Endoscopic therapy.

48. 2011 AGA Guidelines High-Grade Dysplasia  RFA, EMR, & PDT recommended.  70-80% can be successfully tx w/ endoscopic tx alone.\ Low-Grade Dysplasia  “RFA should also be a therapeutic option for treatment”.  >90% reversion to normal-appearing squamous epithelium.

49. 2011 AGA Guidelines Nondysplastic  “RFA, with or wthout EMR, should be a therapeutic option for select individuals with nondysplastic Barrett’s esophagus who are judged to be at increased risk for progression to high-grade dysplasia or cancer”.

52. Radiofrequency Ablation

55. Screening ACG: No recommendation – individualized in high risk patients. ASGE: “may be appropriate in selected pts w/ frequent (e.g., several times/wk), chronic, long- standing GERD (> 5 yrs).”  If negative screening exam, no further screening indicated.

56. Questions?