Transcript GERD
GERD Ahmad Shavakhi.MD Associate professor of gastroenterology Isfahan university of medical sciences GERD • Definition : • "a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications“ • at least weekly heartburn and/or acid regurgitation • "clinically significant" :occurring ≥ twice weekly CLINICAL MANIFESTATIONS • • • • Heartburn Regurgitation Dysphagia Other symptoms • • • • • chest pain water brash globus sensation Odynophagia nausea Case history • A 32-year- old woman with : • heart burn and acid regurgitation from 1 year ago • Commonly occur within 60 minutes of eating and while lying recumbent • Relieved by drinking water or using antacid but can occur frequently • 4 times in week • She is smoker and obese She denied • • • • Weight loss Dysphagia GIB Vomiting • P/E: • Unremarkable What is the treatment? Life style modification Dietary modification • Should not be routinely recommended in all • selective elimination of • fatty foods • caffeine • Chocolate • spicy foods • food with high fat content • carbonated beverages, and peppermint) • correlation with symptoms and an improvement with elimination • Avoidance of tight-fitting garments • Promotion of salivation through chewing gum to neutralize refluxe • Avoidance of tobacco and alcohol • reduce LES pressure • smoking also diminishes salivation • ●Abdominal breathing exercise • to strengthen the anti-reflux barrier of LES Treatment strategy •Step-up • Step-down Step-up • Mild and intermittent symptoms • fewer than two episodes per week • No evidence of erosive esophagitis on upper endoscopy • incremental changes at two- to four-week intervals • low-dose H2RA concomitant antacids H2 blocker • The different H2 receptor antagonists have equivalent efficacy if drug dose is adjusted for potency • An increased dose , prolonged course of H2RA is unlikely to produce relief for patients who continue to have heartburn after six weeks • H2RAs are ineffective in patients with severe esophagitis • tachyphylaxis within two to six weeks of initiation of H2RAs Step-down • Erosive esophagitis • frequent symptoms (two or more episodes per week) • And/or severe symptoms that impair quality of life • standard-dose PPI once daily for eight weeks in addition to lifestyle and dietary modification Maintenance PPI therapy • Severe erosive esophagitis • Barrett's esophagus • If recurrent symptoms occur within three months after therapy was discontinued intermittent (on-demand) therapy ) • Continuous therapy provided better symptom control, quality of life, and higher endoscopic remission rates PPI • • • • • • The PPIs are comparably effective omeprazole (20 mg/d) lansoprazole (30 mg/d) pantoprazole (40 mg/d) esomeprazole (40 mg/d) rabeprazole (20 mg/d) proton pump inhibitor • complete relief from heartburn occurred at a rate of 11.5 percent per week with a proton pump inhibitor compared to 6.4 percent per week with an H2 receptor antagonist • dose-response curve for healing highgrade esophagitis Differences in proton pump inhibitors • magnitude of differences has been small and of uncertain clinical importance Side effect of PPI • Hypomagnesemia : • More than 1 year • With other drug like digoxin or diuretics • Hip fracture • More than 50 years • Smokers or exsmokers • B12 deficiency • Iron deficiency : not appear to be of clinical significance • Atrophic gastritis: uncertain significance • Acute interstitial nephritis Taper the PPI • ● GERD are considered for a taper after being asymptomatic for a minimum of three months • ● treated for acute duodenal and gastric ulcers for four to eight weeks do not require a taper • ● PPI as part of a course of treatment for H. pylori do not require a taper. • ●For patients on a moderate- to high-dose PPI (eg, omeprazole 40 mg daily or twice daily), cut the dose by 50 percent every week (for patients on twice daily dosing, or decreasing the dosing to once in the morning until the patient is on the lowest dose of the medication. • Once on the lowest dose for one week, the patient is instructed to stop the medication PROKINETIC DRUGS/REFLUX INHIBITORS • • • • • bethanechol, metoclopramide, Cisapride tegaserod can potentially be useful adjuncts in the treatment • increasing lower esophageal sphincter pressure, enhancing gastric emptying, or improving peristalsis • However, the currently available promotility agents are not ideal for monotherapy TREATMENT OF HELICOBACTER PYLORI INFECTION • Mild worsening of GERD in patients with corpus dominant gastritis • improvement in those with antralpredominant gastritis • most authorities would advocate eradication • • • 10 percent lifetime risk of developing peptic ulcer disease two to three times higher incidence of gastric adenocarcinoma. The mild increase in reflux associated with eliminating corpus gastritis does not outweigh these risks • the overall impact that H. pylori may have on the risk of esophageal adenocarcinoma is insignificant • She was better with life style modification and ranitidine 150 mg BID for 8 weeks • But symptoms recurred 2 months later • what is the next step? RECURRENT SYMPTOMS AND MAINTENANCE THERAPY • Two-thirds of NERD • Nearly all patients with erosive esophagitis (EE) Relapse when acid suppression is discontinued Indication for surgery • • • • • • Failed optimal medical management Noncompliance with medical therapy High volume reflux Severe esophagitis by endoscopy Benign stricture Barrett's columnar-lined epithelium (without severe dysplasia or carcinoma Pregnancy and lactation Pregnant with GERD GERD in lactation Sucralfete sucralfate H2 RA PPI H2RA