GERD September7 2nd
Transcript of GERD September7 2nd
-
8/14/2019 GERD September7 2nd
1/138
GENETICS
-
8/14/2019 GERD September7 2nd
2/138
BASICANATOMY
ACKNOWLEDGEMENTS
WHAT GERD
IS
GENETICS
INFLAMMATION
PHARMOCOGENOMICS
STRESS RESPONSE
CELL GROWTH
AND DEATH
SUMMARY
-
8/14/2019 GERD September7 2nd
3/138
Population based survey revealed that 44
% of the population reported monthly
heartburn and 19.8 % suffered fromheartburn or acid regurgitation at least
once a week.(Zuckschwerdt, W. 2001)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
4/138
GERD is more common in whites
compared with other ethnic groups.However, the prevalence is increasing inAsians.(Fennerty, 2003)
It is also more common in women,however men & people over the age of 60
develop more complications.(Fennerty, 2003)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
5/138
BASIC ANATOMY
The upper GI or gastro-intestinaltract consists of the:
Mouth
PharynxEsophagus
Stomach
The small & large intestines formthe lower GI tract.
(Porth, 1998 )
-
8/14/2019 GERD September7 2nd
6/138
Once any food enters the mouth, it
moves into the pharynx, which
is the back of the throat.
(Porth,1998)
-
8/14/2019 GERD September7 2nd
7/138
Peristalsis continues in the
esophagus.The food is carried
from the esophagus
to the stomachwhere acid
production is formed.(Porth,1998)
Image with permission from MDA
-
8/14/2019 GERD September7 2nd
8/138
The esophagus is very
muscular and collapses
when empty.
It is 10 inches or 25cm inlength
(Porth, 1998)
-
8/14/2019 GERD September7 2nd
9/138
The esophagus is sometimesreferred to as the food tubeor the gullet. It extends from the
pharynx, which is the back of thethroat and goes through thediaphram to the stomach.
Clip Art derived from
Microsoft OfficeImage with permission from Bristol-Meyers Squibb
-
8/14/2019 GERD September7 2nd
10/138
The esophagus producesbicarbonate and mucus.(Kahrilas, 2003)
The bicarbonate buffers the acid
and mucus forming a protective
barrier.(Kahrilas, 2003)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
11/138
This creates an environment in the
esophagus of a higher pH than that of
the stomach. The pH in the esophagusis normally about 7-8, whereas the pH
in the stomach is generally 2-4. (Kahrilas,2003)
-
8/14/2019 GERD September7 2nd
12/138
pH stands for potential of hydrogen.
Hydrogen is what causes materials to
become acidic. 7 is considered neutral;
anything under 7 is considered acidic. (Porth,1998)
-
8/14/2019 GERD September7 2nd
13/138
There are specialized cells deep in the
stomach lining that affect the rate of acid
production. The primary cells whichcontribute to acid production are known
as parietal cells. (Kahrilas, 2003)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
14/138
The binding of these 3 receptors in the
parietal cells initiates the process of
acid production. (Kahrilas,2003)
PARIETAL
CELLS
Acetylcholine Gastrin Histamine
-
8/14/2019 GERD September7 2nd
15/138
The primary function of the
activated pumps are to :
Exchange hydrogen ions from the parietalcells to potassium using energy derived
from splitting ATP.(Kahrilas, 2003)
Each gastric parietal cell contains
about 1 million acid pumps.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
16/138
The stomach produces an average of 2
liters of HCL a day, which in
combination with the protein-splittingenzyme pepsin, breaks down chemicals in
food. (Kahrilas 2003)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
17/138
The gullet is another name for
the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
18/138
The esophagus is divided into:
Upper
It has a sphincter to
prevent air fromentering the esophagusduring respirations.The sphinctergenerally only opensfor food to pass.
Lower
It has a sphincter thatopens while food is
being passed into thestomach. It is knownas the LES, loweresophageal sphincter.
( Porth, 1998)
-
8/14/2019 GERD September7 2nd
19/138
The esophagus is divided into:
Upper
It has a sphincter to
prevent air fromentering the esophagusduring respirations.The sphinctergenerally only opensfor food to pass.
Lower
It has a sphincter thatopens while food is
being passed into thestomach. It is knownas the LES, loweresophageal sphincter.
( Porth, 1998)
-
8/14/2019 GERD September7 2nd
20/138
Click on
Trueor False
The gullet is part of the
stomach.
-
8/14/2019 GERD September7 2nd
21/138
The gullet is another name for
the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
22/138
The gullet is another name for
the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
23/138
Click on
True or False
The esophagus is in front
of the trachea.
-
8/14/2019 GERD September7 2nd
24/138
The esophagus
is behind (posterior)
the trachea.
Image with permission from
Bristol-Meyers Squibb.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
25/138
The esophagus
is behind (posterior)
the trachea
Image with permission from
Bristol-Meyers Squib.Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
26/138
Click on
Trueor FalseThe upper sphincter of the
esophagus is in the upper GI & the
lower sphincter is the lower GI.
-
8/14/2019 GERD September7 2nd
27/138
The entire esophagus is in the upper
GI. The upper GI tract consists of
the: mouth
pharynx
esophagus
stomachThe small & large intestines form the
lower GI tract. Clip Art derived fromMicrosoft Office
-
8/14/2019 GERD September7 2nd
28/138
The entire esophagus is in the upper GI.
The upper GI tract consists of the: mouth
pharynx
esophagus
stomach
The small & large intestines form the
lower GI tract.Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
29/138
Click on
True or False
There are a million acid pumps in
each gastric parietal cell.
-
8/14/2019 GERD September7 2nd
30/138
There are 1 million acid pumps in
each gastric parietal cell.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
31/138
-
8/14/2019 GERD September7 2nd
32/138
What GERD isIt is quite a complex process, my goal isto simplify it for you. First, lets break it
down to the words it is made up of:
gastro = stomach
esophogeal = food tube
reflux = back flow
disease = abnormal conditionof physiologic functioning.
-
8/14/2019 GERD September7 2nd
33/138
The Lower
Esophageal
Sphincter isThe primary
focus relating
to GERD.
Image with permission from Dr. Scott Tenner
http://www.gerd.com/maps/grossovw.map -
8/14/2019 GERD September7 2nd
34/138
-
8/14/2019 GERD September7 2nd
35/138
If the Lower Esophageal Sphincter (LES)
is not working properly creating a
dysfunctionthe acid from the stomach
can backflow into the esophagus.(Porth, 1998)
-
8/14/2019 GERD September7 2nd
36/138
Images withpermission from
Life Enhancement
-
8/14/2019 GERD September7 2nd
37/138
In addition to a dysfunction of the
lower esophageal sphincter (LES)
Another factor is:
Percentage of time the esophagus is
exposed to a low pH. Clearance of theacid depends on peristalsis & exposure to
the saliva.(Porth, 1998)
-
8/14/2019 GERD September7 2nd
38/138
In addition to a dysfunction of the
lower esophageal sphincter (LES)
Another factor is:
Percentage of time the esophagus is
exposed to a low pH. Clearance of theacid depends on peristalsis & exposure to
the saliva.(Porth, 1998)
-
8/14/2019 GERD September7 2nd
39/138
Image with permission from
Healthy Living
This uncomfortablefeeling can
sometimes beconfused with otherconditions, even aheart attack.
People with this dysfunction, often experience an
uncomfortable feeling in the chest, neck,
and throat area due to acid exposure.
-
8/14/2019 GERD September7 2nd
40/138
Sometimes, just drinking water may
help relieve the symptoms, by
washing the irritating acids back
into the stomach.(Porth, 1998)
-
8/14/2019 GERD September7 2nd
41/138
This discomfort can be
precipitated by lifestyle, diet, and
even certain medications.(Kaynard,, Flora, 2001)
-
8/14/2019 GERD September7 2nd
42/138
-
8/14/2019 GERD September7 2nd
43/138
-
8/14/2019 GERD September7 2nd
44/138
Medications that relax the LES
Benzodiazepines
Theophylline
Narcotics containingcodeine.
Calium channelBlockers
Nitroglycerine
Anticholinergics
Potassium
supplements Iron supplements
NSAIDS
Fosamax
Erythromycin(CNN)
Clip Art derived from
Microsoft Office
The 3 mechanisms d ring s allo ing
-
8/14/2019 GERD September7 2nd
45/138
The 3 mechanisms during swallowing
that keep acid out of the esophagus
include: Swallowed saliva which helps neutralize
stomach acid.
Sweeping muscles contractions that actto cleanse the lower esophagus of
stomach acid.
Protective contracture of the LES(Jackson Gastroenterology - 2005)
-
8/14/2019 GERD September7 2nd
46/138
The 3 mechanisms of the lower
esophageal sphincter (LES)
which prevent backflow are: Pressure in the LES is greater than that of
the stomach.
High levels of Acetylcholine, a
neurotransmitter increases constriction of
the LES.
Gastrin, a hormone also increasesconstriction of the LES.
(Porth 1998 )
-
8/14/2019 GERD September7 2nd
47/138
Some conditions that can interfere
with the 3 mechanisms of the Lower
Esophageal Sphincter (LES): OBESITY - excess weight puts extra pressure on the
stomach & diaphragm. (CNN.com)
Pregnancyresults in greater pressure on the stomach
& also has a higher level of progesterone. Thishormone relaxes many muscles, including the LES.(CNN.com)
ASTHMAit is unsure why, but, is believed that thecoughing leads to pressure changes on the diaphragm.
(CNN.com)
HIATAL HERNIAwhich is the following topic.
-
8/14/2019 GERD September7 2nd
48/138
In addition to the 3 swallowing
mechanisms & the 3 mechanisms of
the LESanatomical structures
certainly play a role in the
development of GERD.
-
8/14/2019 GERD September7 2nd
49/138
In individuals with hiatal hernia, the
opening of the esophageal hiatus is larger
than normal, and a portion of the upper
stomach slips up or passes (herniates)
through the hiatus and into the chest.(Kahrilas, 2003)
A hiatal hernia is an
anatomical abnormality
-
8/14/2019 GERD September7 2nd
50/138
In individuals with hiatal hernia, the
opening of the esophageal hiatus is larger
than normal, and a portion of the upper
stomach slips up or passes (herniates)
through the hiatus and into the chest.(Kahrilas, 2003)
A hiatal hernia is an
anatomical abnormality
-
8/14/2019 GERD September7 2nd
51/138
The diaphragm supports and puts
pressure on the sphincter to keep it closedwhen youre swallowing.
But a hiatal hernia raises the sphincterabove the diaphragm, reducing pressure
on the valve. This causes the sphincter
muscle to open at the wrong time.(MayoClinic.com)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
52/138
Do you think Genetics is a
factor?
There is evidence that genetics is a
factor in pediatric patients. This is
reported in the Journal of the American
Medical Association from the July issue
in 2000. (Spice, B., 2000)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
53/138
The specific gene has not been
identified as of yet, however research
has narrowed it to a portion ofchromosome 13
(Hu, Fen Ze MS; et al 2000)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
54/138
As far as adults, studies have been
performed on identical twins who
share the same genes & it has been
identified that there is a 43%
chance of genetic influence.
( MedicineNet.com)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
55/138
Click on
Trueor False
GERD can sometimes cause a discomfort
in the chest, confusing it
with a heart attack.
-
8/14/2019 GERD September7 2nd
56/138
-
8/14/2019 GERD September7 2nd
57/138
Image with permission from
Healthy Living
People with GERD
can experience an
uncomfortable
feeling in the neck,chest, & throat area.
This can be confused
with other diseases,
even a heart attack.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
58/138
Narcotics such as codeine relax the
LES, making it more likely for acidto reflux back into
the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
59/138
Narcotics such as codeine relax the
LES, making it more likely for acidto reflux back into
the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
60/138
Narcotics such as codeine relax the
LES, making it more likely for acid
to reflux back into
the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
61/138
Click on
Trueor False
The diaphragm helps to open
the esophagus.
-
8/14/2019 GERD September7 2nd
62/138
The diaphragm supports and puts
pressure on the sphincter to keepit closed while swallowing.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
63/138
The diaphragm supports and puts
pressure on the sphincter to keep
it closed while swallowing.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
64/138
Saliva produces more acid,
creating a potential
for increased reflux.
Click on
Trueor False
-
8/14/2019 GERD September7 2nd
65/138
Swallowed saliva helps neutralize
acid. It is one of the 3 mechanismsthat keeps acid out of the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
66/138
Swallowed saliva helps neutralize
acid. It is one of the 3 mechanisms
that keeps acid out of the esophagus.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
67/138
-
8/14/2019 GERD September7 2nd
68/138
Inflammation is the bodys response, as
a protective measure against
infection and injury.
Repeated exposure to acid in theesophagus will cause inflammation
and injury to the mucosa.
-
8/14/2019 GERD September7 2nd
69/138
Inflammation as a result of GERD can
cause epithelial changes, marked by
polymorphonuclear or mixedpolymorphonuclear and round cell
infiltration.(Fennerty, 2003)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
70/138
There are 3 inflammatory
processes that can occur withesophagitis:
Erosive Esophagitis
Esophageal Strictures
Barretts Esophagus (Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
71/138
Erosive Esophagitis
Erosions appear in esophageal
mucosa as eroded endothelium.(Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
72/138
Contributing factors of
Erosive Esophagitis:
Hiatal Hernia
Decreased pressure in
the lower esophagealsphincter (LES)
Impaired ability of the
tissue to resist injury
Impaired esophageal
clearance
Increased volume ofacid(Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
73/138
-
8/14/2019 GERD September7 2nd
74/138
Strictures
A stricture is a narrowing If
esophagitis is left untreated, scarring
can occur resulting in a
stricture that is irreversible.(Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
75/138
Contributing Factors of
Esophageal Strictures
Decreased pressure in the lower
esophageal sphincter (LES)
Hiatal Hernia
Ineffective peristalsis(Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
76/138
Clip Art derived from
Microsoft Office
People with strictures often feel like
there is something stuck in their throat.
Severe strictures result in difficultyswallowing (dysphagia).
(Fennerty,2003)
-
8/14/2019 GERD September7 2nd
77/138
Those with severe strictures usually have
less symptoms of heartburn, acid is
not able to reflux due to the narrowing
of the esophagus.(Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
78/138
Those with strictures may also have weight
loss, due to a change in their diet to
accommodate the strictures.(Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
79/138
Stress Response
Stress is a complex physiological
response to changes in
the environment.
-
8/14/2019 GERD September7 2nd
80/138
Prolonged stress has the
ability to decrease the immune system,
making the body susceptibleto inflammation and infection. (Porth, 1998)
-
8/14/2019 GERD September7 2nd
81/138
In an effort to cope with the
disruption in routine, caused by
stress, unhealthy lifestylesbecome evident.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
82/138
Pharmocogenomics
There are 3 categories
of medications that
can help alleviate or
prevent symptoms
from occurring.(Kaynard, Flora, 2001)
Antacids
H-2 receptor blockers
Proton pump
inhibitors
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
83/138
In an effort to cope with the
disruption in routine, caused by
stress, unhealthy lifestylesbecome evident.
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
84/138
Pharmocogenomics
There are 3 categories
of medications that
can help alleviate or
prevent symptoms
from occurring.(Kaynard, Flora, 2001)
Antacids
H-2 receptor blockers
Proton pump
inhibitors
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
85/138
Antacids
Maalox
Mylanta
Tums
Rolaids
These medications help
to neutralize stomach
acid. They usually
provide quick relief,
however, will not heal
any inflammation.(CNN.Com)
-
8/14/2019 GERD September7 2nd
86/138
H-2 Receptor Blockers
Tagamet
Zantac
Pepcid AC
These medicationsreduce the acid
production. They do
not act as quickly asantacids, but providelonger relief. (CNN.Com)They start working in
about 30 minutes.
-
8/14/2019 GERD September7 2nd
87/138
Proton Pump Inhibitors Prevacid
Prilosec
Aciphex
Protonix
Nexium
These medications are
long acting and blockacid production.Because of this,they have the abilityto allow time fordamaged tissue toheal frominflammation.
(CNN.Com)
-
8/14/2019 GERD September7 2nd
88/138
Cell Growth and Death
As mentioned earlier, as a result of
inflammation:
cellular changes can occur.
-
8/14/2019 GERD September7 2nd
89/138
These cellular changes can be
a precursor to cancer. (Fennerty, 2003)
Clip Art derived from
Microsoft Office
-
8/14/2019 GERD September7 2nd
90/138
Barretts Esophagus is the outcome
-
8/14/2019 GERD September7 2nd
91/138
Barrett s Esophagus is the outcome
of these cellular changes.
Cells in the lining of the esophagus are
actually replaced with abnormal cells
similar to those in the stomach.(Fennerty, 2003)
-
8/14/2019 GERD September7 2nd
92/138
This would be, metaplasia. Asthe cells replicate to multiply,
dysplasia is occurring. (Porth, 1998)
-
8/14/2019 GERD September7 2nd
93/138
-
8/14/2019 GERD September7 2nd
94/138
Ulcers, although not a common symptom,can be found with Barretts Esophagus.
The ulcers can lead to Gastrointestinal
bleeding. (Fennerty, 2003)
Cli k
-
8/14/2019 GERD September7 2nd
95/138
Click on
Trueor False
Some people with strictures have
decreased symptoms of reflux.
-
8/14/2019 GERD September7 2nd
96/138
A stricture is a narrowing, as a
result, the acid is sometimes
unable to reflux.
-
8/14/2019 GERD September7 2nd
97/138
Cli k
-
8/14/2019 GERD September7 2nd
98/138
Click on
Trueor False
If esophagitis is left untreated,
scarring can occur resulting in a
stricture, which eventuallyheals itself.
Cli k
-
8/14/2019 GERD September7 2nd
99/138
Click on
Trueor False
GI bleeding is one of the symptoms
of Barretts Esophagus.
-
8/14/2019 GERD September7 2nd
100/138
GI bleeding can be a symptom
of an ulcer, which can be
present in someone with Barretts
Esophagus, although not common.
-
8/14/2019 GERD September7 2nd
101/138
Gi bleeding can be a symptom
of an ulcer, which can be
present in someone with Barretts
Esophagus, although not common.
-
8/14/2019 GERD September7 2nd
102/138
High Prevalence of Gastroesophageal
-
8/14/2019 GERD September7 2nd
103/138
Locke et al. Gastroenterology 1997;112:1148.
High Prevalence of Gastroesophageal
Reflux Symptoms
19.8%
59%
0%
10%
20%
30%
40%
50%
60%
Weekly Monthly
Frequency of heartburn and/or
regurgitation
-
8/14/2019 GERD September7 2nd
104/138
Important Reasons to Diagnose and Treat
-
8/14/2019 GERD September7 2nd
105/138
GERD
Negative impact on health-related quality of life1
Risk factor for esophageal adenocarcinoma2
1. Revicki et al. Am J Med 1998;104:252.
2. Lagergren et al. N Engl J Med 1999;340:825.
-
8/14/2019 GERD September7 2nd
106/138
-
8/14/2019 GERD September7 2nd
107/138
Clinical Presentations of GERD
-
8/14/2019 GERD September7 2nd
108/138
Classic GERD
Extraesophageal/Atypical GERD Complicated GERD
-
8/14/2019 GERD September7 2nd
109/138
Extraesophageal Manifestations
-
8/14/2019 GERD September7 2nd
110/138
of GERD
Pulmonary
Asthma
Aspiration pneumonia
Chronic bronchitisPulmonary fibrosis
OtherChest pain
Dental erosion
ENT
Hoarseness
Laryngitis
PharyngitisChronic cough
Globus sensation
Dysphonia
SinusitisSubglottic stenosis
Laryngeal cancer
Potential Oral and Laryngopharyngeal SignsAssociated with GERD
-
8/14/2019 GERD September7 2nd
111/138
Associated with GERD
Edema and hyperemia of
larynx
Vocal cord erythema,
polyps, granulomas,
ulcers
Hyperemia and lymphoid
hyperplasia of posterior
pharynx
Interarytenyoid changes
Dental erosion
Subglottic stenosis
Laryngeal cancer
Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.
Pathophysiology of Extraesophageal
-
8/14/2019 GERD September7 2nd
112/138
GERD
-
8/14/2019 GERD September7 2nd
113/138
-
8/14/2019 GERD September7 2nd
114/138
When to Perform Diagnostic Tests
-
8/14/2019 GERD September7 2nd
115/138
When to Perform Diagnostic Tests
Uncertain diagnosis
Atypical symptoms
Symptoms associated with complications Inadequate response to therapy
Recurrent symptoms
Prior to anti-reflux surgery
-
8/14/2019 GERD September7 2nd
116/138
Diagnostic Tests for GERD
Barium swallow
Endoscopy Ambulatory pH monitoring
Esophageal manometry
Barium Swallow
-
8/14/2019 GERD September7 2nd
117/138
Useful first diagnostic test forpatients with dysphagia
Stricture (location, length)
Mass (location, length) Birds beak
Hiatal hernia (size, type)
Limitations
Detailed mucosal exam for erosiveesophagitis, Barretts esophagus
Endoscopy
-
8/14/2019 GERD September7 2nd
118/138
Indications for endoscopy
Alarm symptoms
Empiric therapy failure
Preoperative evaluation
Detection of Barretts
esophagus
Ambulatory 24 hr. pH Monitoring
-
8/14/2019 GERD September7 2nd
119/138
Physiologic study
Quantify reflux in
proximal/distalesophagus
% time pH < 4
DeMeester score
Symptom correlation
Ambulatory 24 hr. pH Monitoring
-
8/14/2019 GERD September7 2nd
120/138
Normal
GERD
Wireless, Catheter-Free Esophageal pH Monitoring
-
8/14/2019 GERD September7 2nd
121/138
Improved patient
comfort and acceptance
Continued normal work,activities and diet study
Longer reporting periods
possible (48 hours)Maintain constant probe
position relative to SCJ
Potential Advantages
Esophageal Manometry
-
8/14/2019 GERD September7 2nd
122/138
Assess LES pressure,
location and relaxation Assist placement of 24 hr.
pH catheter
Assess peristalsis
Prior to antireflux surgery
Limited role in GERD
Treatment Goals for GERD
-
8/14/2019 GERD September7 2nd
123/138
Treatment Goals for GERD
Eliminate symptoms
Heal esophagitis Manage or prevent complications
Maintain remission
Lifestyle Modifications areCornerstone of GERD Therapy
-
8/14/2019 GERD September7 2nd
124/138
Cornerstone of GERD Therapy
Elevate head of bed 4-6 inches
Avoid eating within 2-3 hours of bedtime
Lose weight if overweight
Stop smoking
Modify diet
Eat more frequent but smaller meals
Avoid fatty/fried food, peppermint, chocolate,alcohol, carbonated beverages, coffee and tea
OTC medications prn
Acid Suppression Therapy for GERD
-
8/14/2019 GERD September7 2nd
125/138
H2-Receptor Antagonists
(H2RAs)
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)Nizatidine (Axid)
Proton Pump Inhibitors
(PPIs)
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex)
Pantoprazole (Protonix)Esomeprazole (Nexium )
Effectiveness of Medical Therapies for
-
8/14/2019 GERD September7 2nd
126/138
Effectiveness of Medical Therapies for
GERD
Treatment Response
Lifestyle modifications/antacids 20 %
H2-receptor antagonists 50 %
Single-dose PPI 80 %
Increased-dose PPI up to 100 %
Treatment Modifications forPersistent Symptoms
-
8/14/2019 GERD September7 2nd
127/138
y p
Improve compliance
Optimize pharmacokinetics
Adjust timing of medication to 1530 minutesbefore meals (as opposed to bedtime)
Allows for high blood level to interact with
parietal cell proton pump activated by the meal
Consider switching to a different PPI
GERD is a Chronic Relapsing Condition
-
8/14/2019 GERD September7 2nd
128/138
Esophagitis relapses quickly after cessation
of therapy
> 50 % relapse within 2 months
> 80 % relapse within 6 months
Effective maintenance therapy is imperative
Complications of GERD
-
8/14/2019 GERD September7 2nd
129/138
p
Erosive/ulcerative esophagitis
Esophageal (peptic) stricture
Barretts esophagus
Adenocarcinoma
-
8/14/2019 GERD September7 2nd
130/138
Peptic Stricture
-
8/14/2019 GERD September7 2nd
131/138
Barium Swallow Endoscopy
-
8/14/2019 GERD September7 2nd
132/138
-
8/14/2019 GERD September7 2nd
133/138
Barretts Esophagus
-
8/14/2019 GERD September7 2nd
134/138
Esophageal Cancer
-
8/14/2019 GERD September7 2nd
135/138
Barium Swallow Endoscopy
-
8/14/2019 GERD September7 2nd
136/138
When to Discuss Anti-Reflux
-
8/14/2019 GERD September7 2nd
137/138
Surgery with Patients
Intractable GERDrare
Difficult to manage strictures
Severe bleeding from esophagitisNon-healing ulcers
GERD requiring long-term PPI-BID in a
healthy young patient Persistent regurgitation/aspiration symptoms
Not Barretts esophagus alone
Endoscopic GERD Therapy
-
8/14/2019 GERD September7 2nd
138/138
Endoscopic antireflux therapies
Radiofrequency energy delivered to the LES
Stretta procedure
Suture ligation of the cardia
Endoscopic plication
Submucosal implantation of inert material in
the region of the lower esophageal sphincter Enteryx