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Gastroesophageal Reflux Disease (GERD)

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Gastroesophageal Reflux Disease (GERD) ... Surgery in GERD Nissan Fundoplication 40-50% have required medical treatment after surgery. High failure rate. – PowerPoint PPT presentation

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Title: Gastroesophageal Reflux Disease (GERD)


1
Gastroesophageal Reflux Disease (GERD)
  • Dr. Kairu S. M.

2
GERD - Definitions
  • Gastro-oesophageal reflux disease (GORD)
  • Abnormal reflux of gastric juice (acid and bile)
    into the oesophagus leading to symptoms
  • Pathological reflux ranges from simple to erosive
    to Barretts
  • Non-erosive reflux disease (NERD)
  • Reflux disease in which erosion does not occur
  • Heartburn
  • Burning retrosternal pain radiating upward due to
    exposure of the oesophagus to acid
  • Oesophagitis
  • Endoscopically demonstrated damage to the
    oesophageal mucosa

3
Prevalence.
  • Increased prevalence last 10 years.
  • Accompanied increase in adenocarcinoma lower
    esophagus.
  • Obesity associated with increased GERD.

4
Anti Reflux Mechanism(ARM)
  • This has both-
  • (1) Anatomical.
  • (2) Functional.

5
Anatomical.
  • The lower esophageal sphincter (LES) at the OG
    junction consists of tonically contracted smooth
    muscle at approx. 8-20 mmHg above the gastric
    pressure.
  • The outside (extrinsic) compression at the OG
    junction from the crural diaphragm.
  • Sharp angle- entry of esophagus into stomach
    (angle of His).

6
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7
TLESR (Transient Lower Esophageal Sphincter
Relaxations)
  • A normal phenomenon in healthy individuals.
  • Dominant mechanism of pathological reflux.
  • Too frequent TLESRs.
  • Too prolonged TLESRs.

8
Functional.
  • Esophageal peristalsis that serves to clear
    luminal contents into the stomach.
  • Secretion and swallowing of saliva to neutralize
    the acid and enhance clearance.
  • Prompt Gastric emptying.

9
Pathophysiology of GERD
salivary HCO3
Impaired mucosal defence
oesophageal clearance of acid (lying flat,
alcohol, coffee)
Impaired LOS (smoking, fat, alcohol)
transient LOS relaxations basal tone
Hiatus hernia
acid output (smoking, coffee)
H Pepsin
Bile and pancreatic enzymes
intragastric pressure (obesity, lying flat)
gastric emptying (fat)
10
Symptoms.
11
  • Heartburn and Regurgitation are the two cardinal
    symptoms of GERD.
  • Others-
  • (1) Dysphagia-due to peptic stricture or
  • peristaltic dysfunction.
  • (2) Chest pain (NCCP).
  • (3) Water brash.
  • (4) Globus Sensation.
  • (5) Odynophagia.

12
Extra Esophageal Manifestations.
  • Asthma.
  • Microaspiration.
  • Vagal reflex activation.
  • Laryngitis.
  • Complications of GERD.
  • Bleeding.
  • Stricture.
  • Barrets esophagus adenocarcinoma

13
Role of Endoscopy in GERD.
  • Confirm diagnosis of GERD -erosions/ulcerations.
  • Diagnose endoscopy-negative reflux.
  • Exclude other causes of esophagitis/
  • odynophagia e.g.Candida, Herpes Simplex.
  • Diagnose complications of chronic GERD e.g
    Barrets esophagus, stricture, adenocarcinoma.

14
1.Savary-Miller classification.
  • Solitary erythematous /erosions covering one
    mucosal fold.
  • Solitary erythematous /erosion covering more than
    one mucosal folds but not circumferential.
  • Circumferential erythematous / erosions.
  • Complications?
  • Ulcers.
  • Strictures.
  • Barretts esophagus.

15
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17
Grade I
18
Grade 1
19
Grade 2
20
Grade 2
21
Grade 2
22
Grade 3
23
Grade 4
24
Grade 4
25
Grade 4
26
Grade 4.
27
Modes of Treatment
  • Proton Pump Inhibitors
  • Longer acting PPIs.
  • Adverse events/effects of PPIs.
  • Potassium competitive acid blockers (PCABs)
  • Motility agents.
  • GABA agonists
  • Endoscopic therapy
  • Full-thickness plication

28
The Step up Approach.
  • PPI
  • ?
  • LOW DOSE PB.
  • ?
  • H2RA PROKINETIC.
  • ?
  • H2RA
  • ?
  • OTC ANTACIDS LIFESTYLE ADVICE.

29
The Step Down Approach.
  • PPI
  • ?
  • LOW DOSE PB.
  • ?
  • H2RA PROKINETIC.
  • ?
  • H2RALIFESTYLE ADVICE.
  • ?

  • OTC ANTACIDS.

30
Long Term Therapy.
  • Many patients, GERD a chronic relapsing problem
    because the underlying motor abnormalities
    persist.
  • PPIs.
  • Majority of patients require PPI even in low
    doses.
  • Occasional patients may require high doses
    (double dose of PPI to control symptoms.)
  • Nocturnal acid breakthrough.

31
Surgery in GERD Nissan Fundoplication
  • 40-50 have required medical treatment after
    surgery.
  • High failure rate.
  • Mortality operator dependent.
  • Morbidity / complications 10 dysphagia
    requiring repeated esophageal dilatation.

32
Potential Risks of Chronic PPI Therapy
  • Hypergastrinemia, carcinoids
  • Gastritis, intestinal metaplasia, gastric cancer
  • Achlorhydria and loss of gastric sterility
  • Increased enteric infections, C, difficile.
  • N-nitrosamine and carcinogen risk
  • Community acquired pneumonia
  • Safety during pregnancy /lactation
  • Drug interactions.

33
Potential Risks of Chronic PPI Therapy
Hypergastrinemia, carcinoids
  • RATS
  • Elevated gastrin
  • ECL cell hyperplasia
  • ECL cell carcinoid tumors
  • HUMANS
  • Elevated gastrin
  • ECL cell hyperplasia
  • NO CARCINOID TUMORS

Species specific problem (rat) Up to 8 year
continuous use in patients (as of 2000)
34
Potential Risks of Chronic PPI Therapy Achlorhydr
ia, N-nitrosamine generation
The RISK
The REALITY
  • Increased UGI bacteria has been detected in PPI
    takers.
  • N-nitrosamine formation is also catalyzed by acid.
  • Achlorhydria permits growth of bacteria that can
    convert nitrates to nitrites to N- nitrosamine
    (carcinogen)

Data on PPI use and increased gastric
N-nitrosamine remain uncertain and the cancer
risk is speculative
35
Potential Risks of Chronic PPI Therapy
Achlorhydria, enteric infection
The RISK
The REALITY
  • Achlorhydria disables the gastric barrier to
    ingested pathogens
  • Case-control study Small increase in enteric
    infections with PPIs for 2 months.
  • Relative risk 1.6 (Cl 1.0-2.4)
  • PPPI use is independent risk of C. difficile
    diarrhea in antibiotic users.
  • PPI use OR 2.1 (Cl 1.2-3.5)
  • 3 AB OR 2.1 (Cl 1.3-3.4)
  • Medical ward OR 4.1 (Cl 2.3-7.3)

Only occasional cases of enteric infections in
patients taking PPIs have been reported.
Garcia Rodriguez LA et al. Epidemiol
19978571-4, Dial S et al CMAJ 2004 171 33-8
36
Potential Risks of Chronic PPI TherapyCommunity
acquired pneumonia
The RISK
The REALITY
  • Case-control Dutch primary case database
    1/1/95-12/31/2002.
  • 364,683 Individuals
  • 5551 1st Pneumonias
  • PPI user risk 0.60/100 pt yrs
  • Nested case control analysis to reduce
    confounding effects of indication
  • Non-PPI user risk 0.60/100 pt yrs Adjusted OR all
    1.27 (Cl 1.06-1.54)
  • Adjusted OR PPI 1.73 (Cl 1.33-2.25)
  • Gastric colonization followed by reflux and
    aspiration of gastric contents results in
    pneumonia

Association does not prove causation PPI takers
are also more likely to smoke, drink, be obese,
have GERD, and ?? (note how OR 4.08 dwindled to
1.73)

Laheji RJ et al. JAMA 2004 292 1955-60
37
Potential Risks of Chronic PPI Therapy
Safety during pregnancy/lactation
The RISK
The REALITY
  • Omeprazole crosses placenta, category C Other
    PPIs category B
  • controlled human studies no risk.
  • animal studies or, adverse fetal.
  • no adequate studies or, adverse fetal effects in
    animals at some dose.
  • evidence of fetal risk benefit gt risk
  • Evidence of fetal risk benefit lt risk
  • 1992-2001 prospective controlled evaluation of
    PPI gestational exposures
  • Omeprazole 247 births 3.6 major anomalies.
  • Lansoprazole 50 births, 3.9 MA
  • Pantoprazole 48 births, 2.1 MA
  • Controls 787 births, 3.8MA

European Network of Teratology Information
Servicesthe PPIs do not represent a major
teratogenic risk in humans
Diav-Citrin O et al,
Aliment Pharmacol Ther 2005 21 269-75
38
PPIs Adverse Events/Effects
  • Clopidogrel
  • Prospective studies of platelet aggregation.
  • Retrospepctive studies of clinical outcomes.
  • Randomized, double-blind trail of PPI vs placebo
    among clopidogrel users.
  • No difference in cardiac events, mortality
  • Significant reduction in GI events with PPI

39
GABA ß Agonist Baclofen
  • Baclofen 40mg
  • Reduced TLESRs in patients with GERD
  • Reduced esophageal acid exposure
  • Limitations
  • CNS side-effects mainly drowsiness.
  • Short half-life.


Van Herwaarden et al. Aliment Phar,acol
Ther 2002
40
New motility agent (GABA ß Agonist)Lesogaberan
  • Lesogaberan a peripheral acting GABA ß agonist.
  • Study showed 35 ? in TLESR.
  • A potential agent for treatment of GERD as
    co-therapy.

41
Summary
  • PPIs remain the standard treatment for GERD.
  • Well established to be very safe.
  • Prevalence of GERD increasing with increase in
    lower esophageal adenocarcinoma.
  • New motility drugs in development Lesogaberan.

42
THE END
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