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Gastro esophageal Reflux Disease My room My mess ENT Central emergency
Gasroesophageal reflux disease (GERD)
 
Objectives <ul><li>Definition of GERD </li></ul><ul><li>Epidemiology of GERD </li></ul><ul><li>Pathophysiology of GERD </l...
Definition <ul><li>American College of Gastroenterology (ACG) </li></ul><ul><ul><li>Symptoms OR mucosal damage produced by...
Physiologic vs Pathologic <ul><li>Physiologic GERD </li></ul><ul><li>Postprandial </li></ul><ul><ul><li>Short lived </li><...
Epidemiology <ul><li>About 44% of the adult population have heartburn at least once a month </li></ul><ul><li>14% of adult...
 
 
Pathophysiology <ul><li>Primary barrier to gastroesophageal reflux is the lower esophageal sphincter </li></ul><ul><li>LES...
Clinical Manisfestations  <ul><li>Most common symptoms </li></ul><ul><ul><li>Heartburn—retrosternal burning discomfort </l...
 
Clinical Manisfestations <ul><ul><li>Dysphagia—difficulty swallowing </li></ul></ul><ul><ul><li>Other symptoms include: </...
Extraesophageal Manifestations of GERD <ul><li>Pulmonary </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Aspiratio...
Potential Oral and Laryngopharyngeal Signs Associated with GERD <ul><li>Edema and hyperemia of larynx </li></ul><ul><ul><l...
Pathophysiology of Extraesophageal GERD
 
Diagnostic Evaluation <ul><ul><li>If classic symptoms of heartburn and regurgitation exist in the absence of “alarm sympto...
Alarms <ul><ul><li>Alarm Signs/Symptoms </li></ul></ul><ul><ul><ul><li>Dysphagia </li></ul></ul></ul><ul><ul><ul><li>Early...
When to Perform Diagnostic Tests <ul><li>Uncertain diagnosis </li></ul><ul><li>Atypical symptoms </li></ul><ul><li>Symptom...
Diagnostic Tests for GERD <ul><li>Trial of H2RA/PPI </li></ul><ul><li>Barium swallow </li></ul><ul><li>Ambulatory pH monit...
Trial of Medications <ul><li>H2RA or PPI </li></ul><ul><ul><li>Expect response in 2-4 weeks </li></ul></ul><ul><ul><li>If ...
Trial of Medications <ul><li>If PPI response inadequate despite maximal dosage  </li></ul><ul><ul><li>Confirm diagnosis </...
Barium Swallow <ul><li>Useful first diagnostic test for patients with dysphagia </li></ul><ul><ul><li>Stricture (location,...
Ambulatory 24 hr. pH Monitoring <ul><li>Physiologic study </li></ul><ul><li>Quantify reflux in proximal/distal esophagus <...
Ambulatory 24 hr. pH Monitoring Normal GERD
Wireless, Catheter-Free Esophageal pH Monitoring <ul><li>Improved patient comfort and acceptance </li></ul><ul><li>Continu...
Esophagogastrodudenoscopy <ul><li>Endoscopy (with biopsy if needed) </li></ul><ul><ul><li>In patients with alarm signs/sym...
Esophageal Manometry investigation of choice in diffuse esophageal spasm(AI08) <ul><li>Assess LES pressure, location and r...
Patient with heartburn Iniate tx with H2RA or PPI H2RA taken  BID Good response Frequent relapses On demand tx PPI taken Q...
Differential diagnosis <ul><li>Angina pectoris </li></ul><ul><li>Gastritis </li></ul><ul><li>Peptic ulcer disease </li></u...
Treatment <ul><li>Goals of therapy </li></ul><ul><ul><li>Symptomatic relief </li></ul></ul><ul><ul><li>Heal esophagitis </...
Better Living <ul><li>Lifestyle modifications </li></ul><ul><ul><li>Avoid large meals </li></ul></ul><ul><ul><li>Avoid aci...
1. Orr WC, et al.  Gastroenterology . 1984;86:814-819. 2. Orr WC, et al.  Am J Gastroenterol . 2000;95:37-42. 3. Orr WC, e...
Treatment <ul><li>Antacids </li></ul><ul><ul><li>Over the counter acid suppressants and antacids appropriate initial thera...
Treatment <ul><li>Histamine H2-Receptor Antagonists </li></ul><ul><ul><li>More effective than placebo and antacids for rel...
Treatment <ul><li>AGENT  EQUIVALENT  DOSAGE </li></ul><ul><li>DOSAGES </li></ul><ul><li>Cimetadine  400mg twice daily  400...
Treatment <ul><li>Proton Pump Inhibitors </li></ul><ul><ul><li>Better control of symptoms with PPIs vs H2RAs and better re...
Treatment <ul><li>AGENT  EQUIVALENT  DOSAGE </li></ul><ul><li>DOSAGES </li></ul><ul><li>Esomeprazole  40mg daily  20-40mg ...
Treatment <ul><li>H2RAs vs PPIs </li></ul><ul><ul><li>12 week freedom from symptoms </li></ul></ul><ul><ul><ul><li>48% vs ...
NOT ALL PROTON PUMPS ARE ACTIVE  AT ANY GIVEN TIME 1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds.  T...
PPIs ONLY BIND TO ACTIVE  PROTON PUMPS Acid is required to convert a PPI into its active form 1 1. Del Valle J, et al. Aci...
PPI USE AND INFECTION RISK: IS THERE A RELATIONSHIP? <ul><li>Gastric acid plays a role in eliminating ingested bacteria fr...
Treatment <ul><li>Antireflux surgery </li></ul><ul><ul><li>Failed medical management </li></ul></ul><ul><ul><li>Patient pr...
Treatment <ul><li>Antireflux surgery candidates </li></ul><ul><ul><li>EGD proven esophagitis </li></ul></ul><ul><ul><li>No...
Treatment <ul><li>Antireflux surgery </li></ul><ul><ul><li>Tenets of surgery </li></ul></ul><ul><ul><ul><li>Reduce hiatal ...
 
(Nissen’s)
Complete vs. partial fundoplication <ul><li>Complete – Nissen fundoplication </li></ul><ul><li>Ant. partial fundoplication...
Laparoscopic Nissen Fundoplication
Treatment <ul><li>Postsurgery </li></ul><ul><ul><li>10% have solid food dysphagia </li></ul></ul><ul><ul><li>2-3% have per...
Treatment <ul><li>Endoscopic treatment </li></ul><ul><ul><li>Relatively new </li></ul></ul><ul><ul><li>No definite indicat...
Complications <ul><li>Erosive esophagitis </li></ul><ul><li>Stricture </li></ul><ul><li>Barrett’s esophagus </li></ul>
Complications <ul><li>Erosive esophagitis </li></ul><ul><ul><li>Responsible for 40-60% of GERD symptoms </li></ul></ul><ul...
Complications <ul><li>Esophageal stricture </li></ul><ul><ul><li>Result of healing of erosive esophagitis </li></ul></ul><...
Peptic Stricture Barium Swallow Endoscopy
Esophageal Stricture: Dilating Devices
TTS Balloon Dilation of a Peptic Stricture
Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Columnar metaplasia of the esophagus  (AIIMS06) </li></ul>...
Barrett’s Esophagus
Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Acid damages lining of esophagus and causes chronic esopha...
Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Manage in same manner as GERD </li></ul></ul><ul><ul><li>E...
Complications <ul><ul><li>Patient’s who need EGD </li></ul></ul><ul><ul><ul><li>Alarm symptoms </li></ul></ul></ul><ul><ul...
Esophageal Cancer Barium Swallow Endoscopy
MCQ’s <ul><li>Most prevalent esophageal cancer worldwide  (AI91) </li></ul><ul><li>Most common site of Ca oesophagus  (AII...
MCQ’s <ul><li>Most common site for Ca oesophagus in india </li></ul><ul><li>Predisposing fators for Ca oesophagus are all ...
MCQ’s <ul><li>Chemotherapy regimens for Ca oesophagus have improved with the use of  (AI96) </li></ul><ul><li>Commonest ad...
Summary <ul><li>Definition of GERD </li></ul><ul><li>Epidemiology of GERD </li></ul><ul><li>Pathophysiology of GERD </li><...
<ul><li>?QUESTIONS? </li></ul>
<ul><li>A slideshow presentation  </li></ul><ul><li>Prepared by </li></ul><ul><li>Dr. ZEESHAN AHMAD </li></ul><ul><li>unde...
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Zee ppt gerd

  1. 1. Gastro esophageal Reflux Disease My room My mess ENT Central emergency
  2. 2. Gasroesophageal reflux disease (GERD)
  3. 4. Objectives <ul><li>Definition of GERD </li></ul><ul><li>Epidemiology of GERD </li></ul><ul><li>Pathophysiology of GERD </li></ul><ul><li>Clinical Manisfestations </li></ul><ul><li>Diagnostic Evaluation </li></ul><ul><li>Treatment </li></ul><ul><li>Complications </li></ul>
  4. 5. Definition <ul><li>American College of Gastroenterology (ACG) </li></ul><ul><ul><li>Symptoms OR mucosal damage produced by the abnormal reflux of gastric contents into the esophagus </li></ul></ul><ul><ul><li>Often chronic and relapsing </li></ul></ul><ul><ul><li>May see complications of GERD in patients who lack typical symptoms </li></ul></ul>
  5. 6. Physiologic vs Pathologic <ul><li>Physiologic GERD </li></ul><ul><li>Postprandial </li></ul><ul><ul><li>Short lived </li></ul></ul><ul><ul><li>Asymptomatic </li></ul></ul><ul><ul><li>No nocturnal sx </li></ul></ul><ul><li>Pathologic GERD </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Mucosal injury </li></ul></ul><ul><ul><li>Nocturnal sx </li></ul></ul>
  6. 7. Epidemiology <ul><li>About 44% of the adult population have heartburn at least once a month </li></ul><ul><li>14% of adults have symptoms weekly </li></ul><ul><li>7% have symptoms daily </li></ul>These are US data In INDIA the prevalence is somewhat lesser but on an INCREASING trend
  7. 10. Pathophysiology <ul><li>Primary barrier to gastroesophageal reflux is the lower esophageal sphincter </li></ul><ul><li>LES normally works in conjunction with the diaphragm </li></ul><ul><li>If barrier disrupted, acid goes from stomach to esophagus </li></ul>
  8. 11. Clinical Manisfestations <ul><li>Most common symptoms </li></ul><ul><ul><li>Heartburn—retrosternal burning discomfort </li></ul></ul><ul><ul><li>Regurgitation—effortless return of gastric contents into the pharynx without nausea, retching, or abdominal contractions </li></ul></ul>
  9. 13. Clinical Manisfestations <ul><ul><li>Dysphagia—difficulty swallowing </li></ul></ul><ul><ul><li>Other symptoms include: </li></ul></ul><ul><ul><ul><li>Chest pain, water brash, globus sensation, odynophagia, nausea </li></ul></ul></ul><ul><ul><li>Extraesophageal manifestations </li></ul></ul><ul><ul><ul><li>Asthma, laryngitis, chronic cough </li></ul></ul></ul>
  10. 14. Extraesophageal Manifestations of GERD <ul><li>Pulmonary </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Aspiration pneumonia </li></ul></ul><ul><ul><li>Chronic bronchitis </li></ul></ul><ul><ul><li>Pulmonary fibrosis </li></ul></ul><ul><li>Other </li></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Dental erosion </li></ul></ul><ul><li>ENT </li></ul><ul><ul><li>Hoarseness </li></ul></ul><ul><ul><li>Laryngitis </li></ul></ul><ul><ul><li>Pharyngitis </li></ul></ul><ul><ul><li>Chronic cough </li></ul></ul><ul><ul><li>Globus sensation </li></ul></ul><ul><ul><li>Dysphonia </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul><ul><ul><li>Subglottic stenosis </li></ul></ul><ul><ul><li>Laryngeal cancer </li></ul></ul>
  11. 15. Potential Oral and Laryngopharyngeal Signs Associated with GERD <ul><li>Edema and hyperemia of larynx </li></ul><ul><ul><li>Vocal cord erythema, polyps, granulomas, ulcers </li></ul></ul><ul><li>Hyperemia and lymphoid hyperplasia of posterior pharynx </li></ul><ul><li>Interarytenyoid changes </li></ul><ul><li>Dental erosion </li></ul><ul><li>Subglottic stenosis </li></ul><ul><li>Laryngeal cancer </li></ul>
  12. 16. Pathophysiology of Extraesophageal GERD
  13. 18. Diagnostic Evaluation <ul><ul><li>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 </li></ul></ul>
  14. 19. Alarms <ul><ul><li>Alarm Signs/Symptoms </li></ul></ul><ul><ul><ul><li>Dysphagia </li></ul></ul></ul><ul><ul><ul><li>Early satiety </li></ul></ul></ul><ul><ul><ul><li>GI bleeding </li></ul></ul></ul><ul><ul><ul><li>Odynophagia </li></ul></ul></ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul><ul><ul><ul><li>Weight loss </li></ul></ul></ul><ul><ul><ul><li>Iron deficiency anemia </li></ul></ul></ul>
  15. 20. When to Perform Diagnostic Tests <ul><li>Uncertain diagnosis </li></ul><ul><li>Atypical symptoms </li></ul><ul><li>Symptoms associated with complications </li></ul><ul><li>Inadequate response to therapy </li></ul><ul><li>Recurrent symptoms </li></ul><ul><li>Prior to anti-reflux surgery </li></ul>
  16. 21. Diagnostic Tests for GERD <ul><li>Trial of H2RA/PPI </li></ul><ul><li>Barium swallow </li></ul><ul><li>Ambulatory pH monitoring </li></ul><ul><li>Esophagogastroduodenoscopy(EGD) </li></ul><ul><li>Esophageal manometry </li></ul>
  17. 22. Trial of Medications <ul><li>H2RA or PPI </li></ul><ul><ul><li>Expect response in 2-4 weeks </li></ul></ul><ul><ul><li>If no response </li></ul></ul><ul><ul><ul><li>Change from H2RA to PPI </li></ul></ul></ul><ul><ul><ul><li>Maximize dose of PPI </li></ul></ul></ul>
  18. 23. Trial of Medications <ul><li>If PPI response inadequate despite maximal dosage </li></ul><ul><ul><li>Confirm diagnosis </li></ul></ul><ul><ul><ul><li>EGD </li></ul></ul></ul><ul><ul><ul><li>24 hour pH monitor </li></ul></ul></ul>
  19. 24. Barium Swallow <ul><li>Useful first diagnostic test for patients with dysphagia </li></ul><ul><ul><li>Stricture (location, length) </li></ul></ul><ul><ul><li>Mass (location, length) </li></ul></ul><ul><ul><li>Bird’s beak </li></ul></ul><ul><ul><li>Hiatal hernia (size, type) </li></ul></ul><ul><li>Limitations </li></ul><ul><ul><li>Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus </li></ul></ul>
  20. 25. Ambulatory 24 hr. pH Monitoring <ul><li>Physiologic study </li></ul><ul><li>Quantify reflux in proximal/distal esophagus </li></ul><ul><ul><li>% time pH < 4 </li></ul></ul><ul><ul><li>DeMeester score </li></ul></ul><ul><li>Symptom correlation </li></ul>
  21. 26. Ambulatory 24 hr. pH Monitoring Normal GERD
  22. 27. Wireless, Catheter-Free Esophageal pH Monitoring <ul><li>Improved patient comfort and acceptance </li></ul><ul><li>Continued normal work, activities and diet study </li></ul><ul><li>Longer reporting periods possible (48 hours) </li></ul><ul><li>Maintain constant probe position relative to SCJ </li></ul>Potential Advantages
  23. 28. Esophagogastrodudenoscopy <ul><li>Endoscopy (with biopsy if needed) </li></ul><ul><ul><li>In patients with alarm signs/symptoms </li></ul></ul><ul><ul><li>Those who fail a medication trial </li></ul></ul><ul><ul><li>Those who require long-term tx </li></ul></ul><ul><li>Lacks sensitivity for identifying pathologic reflux </li></ul><ul><li>Absence of endoscopic features does not exclude a GERD diagnosis </li></ul><ul><li>Allows for detection, stratification, and management of esophageal manisfestations or complications of GERD </li></ul>
  24. 29. Esophageal Manometry investigation of choice in diffuse esophageal spasm(AI08) <ul><li>Assess LES pressure, location and relaxation </li></ul><ul><ul><li>Assist placement of 24 hr. pH catheter </li></ul></ul><ul><li>Assess peristalsis </li></ul><ul><ul><li>Prior to antireflux surgery </li></ul></ul>Limited role in GERD
  25. 30. Patient with heartburn Iniate tx with H2RA or PPI H2RA taken BID Good response Frequent relapses On demand tx PPI taken QD Good response Maintenance therapy with lowest effective dose Symptoms persist Consider EGD if risk factors present ( > 45, white, male and > 5 yrs of sx) Increase to max dose QD or BID Good response Confirm diagnosis EGD, ph monitor No Yes Yes No Yes Yes No No
  26. 31. Differential diagnosis <ul><li>Angina pectoris </li></ul><ul><li>Gastritis </li></ul><ul><li>Peptic ulcer disease </li></ul><ul><li>Gallstones </li></ul><ul><li>pancreatitis </li></ul><ul><li>Achalasia cardia </li></ul><ul><li>Carcinoma oesophagus </li></ul>
  27. 32. Treatment <ul><li>Goals of therapy </li></ul><ul><ul><li>Symptomatic relief </li></ul></ul><ul><ul><li>Heal esophagitis </li></ul></ul><ul><ul><li>Avoid complications </li></ul></ul>
  28. 33. Better Living <ul><li>Lifestyle modifications </li></ul><ul><ul><li>Avoid large meals </li></ul></ul><ul><ul><li>Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, peppermint </li></ul></ul><ul><ul><li>Decrease fat intake </li></ul></ul><ul><ul><li>Avoid lying down within 3-4 hours after a meal </li></ul></ul><ul><ul><li>Elevate head of bed 4-8 inches </li></ul></ul><ul><ul><li>Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, sedatives, NSAIDS) </li></ul></ul><ul><ul><li>Avoid clothing that is tight around the waist </li></ul></ul><ul><ul><li>Lose weight </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul>
  29. 34. 1. Orr WC, et al. Gastroenterology . 1984;86:814-819. 2. Orr WC, et al. Am J Gastroenterol . 2000;95:37-42. 3. Orr WC, et al. Am J Gastroenterol . 1994;89:509-512. 4. Kjellén G, Tibbling L. Scand J Gastroenterol . 1978;13:283-288. Sleep May Impair Esophageal Acid Clearance  Gravity-Mediated Drainage 4  Esophageal Acid Clearance 1–3  Salivary Flow and Swallowing 1 Asleep Awake Factors     FACTORS THAT MAY CONTRIBUTE TO INCREASED ESOPHAGEAL ACID EXPOSURE DURING SLEEP
  30. 35. Treatment <ul><li>Antacids </li></ul><ul><ul><li>Over the counter acid suppressants and antacids appropriate initial therapy </li></ul></ul><ul><ul><li>Approx 1/3 of patients with heartburn-related symptoms use at least twice weekly </li></ul></ul><ul><ul><li>More effective than placebo in relieving GERD symptoms </li></ul></ul>
  31. 36. Treatment <ul><li>Histamine H2-Receptor Antagonists </li></ul><ul><ul><li>More effective than placebo and antacids for relieving heartburn in patients with GERD </li></ul></ul><ul><ul><li>Faster healing of erosive esophagitis when compared with placebo </li></ul></ul><ul><ul><li>Can use regularly or on-demand </li></ul></ul>
  32. 37. Treatment <ul><li>AGENT EQUIVALENT DOSAGE </li></ul><ul><li>DOSAGES </li></ul><ul><li>Cimetadine 400mg twice daily 400-800mg twice daily </li></ul><ul><li>Famotidine 20mg twice daily 20-40mg twice daily </li></ul><ul><li>Nizatidine 150mg twice daily 150mg twice daily </li></ul><ul><li>Ranitidine 150mg twice daily 150mg twice daily </li></ul>
  33. 38. Treatment <ul><li>Proton Pump Inhibitors </li></ul><ul><ul><li>Better control of symptoms with PPIs vs H2RAs and better remission rates </li></ul></ul><ul><ul><li>Faster healing of erosive esophagitis with PPIs vs H2RAs </li></ul></ul>
  34. 39. Treatment <ul><li>AGENT EQUIVALENT DOSAGE </li></ul><ul><li>DOSAGES </li></ul><ul><li>Esomeprazole 40mg daily 20-40mg daily </li></ul><ul><li>Omeprazole 20mg daily 20mg daily </li></ul><ul><li>Lansoprazole 30mg daily 15-10md daily </li></ul><ul><li>Pantoprazole 40mg daily 40mg daily </li></ul><ul><li>Rabeprazole 20mg daily 20mg daily </li></ul>
  35. 40. Treatment <ul><li>H2RAs vs PPIs </li></ul><ul><ul><li>12 week freedom from symptoms </li></ul></ul><ul><ul><ul><li>48% vs 77% </li></ul></ul></ul><ul><ul><li>12 week healing rate </li></ul></ul><ul><ul><ul><li>52% vs 84% </li></ul></ul></ul><ul><ul><li>Speed of healing </li></ul></ul><ul><ul><ul><li>6%/wk vs 12%/wk </li></ul></ul></ul>
  36. 41. NOT ALL PROTON PUMPS ARE ACTIVE AT ANY GIVEN TIME 1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. Unstimulated proton pumps Active proton pumps Unstimulated proton pumps in cytoplasmic tubules 1. Blair JA, et al. J Clin Invest. 1987;79:582-587. 2. Sachs G. Pharmacotherapy . 1997;17:22-37. H 2 = Histamine ACh = Acetylcholine Proton pumps become activated in response to food 1 Inactive Parietal Cell After activation, the parietal cell undergoes a series of changes, allowing proton pumps to reach the surface of the parietal cell 1 Active Parietal Cell Only active proton pumps can secrete acid 1 However, not all pumps become activated 1,2 ATPase ATPase MOA     Gastrin H 2 ACh H+ H+ H+ H+ K+ K+ K+ K+
  37. 42. PPIs ONLY BIND TO ACTIVE PROTON PUMPS Acid is required to convert a PPI into its active form 1 1. Del Valle J, et al. Acid peptic disorders. In: Yamada et al, eds. Textbook of Gastroenterology . 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2003:1321-1376. PPIs only bind to active proton pumps 1 Unstimulated proton pumps remain MOA     PPI PPI PPI PPI
  38. 43. PPI USE AND INFECTION RISK: IS THERE A RELATIONSHIP? <ul><li>Gastric acid plays a role in eliminating ingested bacteria from the digestive tract 1 </li></ul><ul><li>PPI use associated with </li></ul><ul><ul><li>Enteric infection such as Clostridium difficile </li></ul></ul><ul><ul><li>Nonenteric infection such as community-acquired pneumonia </li></ul></ul>C. difficile Safety    
  39. 44. Treatment <ul><li>Antireflux surgery </li></ul><ul><ul><li>Failed medical management </li></ul></ul><ul><ul><li>Patient preference </li></ul></ul><ul><ul><li>GERD complications </li></ul></ul><ul><ul><li>Medical complications attributable to a large hiatal hernia </li></ul></ul><ul><ul><li>Atypical symptoms with reflux documented on 24-hour pH monitoring </li></ul></ul>
  40. 45. Treatment <ul><li>Antireflux surgery candidates </li></ul><ul><ul><li>EGD proven esophagitis </li></ul></ul><ul><ul><li>Normal esophageal motility </li></ul></ul><ul><ul><li>Partial response to acid suppression </li></ul></ul>
  41. 46. Treatment <ul><li>Antireflux surgery </li></ul><ul><ul><li>Tenets of surgery </li></ul></ul><ul><ul><ul><li>Reduce hiatal hernia </li></ul></ul></ul><ul><ul><ul><li>Repair diaphragm </li></ul></ul></ul><ul><ul><ul><li>Strengthen GE junction </li></ul></ul></ul><ul><ul><ul><li>Strengthen antireflux barrier via gastric wrap </li></ul></ul></ul><ul><ul><ul><li>75-90% effective at alleviating symptoms of heartburn and regurgitation </li></ul></ul></ul>
  42. 48. (Nissen’s)
  43. 49. Complete vs. partial fundoplication <ul><li>Complete – Nissen fundoplication </li></ul><ul><li>Ant. partial fundoplication </li></ul><ul><li> Thal/Dor procedure </li></ul><ul><li>Post. partial fundoplication </li></ul><ul><li> Toupet procedure </li></ul>
  44. 50. Laparoscopic Nissen Fundoplication
  45. 51. Treatment <ul><li>Postsurgery </li></ul><ul><ul><li>10% have solid food dysphagia </li></ul></ul><ul><ul><li>2-3% have permanent symptoms </li></ul></ul><ul><ul><li>7-10% have gas, bloating, diarrhea, nausea, early satiety </li></ul></ul><ul><ul><li>Within 3-5 years 52% of patients back on antireflux medications </li></ul></ul>
  46. 52. Treatment <ul><li>Endoscopic treatment </li></ul><ul><ul><li>Relatively new </li></ul></ul><ul><ul><li>No definite indications </li></ul></ul><ul><ul><li>Select well-informed patients with well-documented GERD responsive to PPI therapy may benefit </li></ul></ul><ul><li>Three categories </li></ul><ul><ul><li>Radiofrequency application to increase LES reflux barrier </li></ul></ul><ul><ul><li>Endoscopic sewing devices </li></ul></ul><ul><ul><li>Injection of a nonresorbable polymer into LES area </li></ul></ul>
  47. 53. Complications <ul><li>Erosive esophagitis </li></ul><ul><li>Stricture </li></ul><ul><li>Barrett’s esophagus </li></ul>
  48. 54. Complications <ul><li>Erosive esophagitis </li></ul><ul><ul><li>Responsible for 40-60% of GERD symptoms </li></ul></ul><ul><ul><li>Severity of symptoms often fail to match severity of erosive esophagitis </li></ul></ul>
  49. 55. Complications <ul><li>Esophageal stricture </li></ul><ul><ul><li>Result of healing of erosive esophagitis </li></ul></ul><ul><ul><li>May need dilation </li></ul></ul>
  50. 56. Peptic Stricture Barium Swallow Endoscopy
  51. 57. Esophageal Stricture: Dilating Devices
  52. 58. TTS Balloon Dilation of a Peptic Stricture
  53. 59. Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Columnar metaplasia of the esophagus (AIIMS06) </li></ul></ul><ul><ul><li>Associated with the development of adenocarcinoma (AIMS97,06) </li></ul></ul>
  54. 60. Barrett’s Esophagus
  55. 61. Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Acid damages lining of esophagus and causes chronic esophagitis (AIIMS98) </li></ul></ul><ul><ul><li>Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells </li></ul></ul><ul><ul><li>This specialized intestinal metaplasia can progress to dysplasia and adenocarcinoma </li></ul></ul>
  56. 62. Complications <ul><li>Barrett’s Esophagus </li></ul><ul><ul><li>Manage in same manner as GERD </li></ul></ul><ul><ul><li>EGD every 3 years in patient’s without dysplasia </li></ul></ul><ul><ul><li>In patients with dysplasia annual to shorter interval surveillance </li></ul></ul>
  57. 63. Complications <ul><ul><li>Patient’s who need EGD </li></ul></ul><ul><ul><ul><li>Alarm symptoms </li></ul></ul></ul><ul><ul><ul><li>Poor therapeutic response </li></ul></ul></ul><ul><ul><ul><li>Long symptom duration </li></ul></ul></ul><ul><ul><li>“Once in a lifetime” EGD for patient’s with chronic GERD becoming accepted practice </li></ul></ul><ul><ul><li>Many patients with Barrett’s are asymptomatic </li></ul></ul>
  58. 64. Esophageal Cancer Barium Swallow Endoscopy
  59. 65. MCQ’s <ul><li>Most prevalent esophageal cancer worldwide (AI91) </li></ul><ul><li>Most common site of Ca oesophagus (AIIMS 97) </li></ul><ul><li>Most common site for squamous cell Ca (AI 01) </li></ul><ul><li>Most common site of esophageal adenocarcinoma (AIIMS 96,2000) </li></ul>
  60. 66. MCQ’s <ul><li>Most common site for Ca oesophagus in india </li></ul><ul><li>Predisposing fators for Ca oesophagus are all except </li></ul><ul><li>a-plummer vinson syn </li></ul><ul><li>b-tulosis palmaris </li></ul><ul><li>c-gerd </li></ul><ul><li>d benzene therapy </li></ul>
  61. 67. MCQ’s <ul><li>Chemotherapy regimens for Ca oesophagus have improved with the use of (AI96) </li></ul><ul><li>Commonest adverse effect of cisplatin (AIIMS01) </li></ul><ul><li>Best substitute for esophagus after esophagectomy (AI96) </li></ul>
  62. 68. Summary <ul><li>Definition of GERD </li></ul><ul><li>Epidemiology of GERD </li></ul><ul><li>Pathophysiology of GERD </li></ul><ul><li>Clinical Manisfestations </li></ul><ul><li>Diagnostic Evaluation </li></ul><ul><li>Treatment </li></ul><ul><li>Complications </li></ul>
  63. 69. <ul><li>?QUESTIONS? </li></ul>
  64. 70. <ul><li>A slideshow presentation </li></ul><ul><li>Prepared by </li></ul><ul><li>Dr. ZEESHAN AHMAD </li></ul><ul><li>under guidance of </li></ul><ul><li>DR(Prof)CHANDRA SHEKHAR </li></ul><ul><li>Head ENT deptt </li></ul><ul><li>& </li></ul><ul><li>DR MK VERMA </li></ul><ul><li>Assoc prof ENT deptt </li></ul><ul><li>THANK YOU </li></ul>

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