GERD, Dyspepsia, H pylori, Gastritis, PUD, Gastric Polyps.ppt

GERD Dyspepsia Hpylori Gastritis PUD GastricPolyps Cancer JamesW SimmonsM D Overview GERDDefinition Sx sDiagnosisPathogenesisandTreatmentAtypicalManifestationsFurtherTesting ComplicationsErosiveEsophagitis Barrett sEsophagus Overview DyspepsiaDefinitionPotentialCausesTreatment Overview HelicobacterpyloriTreatmentAssociationwithotherconditions Overview Gastritis GastropathyDefinitionClassificationTreatmentRiskofCancer Overview PepticUlcerDiseaseTreatmentStrategyHpyloritestingBiopsyHighriskulcers Overview GastricPolypsTypesEtiologyMalignantpotentialAssociationwithcolonpolypsManagementSurveillance Overview GastricCancerStatisticsPhysicalsignsDiagnosisBiopsyStagingHistologictypes Overview GastricCancerLesscommoncancersRiskfactorsScreening GERD DefinitionandSx s Chronicsymptomsormucosaldamagebytheabnormalrefluxofgastriccontentsintotheesophagus Heartburnisthemostcommonsymptom Dentetal Gut 1999 44 suppl2 S1 16 GERD DefinitionandSx s Thedescription aburningfeelingrisingfromthestomachorlowerchest hasbeenfoundtobeamorereliableindicatorofpatient ssymptomsthan heartburn 40 vs 13 Carlssonetal ScandJGastroenterol 1998 10 1023 1029 SymptomsofGERD EsophagealHeartburnDysphagiaOdynophagiaRegurgitationBelching ExtraesophagealCoughWheezingHoarsenessSorethroatGlobussensationEpigastricpainNon cardiacchestpain NCCP FactorsThatCanAggravateGERD Diet Caffeine fatty spicyfoods chocolate coffee peppermint citrus alcoholPosition Activity Bending strainingExternalPressure pregnancy tightclothing GERDPrevalence 10 oftheUSpopulationexperienceheartburndaily 40 experienceheartburnmonthly Prevalenceincreasesinindustrializednations Yes USAis 1 Manyself diagnoseandtreat Kahrilasetal In Sleisenger Fordtran sGastrointestinalandLiverDisease 7thed 2002 599 622 GERDPrevalence PrevalenceandseverityincreaseswithageBarrett sesophagusanderosiveesophagitismorecommoninmen GERDPrevalence ExtremelycommoninpregnancyandincreasesasthepregnancyprogressesSeventy twopercentofpatientsintheir3rdtrimesterwillhaveGERDsx s Marreroetal BrJObstetGynaecol 1992 99 731 734 DiagnosisofGERD EmpiricTherapyReductioninsx ssuggestsGERDpHmonitoringAssosx swithreflux eval stxefficacy lackssensitivityEndoscopyEsophagitisandBarrett sBariumEsophagramSensitiveforDysphagia PathogenesisofGERD DecreasedsalivationImpairedloweresophagealsphincterpressure MostpatientswithGERDwillhavenormalpressure ImpairedtissueresistanceTransientLESrelaxationImpairedesophagealclearanceHiatalherniaDelayedgastricemptyingBilereflux AgentsThatLowerLESP HormonesSecretin Cholecystokinin Glucagon Somatostatin GastricInhibitoryPeptide VIP ProgesteroneFoodsFat Chocolate Ethanol PeppermintKahrilasetal In Sleisenger Fordtran sGastrointestinalandLiverDisease 7thed 2002 59 622 AgentsThatLowerLESP MedicationsNitrates Morphine Meperidine Dopamine CCB s Benzo s Barbiturates TheophyllineKahrilasetal In Sleisenger Fortran sGastrointestinalandLiverDisease 7thed 202 599 622 TransientLESRelaxation DentetalshowedthattransientLESrelaxationmaybeakeymechanisminthepathogenesisofGERDOccursintheabsenceofaswallowDentetal GUT 1988 29 1020 1028 HiatalHernia Decreased DisplacedLESPEnhancedTLESR sExageratesstrain inducereflux ImpairedAcidClearance HiatalHerniaImpairedEsophagealMotilityHyposalivationUnderlyingdisordersImpairedGastricEmptying increasesthepressuregradientbetweenthestomachandesophagus PathogenesisGuidingTreatment ProblemTLESR sImpairedacidclearanceEsophagealemptyingAbnormalanti refluxbarrierHyposalivation PossibleTxBaclofen investigational Lifestylemod H2RA s PPI sElevateheadofbedSurgeryGum stopsmoking bethanechol PathogenesisGuidingTreatment ProblemTissueResistanceDelayedGasticEmptyingGastricAcid PossibleTxSucralfateProkineticsAntacids H2RA s PPI s AcidSuppressiveAgents H2RA sOnlytarget1of3pathwaysthateventuallyactontheprotonpumpMoreeffectiveduringfastingandsleepNotaseffectiveforGERDsx s healingerosiveesophagitis improvingQOL orimprovingatypicalsx sCandeveloptolerance AcidSuppressiveAgents PPI sTargetstheprotonpumpitselfMoreeffectiveformeal relatedacidsecretionNotoleranceissuesEfficacyenhancedathigherdosesMoreeffectivelykeepsgastricpH 4 GERDTreatment LifestylemodificationMedicationAntirefluxsurgeryEndoscopictreatment EmpiricTherapyforGERD Ifpthastypicalsx sandhasnoalarmsx s EvidencelevelA Considerfurthertestingifempirictxunsuccessfulorpthashaslong standingdisease 1 5years CochraneDatabaseSystemRev2001 4 CD002095 EmpiricTherapyforGERD AtypicalSx s seepriorslideAlarmSx s Dysphagia Earlysatiety GIbleeding Fedeficanemia Odynophagia Vomiting Weightloss DevaultKR CastellDO AmJGastroenterology 1999 94 1434 1442 StepTherapyforGERD Lifestylemodifications OTCantacids H2RA sPrescriptiondoseH2RA sPPI s StepTherapyforGERD StepUpStartswithlifestylemodificationTendtobelesseffectiveCandelaydiagnosisFavoredbyinsurancecompanies StepDownStartswithPPICanbemoreexpensiveMaydecreasetheneedformoreexpensivetesting GERDTherapy GoalistomaintainanintragastricpHof 4PepsinandmostbileacidsandpancreaticenzymesareinactiveatapH 4 GERDTherapy Non medicalTreatmentChoices NissenFundoplicationCancauseothersignificantsideeffectsMorbidityrelatedtoexperienceofsurgeonCaneffectivelytreatGERDsx sbutamajorityofpatientsmaystillrequireanti refluxmedicationstocontrolsymptomsDoesnotworkaswellforatypicalGERDsymptoms GERDTherapy Non medicalTreatmentChoices EndoscopicSuturing EndoCinch Radiofrequencyenergyprocedure Stretta Submucosalbulkingprocedure Enteryx recalled Gatekeeper PMMA Usuallyonlyforthosewithmildersx sMaynotlastlong AtypicalGERD AtypicalmanifestationsofGERDsuchaslaryngitis chroniccough non cardiacchestpain NCCP andasthmaclearlybenefitfromacidsuppression AtypicalGERD GERDaccountsforupto40 60 ofpatientswithNCCP AcidsuppressionmayhelpevenifpHtestingisnormal Malagon CurrOpinGastroenterol 2001 17 376 380 AtypicalGERD 70 80 ofasthmaticsalsohaveGERDClues Adultonset Nofamilyhx Refluxsx sprecedetheonsetofasthma Wheezingexacerbatedbymeals exercise orsupineposition AsthmarefractorytoroutinetherapyHardingandRichter Chest 1997 111 1389 1402 Richter CleveClinJMed 1997 64 37 45 AtypicalGERD Asthma CoughsymptomsmaybetriggeredbyaspirationofgastricrefluxateorbystimulationoftheEsophageal BronchialReflexviatheVagusnerveIrwinandRichter AmJGastroenterol 2000 95 suppl8 S9 S14 AtypicalGERD EmpirictreatmentwithaPPIforatypicalGERDisagoodoptionsincethesensitivityofpHtestingislowerTreatmentoftenrequiresBIDdosingandatleast2 3monthstoobtainagoodresponse WhentodoFurtherTesting 24 hrpHMonitoringPPIfailures pre antirefluxsurgeryEndoscopyAlarmsymptoms excludeBarrett sBariumEsophagramDysphagiaEsophagealManometrySuspecteddysmotility 24 HourpHMonitoring Measurespattern frequencyanddurationofrefluxepisodesCancorrelatesymptomswithrefluxepisodesMostusefulwhenempirictherapyhasfailedandendoscopynormal Endoscopy AlarmsymptomsPre antirefluxsurgeryLong standing frequent orseveresymptomsTodetectandmanageEEandBarrett sPatientreassurance BariumEsophagram MostsensitivetoolforevaluationofdysphagiaCanidentifyasubtlestricturenoteasilynoticedonendoscopyMayidentifyimpairedmotilityandhiatalhernia EsophagealManometry CanidentifyesophagealdysmotilityMeasuresLESpressureCannotevaluate diagnoseGERD GERDComplications Thereisanassociationbetweenalarmsymptomsandcomplicationsoferosiveesophagitis EE andpepticstrictureWoetal AmJGastroenterol 1999 94 2603 Abstract104 GERDComplications However typicalGERDsymptomfrequencyandseveritydoNOTpredictthepresenceofEE Chronicacidexposure esophagitiscanleadtoesophagealstrictureand orBarrett sesophagus Venablesetal ScandJGastroenerol 1997 32 965 973 RiskFactorsforErosiveEsophagitisandBarrett sEsophagus ErosiveEsophagitisGERD 1yearMalegenderRegularETOHSmoking currentorprevious Barrett sAge 50yearsWhiterace4 1Men WomenEarlyageatonsetofsx s longerduration ErosiveEsophagitis LAClassificationGradeA 1isolatedmucosalbreaks1isolatedmucosalbreaks 5mmlongGradeC 1mucosalbreaksbridgingthetopsoffolds 75 ofcircumference ErosiveEsophagitis TreatmentPPI shavebeenshowntobemoreeffectiveinhealingEEandinmaintainingremission ErosiveEsophagitis PepticStrictureOccursin7 23 ofpatientswithuntreatedesophagitis DysphagiaisusuallythemostcommonsymptomMayrequiredilationChronicPPItherapyrequiredtodecreasetheriskofstricturereformation Murphyetal Endoscopy 1998 30 367 370 Barrett sEsophagus Definition Achangeintheesophagealepitheliumofanylengththat Canberecognizedatendoscopy Isconfirmedbybiopsytohaveintestinalmetaplasia ExcludesintestinalmetaplasiaofthecardiaSampliner AmJGastroenterol 2002 97 1888 1895 Barrett sEsophagus Columnar linedmucosa Gastricfundictype stomach Junctionaltype betweenesophagusandstomach Intestinalmetaplasia Gobletandmucoussecretingcells Dysplasiaandcancerarealmostinvariablyassowithintestinalmetaplasia Barrett sEsophagus Spechler NEJM 2002 346 836 842 Barrett sEsophagus PremalignantConditionPrevalenceofBarrett sincreasesassymptomdurationincreasesProlongedacidandbileexposurecomparedtopt swithGERDHigherprevalenceofHiatalHernia Barrett sEsophagus AggressiveacidsuppressioncandecreasebothacidandbilerefluxPatientswithchronicGERDsx sarethosemostlikelytobenefitfromendoscopytoruleoutBarrett sOnce in a lifetimeendoscopytoexcludeBarrett s Barrett sEsophagus ClassificationShortsegment 3cmaboveGEjxn morelikelytohaveintestinalmetaplasia Barrett sEsophagus Esophagealadenocarcinomadevelopsinapproximately0 5 ofpatientswithBarrett sesophaguseachyear Upto40 ofpatientswithesophagealadenocarcinomahavenohistoryofGERD Approx30 foldincreaseriskofcanceroverthegeneralpopulation Spechler NEJM 2002 346 836 842 Barrett sEsophagus TreatmentoptionsMedicaltherapyAntirefluxsurgeryShouldyoutreatanasymptomaticpatientwithBarrett s Barrett sEsophagus Barrett sepitheliumislesssensitivetoacid sopatientswhoreportadecreaseinsx safterlong standingGERDmaybedevelopingBarrett sNOANTIREFLUXTHERAPYHASBEENSHOWNTOREDUCETHERISKOFADENOCARCINOMAORTHEEXTENTOFBARRETT S Barrett sEsophagus Sowhytreat ProlongedacidexposurehasbeenassociatedwithcellproliferationinBarrett sesophagusHowaggressivelydoyoutreat Controversial Barrett sEsophagus ASA NSAIDs multiplestudieshaveshownaprotectiveassociationbetweenASA NSAIDsandesophagealcancerEpithelialexpressionofCOX 2hasbeendetectedin100 ofhigh gradedysplasiaoradenocarcinoma Morrisetal AmJGastroenterol 2001 96 990 996 Barrett sEsophagus SurveillanceSpechler NEJM 2002 346 836 842 Barrett sEsophagus Managementoptionsforhigh gradedysplasiaEsophagectomyEndoscopicablativetherapiesEndoscopicmucosalresectionIntensivesurveillanceuntilactualcancerisfound Barrett sEsophagus EndoscopicablativetherapiesPhotodynamicTherapy PDT InjectphotosensitizingdrugDeliverredlaserlighttotargetedcellsCellscontainingthedrugaredestroyedUsedinpastforesophagealcancerpatientswithdifficultyswallowing Barrett sEsophagus CryotherapyElectrocauteryLaser Argon Yag Argonplasmacoagulation highfrequencycurrentdeliveredbyionizedargongas Barrett sEsophagus RadiofrequencyablationSizingballoonsdeterminediameteroflumentobeablatedA3cmballoon basedelectrodedeliversa 1secburstofenergywhichshouldcontroldepthofinjuryVideo Barrett sEsophagus DangerofablativetherapiesAllbutPDTareinvestigationalNodocumentationofimprovedoutcomesyetPossibilityofleavingsomedysplastictissueundernewsquamousmucosathatwouldnotbedetected Barrett sEsophagus Barrett sEsophagus EndoscopicMucosalResectionVideodemonstration http mayoresearch mayo edu mayo research wang lab endoscopic cfmSaferresectionofdysplastictissueorhardtoresectlestionsProvidesatissuefordiagnosisanddepthofinvasion Barrett sEsophagus Barrett sEsophagus Nodirectevidencethatsurveillancechangesoutcomes Dyspepsia PainordiscomfortintheupperabdomenwithoutheartburnorregurgitationBloating indigestion fullness nausea earlysatietyApprox40 willhaveanorganiccause 60 willbefunctional Dyspepsia PotentialcausesPUDGERDGastricCancerMotilitydisorderMalabsorptionHpylori Dyspepsia SomebelievethatwiththehighrateoforganicdyspepsiaendoscopyshouldbeperformedbeforeanytreatmentisstartedNolikelyadvantagetoearlyendoscopyintheabsenceofalarmsx s Dyspepsia Treatment Ifage 45yearsandnoalarmsymptomsmaydonon invasivetestingforHpyloriandif proceedtodirectlytoeradicationtreatmentIfHpylori maytrylifestylechangesorPPI ProkineticIfunsuccessfulproceedtoendoscopy Patientswithco existingpsychiatricsymptomsmaybenefitfrompsychiatricevaluationandtreatment NoninvasiveHpyloriTesting SerumIgGantibody highfalse rateUreaBreathTest canusetomonitorresponsetotreatmentStoolAntigenTest usefulforinitialdiagnosisPositiveidentificationofactiveHpyloriinfectioncansignificantlydecreaseinappropriateantibioticusage Dyspepsia AlthoughroleofHpyloriindyspepsiaisunclear manyprefertotreatPreventprogressionofgastritistoulcerdiseaseLinktogastricadenocarcinoma Hpylori Treatment TripleTherapyPPI Amoxicillin1000mgbid Clarithromycin500mgbid Metronidazole500mgbidTreatfor7 10days Hpylori Treatment QuadrupleTherapyPPIbid Bismuth525mgqid Metronidazole250mgqid Tetracycline250mgqidTreatfor14daysUsedinareasofhighresistancetoClarithromycinGotoTIDdosingifcomplianceisanissue HelicobacterpyloriInducedGastritis PrevalenceinUSisincreasingStronglinktogastriccancerandMALTlymphomaControversialroleinNSAID inducedulcersControversialroleinfunctionaldyspepsia Cochranereviewsuggestsonly9 improvementwitheradicationUnclearrelationshipwithGERD Helicobacterpylori ResponsibleforthemajorityofduodenalandgastriculcersLabeledasaTypeI definite carcinogenin1994 Helicobacterpylori Japanesestudywith1526subjectsshowed 2 9 ofHpylori subjectsdevelopedgastriccancer0 ofHpylori patientsdevelopedgastriccancer0 ofHpylori subjectswhoweretreatedtoeradicateHpyloridevelopedgastriccancerUemura Okamoto Yamamoto NEJM 2001 345784 789 Helicobacterpylori IncreasedriskofMALTlymphoma72 98 ofpatientswithMALTlymphomahave HpyloriEradicationinducesregressionoflymphomain70 80 ofcasesSuerbaum NEJM 2002 347 1175 1186 HelicobacterpyloriInducedGastritis PathogenesisCausescontinuousgastricinflammationAntralpredominantgastritis mostcommon duodenalulcersCorpuspredominantgastritis gastricatrophy gastriculcers intestinalmetaplasia gastriccancerSuerbaum NEJM 2002 347 1175 1186 Helicobacterpylori Suerbaum NEJM 2002 347 1175 1186 Hpylori GERD MultiplestudiesshownoeffectofHpylorieradicationonGERDsx sandmultiplestudiesshowaworseningofGERDsx safterHpylorieradicationPatientswhoareHpylori mayhaveabetterresponsetoPPItherapyforGERD Vakiletal AmJGastroenterol 2000 95 2438 Abstract96 Gastritis Gastropathy Gastritis EpithelialdamageandregenerationwithassociatedinflammationGastropathy Epithelialdamageandregenerationwithoutassociatedinflammation Causes GastritisInfectiousAutoimmuneHypersensitivity GastropathyIrritants NSAIDS ETOH BilerefluxHypovolemia Gastritis Gastropathy Gastritis Gastropathy Gastritis Gastropathy DiagnosisBiopsy Gastritis Gastropathy Gastritis Gastropathy TreatmentRemoveoffendingagentPreventfurtherdamagewithantisecretorytherapyPreventstressirritationinthoseatrisk Gastritis Gastropathy Atrophicgastritis intestinalmetaplasiaIncreasedriskforcancerNoagreeduponsurveillancestrategyifanyConsidersurveillanceifany FamHxordysplasia PepticUlcerDisease PepticulcershavevariablebehaviorPriorulcerhistorytendstopredictfuturebehaviorUsuallycontinuetorecuruntiloffendingagentisremoved Hpylori NSAIDS PepticUlcerDisease TreatmentstrategyTreatHpyloriifpresentAntisecretorytherapyRemoveoffenders Etoh smoking NSAIDSNoevidencethatstressorcertaindietarychangesinfluencetreatmentorcourse PepticUlcerDisease MaynotneedtocontinueantisecretorytxaftertreatingHpyloriIfcomplicated continueantisecretorytxuntildocumentedhealing PepticUlcerDisease HpyloritestingCanbefalselynegativeinthepresenceofPPI antibioticsorbismuthCanconfirmwithhistologyofantrumbiopsy PepticUlcerDisease GastriculcersneedtobebiopsiedatthemargintoevalforcancerPPI sslightlybetterathealingcomparedtoH2RA sCandiscontinuetherapyin4 6weeksinanuncomplicated asymptomaticpatient ifHpylori IfHpylori canstoptherapyaftertreatingifsmall 1cm uncomplicated andasymptomatic PepticUlcerDisease Ifcomplicated continueantisecretorytxuntildocumentationofHpylorieradicationIfulcersarerecurrent mayneedtocontinueantisecretorytxMayneedtodoworkupforrecurrentulcers includingevalforgastrinoma PepticUlcerDisease HighriskulcersPatientfromendemicareaAbsenceofduodenalulcerUlcer 2 3cmNoNSAIDuseNoprotractedulcerhistory GastricPolyps UsuallyfoundincidentallyRarelycausesymptomsCanhavemalignantpotential Gastricpolyps Studyof 13 000patientsover4yearswhounderwentEGD 157hadgastricpolyps 1 2 Hyperplastic 75 6 adenomatous 6 6 inflammatory 17 8 Noneweremalignant Archimandritis A Spiliadis C Tzivras M etal ItalJGastroenterol1996 28 387 GastricPolyps Studyover20yearsof4 852patientswhohadpolypsremoved Hyperplastic 75 3 adenomatous 10 othermixed7 2 weremalignant Stolte M Sticht T Eidt S etal Endoscopy1994 26 659 GastricPolyps EtiologyIrritationHpyloriPPI s Familialsyndromes GastricPolyps MalignantpotentialUpto10 inadenomatouspolypsSmallriskinhyperplasticpolyps upto2 insomestudies invasivecancerrarePotentialincreasesassizeincreases GastricPolyps FamilialadenomatouspolyposisNodefiniteriskofgastriccancerDefiniteriskofduodenalandperiampullaryadenocarcinomas Offerhaus GJ Giardiello FM Krush AJ etal Gastroenterology1992 102 1980 GastricPolyps PeutzJeghersHamartomatouspolypsTendencytoprogresstoadenocarcinoma GastricPolyps QuestionableassociationbetweengastricpolypsandcolonpolypsSomerecommendcolonoscopyatleastoncewhengastricpolypsarefound GastricPolyps ManagementEradicateHpyloriifpresentRemovalforpathologyBiopsypriortopolypectomy GastricPolyps Surveillance Allpolypsorjustadenomatous Appropriateinterval Every3 5years Soonerifany FamHxoradenomatouspolyps GastricPolyps GastricCancer Estimated21 860Americansdxwithgastriccancerin200513 510men 8 350womenEstimated11 560deathsin2005 2 3dxatage 65 1 100lifetimechanceofdevelopinggastriccancer 2005CancerStatistics AmericanCancerSociety GastricCancer Morecommoninunder developedcountriesSecondleadingcauseofcancerdeathworldwide 700 000deathsin2002GastriccancerinAmericais25 ofwhatitwasin1930Lesssalted smokedfoods Moreantibioticusage 2005CancerStatistics AmericanCancerSociety GastricCancer GastricCancer