GERD and Peptic ulcer disease

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

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

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

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

10. Alarms Dysphagia Early satiety GI bleeding Odynophagia Vomiting Weight loss Iron deficiency anemia

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

12. Trial of Medications If PPI response inadequate despite maximal dosage Confirm diagnosis EGD 24 hour pH monitor

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

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

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

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 400mg twice daily 400-800mg twice daily Tagamet Famotidine 20mg twice daily 20-40mg twice daily Pepcid Nizatidine 150mg twice daily 150mg twice daily Axid Ranitidine 150mg twice daily 150mg twice daily zantac

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 40mg daily 20-40mg daily Nexium Omeprazole 20mg daily 20mg daily Prilosec Lansoprazole 30mg daily 15-10md daily Prevacid Pantoprazole 40mg daily 40mg daily Protonix Rabeprazole 20mg daily 20mg daily Aciphex

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

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 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

30. Complications Erosive esophagitis Responsible for 40-60% of GERD symptoms Severity of symptoms often fail to match severity of erosive esophagitis

31. Complications Esophageal stricture Result of healing of erosive esophagitis May need dilation

32. Complications Barrett’s Esophagus Columnar metaplasia of the esophagus Associated with the development of adenocarcinoma

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

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 Esophagectomy High-grade dysplasia Esophagectomy or ablation Low-grade dysplasia Treat GERD EGD surviellence

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 • 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 • 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 • EGD • Biopsy • Treatment • Stop NSAIDs • PPI • Treat H pylori • Repeat EGD to check for healing • Surgery • Malignancy • Bleeding • Perforation • Obstruction

45. Questions?