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 . 1 10/31/2013 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 2 10/31/2013 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 3 10/31/2013 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. 4 10/31/2013 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,