10/31/2013
Let’s talk lunch… from which side did you eat from today?
Ate two plates of food Grazed like a cow Two Common UGI Presentations: Loved the cheeseburger Chose tuna fish with garden Piled high onions and hot salad Gerd and Dysphagia peppers on my 8” steak Ate fruit salad with Greek hoagie yogurt and toasted pecans WHERE DO WE GO FROM HERE? Took a 45” lunch nap on the Took a 30” walk after lunch chaise lounge Limited caffeine to two cups Took PPI after lunch
TODAY’S Objectives: WHY I CHOOSE THIS TOPIC? REVIEW AND UNDERSTAND
GERD- Number #1 GI diagnosis/condition for outpatient visits Vital Statistics Diagnostic and Therapeutic Several potentially, serious complications can occur if not treated Test Your Knowledge Procedures early and effectively, I.E. Dysphagia… Normal/Abnormal Anatomy & Treatments (medical and non- Costly to work productivity and national healthcare expenditure Pathophysiology medical) Often preventable with first-line educational strategies but tend Clinical Findings: Signs and Outcomes and Complications not be very effective Symptoms, H & PE VA Case Study Summary Long-term use and adverse effects may be underestimated Differential Diagnosis When should PCP refer? Test Your Knowledge
GERD VITAL STATISTICS TESTING YOUR KNOWLEDGE #1
Prevalence-19 million in the U.S.; affects 20% of adults, at least Dyspepsia is defined as: once weekly, 10% with daily symptoms 1. Pain always associated with adult onset appendicitis Total Costs: > 24 Billion in 2000 according to the AGA, i.e. 25% 2. Syndrome of burping, nausea with eating, bloating and upper drugs, 15% healthcare (visits and workups) and 60% from abdominal pain productivity losses( while at work or sick time usage)www.medscape..com/viewarticle/562736_print 3. Painful swallowing often exhibited with scleroderma 4. A term that describes the lining of the duodenum 5. Esophageal peristalsis .
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TESTING YOUR KNOWLEDGE #2 TEST YOUR KNOWLEDGE #3
Helicobacter Pylori is when: Dysphagia is defined as: 1. Acid levels in the lower esophagus are > 2 1. A person is completely satisfied with the meal they just 2. A condition in which people feel full after a few bites of food consumed 3. Type of stomach bacteria that may be a precursor to bleeding 2. A specialized UGI test that evaluates a person for esophageal ulcers and gastric cancer candidiasis 4. A bacteria which people may get from a lactase deficiency 3. When your patient experiences difficulty swallowing food, water and/or pills 5. An UGI virus transmitted in childhood, prevalent in S.E. Asia 4. Always a consequence of a stroke
5. A procedure that dilates the lower part of the esophagus
TEST YOUR KNOWLEDGE #4 TEST YOUR KNOWLEDGE #5
Barrett’s Esophagus is: Which of the following test would be most appropriate to evaluate 1.A physician who described a twisted esophageal appearance staging associated with recently diagnosed esophageal cancer? 2.A condition that can be diagnosed by an UGI series 1. Barium Swallow 3.Migration of gastric intestinal metaplasia into the lower esophagus 2. Laproscopic fundoplication and a potential risk for esophageal cancer 3. Gastric PH 4.Often seen during the 3rd Trimester of Pregnancy 4. Chest CT 5.Long-term GERD exposure, increasing risk for peptic stricture 5. EGD/EUS
TEST YOUR KNOWLEDGE# 6 A & P OF THE ESOPHAGUS
True or False: There is an increased risk for the following on PPI’s: Muscular Tube 1. Increased cardiovascular risk with Plavix (Clopidogrel) Peristalsis Transporter 1.Bone fractures and C. Difficile Cellular composition 2.Enteric infections, pneumonia and acute interstitial nephritis Lower Esophageal Sphincter(LES)
http://www.keckhospitalofusc.org/services/weight-loss-and-digestive- disorders/esophageal-disorders/anatomy-of-the-esophagus
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ANATOMICAL PERSPECTIVE OF GERD PATHOPHYSIOLOGY OF GERD
Antireflux barrier (GEJ) dependent on LES pressure (normal=10- 30 mm hg), intra-abdominal sphincter location and extrinsic compression of the sphincter by crural diaphragm Most Reflux episodes occur during transient relaxation of the LES, triggered by gastric distension by a vagovagal reflex. Subset of patients have an incompetent LES pressure(<10 mm hg)->increased acid reflux, worse in supine position or by increased lifting/bending. With severe erosive GERD, 50 % have a hypotensive sphincter
OTHER PATHOPHYSIOLOGIC FACTORS: Other Contributing Factors: GEJ competence is also affected by: the cardio
esophageal junction, action of diaphragm and gravity Hiatal Hernia (upright position) Irritant Effects of Refluxate Weight gain, fatty foods, caffeinated or carbonated Abnormal Esophageal Clearance beverages, alcohol, smoking, and illicit drugs Delayed Gastric Emptying Prescribed drugs that lower the LES pressure: anticholinergic, antihistamines, tricyclic antidepressants, CA channel blockers, progesterone, and nitrates.
http://www.keckhospitalofusc.org/services/weight-loss-and-digestive-disorders/esophageal-disorders/anatomy-of-the- esophagus
CLINICAL SYMPTOMS OF GERD: OTHER MANIFESTATIONS :
How is it defined? Stomach acid backwashes into esophagus Patients with mild GERD may get severe esophagitis and when esophageal muscular actions and protective mechanisms fail Dysphagia occurs in 1/3 of patients with erosive esophagitis, abnormal esophageal peristalsis or development of a stricture HALLMARK SYMPTOMS: Dyspepsia (heartburn and regurgitation), and sometimes dysphagia Other symptoms may include: odynophagia (painful swallowing) nausea, vomiting, chest pain, chronic cough, laryngitis, chronic Symptoms usually occur 30-60” after eating, bending over or throat clearing, voice changes, hoarseness, asthma, SOB, when pneumonia, bronchitis, OSA, dental erosions and sensitivity, reclining. sinusitis, pharyngitis and increased salivation (water brash) When heartburn is predominant, GERD 80% sensitivity, 70% http://www.keckhospitalofusc.org/services/weight-loss-and-digestive-disorders/esophageal-disorders/anatomy-of-the- esophagus specificity though severity is not always correlated with severity of mucosal injury
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UGI ALARM SYMPTOMS/OTHER PYROSIS ETIOLOGIES Unexplained weight loss, change in appetite, early satiety, hematemesis, epigastric and/or abdominal pain, melena, hematochezia, IDA History of neurological diseases like stroke, MS, autoimmune conditions like collagen vascular disease, diabetes, and thyroid disease. SH: smoking, drinking, illicit drugs, NSAID use. FH: cancer of tongue, throat, esophagus, stomach, small intestine, gallbladder, liver and/or pancreas; PMH: PUD, UGI surgeries PE: Pertinent + of ENT, LAD, Thyroid, Lungs/Heart, Abdomen www.jwatch.org/jg200503160000005/2005/03/16/alarm-symptoms-and-upper-gi-mal...
DIFFERENTIAL DIAGNOSIS DIAGNOSTIC AND THERAPEUTIC TESTING Achalasia Helicobacter Pylori Infection Acute and Chronic Gastritis Hiatal Hernia Heliobacter Pylori IgG Barrett’s Esophagus (BE) Esophageal Candidiasis Barium Swallow/UGI/Bernstein Test Cholelithiasis Reflux/erosive esophagitis Esophageal Manometry Coronary Artery Atherosclerosis Intestinal Malrotation Ambulatory 24-hour pH monitoring Esophageal Cancer Intestinal Motility Disorders EGD Esophageal Motility Disorders Irritable Bowel Syndrome UEUS Esophageal and Gastric Ulcers Schatzki’s Ring
HELICOBACTER PYLORI BERNSTEIN TEST
Definition: Definition: NGT is temporarily placed with mild hydrochloric acid If lab naïve, send patient for serum H. Pylori IgG or obtain H. followed by saline; process may be repeated several times Pylori urea breath test. However, once IgG test is positive, you Indication: reproduce GERD symptoms to differentiate from can only confirm eradication by the H. Pylori urea breath test cardiac symptoms. (simple/inexpensive) or much more expensive testing via EGD antral/duodenal biopsies. Treat active infection by administering the triple/quadruple protocol.
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UPPER GI SERIES/BARIUM SWALLOW: ESOPHAGEAL MANOMETRY Definition: Definition Indications: Evaluation of non-cardiac chest pain or esophageal Problems it can identify: ulcers, abnormal growths, scars or symptoms not diagnosed under EGD or after GERD has been strictures, hiatal hernia, diverticula, and esophageal varices. excluded, Help identify causes of: abdominal pain, nausea, vomiting, Achalasia or non-obstructive dysphagia, preoperative/postoperative swallow difficulties, GERD, unexplained weight loss corrective surgery, prior to esophageal pH monitoring to assess Preparation: NPO 8 hours prior and then drink copious fluids post- location of LES for proper electrode placement, and evaluation of procedure esophageal motility problems associated with systemic diseases Contraindications:
ESOPHAGEAL GASTRIC 24 HOUR ESOPHAGEAL PH DUODENOSCOPY: MONITORING Definition EGD Definition Indications: Diagnostic evaluation for S/SX suggestive of UGI Indications: to identify causes of various UGI symptoms like: disease, e.g., dyspepsia, dysphagia, non-cardiac chest pain, heartburn not explained by EGD, ineffective medication results or recurrent emesis, surveillance four UGI cancer in high-risk atypical symptoms (i.e. non-cardiac chest pain, chronic cough, settings (e.g.. BE, polyposis syndromes), rule out H. Pylori asthma or throat symptoms) Infection, malabsorption syndromes, neoplasms, infections, Placement: small probe inserted via nostril and positioned near retrieval of foreign bodies, control of hemorrhage, dilatation or LES. Probe via belt monitor or new, wireless device (placed via stenting of stricture, ablation of neoplasms, gastrostomy EGD) transmits 24 hours of pH information. placement, screening for esophageal varices Preparation
UPPER ENDOSCOPIC ULTRASOUND PRIMARY CARE TREATMENT (UEUS) APPROACH: Stepwise Definition: combines endoscopy with ultrasound technology to obtain images/information about UGI tract and surrounding tissue/organs. Goals: Small ultrasound transducer is installed into tip of EGD scope to get high -Control symptoms quality, ultrasound images of organs around esophagaus, stomach, and - Heal esophagitis pancreas. Doppler Ultrasound studies vessel blood flow and with special ultrasonic guidance, can pass a special needle to obtain samples -Prevent recurrent esophagitis/other complications of enlarged lymph nodes or suspicious tumors, called FNA (fine needle Treatment is based on: diet and lifestyle modifications, control of biopsy) gastric acid secretion with antacids, H2 Blockers and/or PPIs and/or Uses: Staging of esophageal, stomach and pancreatic cancers/cysts, corrective antireflux surgery chronic pancreatitis, evaluating bile duct abnormalities, gallbladder and liver.
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Treatment … LIFESTYLE MODIFICATIONS
80% have recurrent, but non-progressive GERD, controlled with Weight loss meds Avoiding large meals and instead eating small frequent meals 20% experience a progressive form, such as strictures/Barrett Waiting 3 hours before lying down Esophagus. Corrective surgery should be considered early on to Elevating head of bed 8 inches avoid serious sequelae of the disease with serious consequences Avoiding GERD food offenders ACG 2005 guidelines show decreased distal acid exposure with these changes but little data confirms it.
PHARMACOLOGIC THERAPIES ANTACIDS-MILD TO MODERATE FIRST LINE FOR MILD GERD SYMPTOMS: Generic/Chemical Name Trade Name -Antacids- taken after meals and at bedtime -Aluminum hydroxide and magnesium carbonate Gaviscon FIRST LINE AGENTS (MILD-MODERATE DISEASE) -Aluminum hydroxide and magnesium hydroxide Maalox, -mild-moderate symptoms, grades 1-II esophagitis Mylanta H2 receptor antagonists: ranitidine (Zantac), cimetidine -Calcium Carbonate Rolaids, Tums (Tagamet), famotidine( Pepcid), and nizatidine (Axid) Side Effects: Calcium Carbonate->constipation, acid 70-80% effective only for mild esophagitis and for preventing relapse rebound(increases acid production), Magnesium-containing antacids->diarrhea, with renal disease, elevates serum magnesium, www.mayoclinic.com/health/gerd/DS00967/DSECTION=treatments- aluminum-containing->constipation, increase aluminum levels in and-... renal disease www.mayoclinic.com/health/gerd/DS00967/DSECTION=treatments- and-...
H2 BLOCKERS/PPIS PROTON PUMP INHIBITORS: PP1S H2 Blockers (takes 30-90” to work and may last several hours) Examples: Examples: Famotidine (Pepcid), Cimetidine (Tagamet), Ranitidine (Zantac), Nizatidine (Axid) Omeprazole (Prilosec), Esomeprazole (Nexium), Lansoprazole (Prevacid), Rabeprazole (Aciphex), Pantoprazole (Protonix), and Potential SE’s: Dexlansoprazole (Kapidex) -Pepcid and Zantac: headache Side Effects: Rare but may see headache, diarrhea, constipation, -Tagamet- Rare diarrhea, dizziness, rashes or headache nausea or itching. Long-term use, infections and bone fractures -Axid-rare www.mayoclinic.com/health/gerd/DS00967/DSECTION=treatments-and-... www.mayoclinic.com/health/gerd/DS00967/DSECTION=treatments- and-...
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POTENTIAL COMPLICATIONS OF GERD REFLUX ESOPHAGITIS
Reflux/Erosive esophagitis/Esophageal Stricture Barrett’s Esophagus (BE) Esophageal Adenocarcinoma Esophageal Motility Disorders (i.e. Achalasia)
ESOPHAGEAL STRICTURE Barrett’s esophagus HTTP://WWW.MERCKMANUALS.COM/MEDIA/PROFESSIONAL/THUMBNAILS/
ESOPHAGEAL DYSMOTILITY ACHALASIA ENDOSCOPICALLY
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ACHALASIA TREATMENT Achalasia treatment cont’d
Primary Goal: Symptom Relief since can’t be cured Pneumatic Dilation: Standard of Care: Forceful distension of the Medications: Smooth muscle relaxants (isosorbide dinitrate, LES to 3 cm with disruption of the circular muscle layer is required nifedipine); non-cardiac chest pain (antireflux therapy, even in for symptomatic relief Response rates vary from 50-93%. absence of typical gerd, Surgical: Botulinum toxin injection (Botox): Potent inhibitor of acetylcholine Heller Myotomy release from nerve terminals. Injected into LES in 4 quadrants; May be good alternative for poor surgical candidates: Disadvantage: emedicine.medscape.com/article/174783-treatment high costs/repeated therapeutic sessions
VA CASE STUDY WHAT WOULD YOU DO NEXT?
August 2008 Mr. O’Conner, a 57yo veteran presents for initial GI visit with a 10 year hx intermittent acid reflux and regurgitation, taking once daily PPI and occasional OTC tums, recently c/o his symptoms getting worse. PMH: Morbid Obesity BMI-36, OSA-on CPAP, poorly controlled NIDDM, +ETOH/Tobacco Abuse x30 years and HTN. FH: Father died from ESLD at age 62.
NPS next move… GERD RADIOGRAPH Diagnostics History/PE If answers no to historical ?’s, Any dysphagia, Order EGD r/o esophagitis, odynophagia, early satiety, gastritis, ulcers, erosions, H hematemesis, melena, Pylori antral/duodenal biopsies. epigastric or abdominal pain, h/o PUD, H pylori infection, Treatment: NSAID use, UGI, EGD or 1.Increase PPI bid UGI surgeries. 2.Avoid GERD Offenders 3.Quit smoking/ETOH, gradual weight loss
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VA CASE STUDY CONt’d NPS NEXT MOVE…
MR. O’CONNER RTC 3 YEARS LATER (2011) DIAGNOSED Obtain EGD with possible UEUS for BE surveillance and WITH BE: P/W PROGRESSIVE FOOD DYSPHAGIA AND evaluate for possible esophageal stricture/adenocarcinoma UNEXPLAINED WT LOSS of 25 LBS. HE’S BEEN COMPLIANT If histology positive for adenocarcinoma of esophagus, will obtain WITH BID PPI. PET CT and refer to medical, surgical and radiation oncology for consultation. WHAT DO YOU DO NEXT?
SUMMARY: WHEN THE PCP SHOULD DISTAL ESOPHAGEAL STRICTURE REFER? UGI Alarm Signs: Unexplained weight loss, nausea/vomiting, hematemesis, dysphagia, odynophagia, uncontrolled or refractory GERD after 2- 3 months of PPI therapy, epigastric or abdominal pain, melena, early satiety/ Abnormal BS, UGI or CT findings Chronic GERD (5-10 years duration)
TESTING YOUR KNOWLEDGE #1 TESTING YOUR KNOWLEDGE #2
Dyspepsia is defined as: Helicobacter Pylori is when: 1. Pain always associated with adult onset appendicitis 1. Acid levels in the lower esophagus are > 2 2. Syndrome of burping, nausea with eating, bloating and upper 2. A condition in which people feel full after a few bites of food abdominal pain 3. Type of stomach bacteria that may be a precursor to bleeding 3. Painful swallowing often exhibited with scleroderma ulcers and gastric cancer 4. A term that describes the lining of the duodenum 4. A bacteria which people may get from a lactase deficiency 5. Esophageal peristalsis 5. An UGI virus transmitted in childhood, prevalent in S.E. Asia
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TEST YOUR KNOWLEDGE #3 TEST YOUR KNOWLEDGE #4
Dysphagia is defined as: Barrett’s Esophagus is: 1. A person is completely satisfied with the meal they just 1.A physician who described a twisted esophageal appearance consumed 2.A condition that can be diagnosed by an UGI series 2. A specialized UGI test that evaluates a person for esophageal 3.Migration of gastric intestinal metaplasia into the lower esophagus candidiasis and potential risk for esophageal cancer 3. When your patient experiences difficulty swallowing food, water 4.Often seen during the 3rd Trimester of Pregnancy and/or pills 5.Long-term GERD exposure, increasing risk for peptic stricture 4. Always a consequence of a stroke 5. A procedure that dilates the lower part of the esophagus
TEST YOUR KNOWLEDGE #5 TEST YOUR KNOWLEDGE# 6
Which of the following test would be most appropriate to evaluate True or False: There is an increased risk for the following on PPI’s: staging associated with recently diagnosed esophageal cancer? 1. Increased cardiovascular risk with Plavix (Clopidogrel) 1. Barium Swallow 1.Bone fractures and C. Difficle 2. Laproscopic fundoplication 2.Enteric infections, pneumonia and acute interstitial nephritis 3. Gastric PH 4. Chest CT 5. EGD/EUS
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ADDITIONAL REFERENCES references cont’d
Helicobacter pylori infection and treatment-Up-to-date. Retrieved Esophageal pH test for heartburn or GERD-WebMD. Retrieved from http://www.uptodate.com/contents/helicobacter-pylori- from http://www.webmd.com/heartburn-gerd/guide/esophageal- infection-and-treatment-beyon... ph-test Upper GI Series-National Digestive Disease Information. Esophagealgastricduodenoscopy. Retrieved from Retrieved from http://emedicine.medscape.com/article/1851864-overview http://digestive.niddk.nih.gov/ddiseases/pubs/uppergi/ - Esophageal Manometry. Retrieved from http://emedicine.medscape.com/article/1891791-overview
THANK YOU FOR YOUR QUESTIONS AND ANSWERS ATTENTION ! Contact Information: [email protected]
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