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    Acid Peptic Disorder and Gerd

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    Ebuka Ani
    1. Acid peptic disorders include conditions caused by damage from gastric acid and pepsin, like gastroesophageal reflux disease (GORD) and peptic ulcer disease. 2. GORD is defined as chronic heartburn, acid regurgitation, or both caused by abnormal reflux of gastric contents into the esophagus. Risk factors include hiatal hernia, obesity, smoking, and certain foods. 3. Diagnosis involves assessing symptoms, response to PPI treatment, and testing like endoscopy and pH monitoring if needed. Management focuses on lifestyle changes, medications like PPIs, and surgery for severe cases.

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    Acid Peptic Disorder and Gerd

    Uploaded by

    Ebuka Ani
    28 views52 pages
    1. Acid peptic disorders include conditions caused by damage from gastric acid and pepsin, like gastroesophageal reflux disease (GORD) and peptic ulcer disease. 2. GORD is defined as chronic heartburn, acid regurgitation, or both caused by abnormal reflux of gastric contents into the esophagus. Risk factors include hiatal hernia, obesity, smoking, and certain foods. 3. Diagnosis involves assessing symptoms, response to PPI treatment, and testing like endoscopy and pH monitoring if needed. Management focuses on lifestyle changes, medications like PPIs, and surgery for severe cases.

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    Lecture notes

    Original Title

    ACID PEPTIC DISORDER AND GERD

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    1. Acid peptic disorders include conditions caused by damage from gastric acid and pepsin, like gastroesophageal reflux disease (GORD) and peptic ulcer disease. 2. GORD is defined as chronic heartburn, acid regurgitation, or both caused by abnormal reflux of gastric contents into the esophagus. Risk factors include hiatal hernia, obesity, smoking, and certain foods. 3. Diagnosis involves assessing symptoms, response to PPI treatment, and testing like endoscopy and pH monitoring if needed. Management focuses on lifestyle changes, medications like PPIs, and surgery for severe cases.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    28 views52 pages

    Acid Peptic Disorder and Gerd

    Uploaded by

    Ebuka Ani
    1. Acid peptic disorders include conditions caused by damage from gastric acid and pepsin, like gastroesophageal reflux disease (GORD) and peptic ulcer disease. 2. GORD is defined as chronic heartburn, acid regurgitation, or both caused by abnormal reflux of gastric contents into the esophagus. Risk factors include hiatal hernia, obesity, smoking, and certain foods. 3. Diagnosis involves assessing symptoms, response to PPI treatment, and testing like endoscopy and pH monitoring if needed. Management focuses on lifestyle changes, medications like PPIs, and surgery for severe cases.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 52

    ACID-PEPTIC DISORDERS

    Dr ANIGBO G E
    ACID-PEPTIC DISORDERS
    • Acid Peptic Disorders (APD) include a number
    of conditions whose pathophysiology is
    believed to be the result of damage from acid
    and peptic activity of gastric secretions.
    • This lecture focuses on Gastro oesophageal
    Reflux Disease (GORD) and Peptic Ulcer
    Disease which are the two most common and
    well defined disease states.
    • Other diseases associated with APD are:
    APD DISEASE ENTITIES
    APD covers ulcer and non-ulcer acid/pepsin-related GIT
    disorders
    • -GORD and peptic oesophagitis
    • -gastritis
    • -duodenitis
    • -gastroduodenitis
    • -gastric erosion – NSAID
    • -gastric ulcer
    • -duodenal ulcer
    • -Zollinger-Ellison syndrome
    • -Stress-related ulcer
    Gastro-oesophageal Reflux
    Disease
    • GORD is defined as chronic symptoms of heartburn, acid
    regurgitation, or both, or mucosal damage produced by the abnormal
    reflux of gastric contents into the esophagus.
    • It is the reflux of gastric contents other than air into or through the
    oesophagus.
    • The reflux of gastric contents produces frequent
    symptoms or results in damage to the oesophageal
    mucosa or contiguous organs of the upper
    aerodigestive system and occasionally the lower
    respiratory tract.
    • Reflux oesophagitis occurs in a subgroup of GORD
    patients with histopathologically demonstrated
    characteristic changes in the oesophageal mucosa.
    GERD: Montreal Definition
    • Gastro-esophageal reflux disease (GERD) is a condition that develops
    when reflux of stomach contents causes
    • troublesome symptoms
    • And/or complications.
    • Symptoms become troublesome when they adversely affect an
    individual’s wellbeing.
    CLASSIFICATION
    • Most of the patients with GERD fall into 1 of 2 categories:
    • A. Nonerosive reflux disease (NERD) or
    • B. Erosive esophagitis.
    • NERD has been commonly defined as the presence of classic GERD
    symptoms in the absence of esophageal mucosal injury during upper
    endoscopy.
    PATHOGENESIS
    • GORD occurs when the normal antireflux barrier
    between the stomach and esophagus is impaired,
    either transiently or permanently.
    I. Pathologic reflux of gastric contents occurs when
    the refluxate overcomes the anti-reflux barriers of
    the GEJ typically in the postprandial state.
    II. Some gastric/abdominal factors also play a role in
    the pathogenesis of GORD
    ANTI-REFLUX MECHANISMS
    • The primary anti-reflux mechanism is the LES.
    • The antireflux barrier of the LES is both
    A. Functional and B. Anatomical
    • A. The two main patterns of LES dysfunction are
    1. Hypotensive LES
    2. Pathologic transient LES relaxation
    • B. Anatomic disruption of the GEJ commonly occurs in
    hiatus hernia.
    • Other factors that decrease LES pressure and contribute to GERD are
    medications, lifestyle and certain foods.
    • Certain medicines can exacerbate GERD by lowering LES pressure;
    others can cause oesophagitis by direct mucosal injury.
    • Certain food, beverages and behaviour will cause heartburn by
    reducing LES pressure.
    • Fatty food, peppermint, chocolate, caffeinated beverages, alcohol and
    smoking can all decrease LES.
    GASTRIC/ABDOMINAL FACTORS
    Gastric factors that promote GORD includes
    increased gastric volume after meals,
    increased gastric pressure due to obesity,
    recumbency after meals, and
    reduced gastric emptying or gastroparesis.
    Pathophysiology
    A. Abnormal lower esophageal sphincter The most
    1. Functional (frequent transient LES relaxation) common cause
    of (GERD).
    2. Mechanical (hypotensive LES)
    decrease the
    3. Foods (eg, coffee, alcohol), pressure of the
    4. Medications (eg, calcium channel blockers), LES.

    5. Anatomic (Location) .......... hiatal hernia

    obesity
    or Pregnancy
    increased gastric volume
    Tight fitting cloth
    B. Increase abdominal pressure
    Lower Esophageal Sphincter

    • Intrinsic distal esophageal muscles – tonically contracted


    • Muscular Sling fibers of the gastric cardia
    • The LES also works in conjunction with the diaphragm
    Oesophageal defense mechanism
    • Esophageal defense mechanisms include
    1. Esophageal clearance
    2. Mucosal resistance
    • Esophageal clearance: has 2 arms
    I. Mechanical arm: Oesophageal peristalsis and
    II. Chemical component: saliva secretion.
    both of which limit the amount of time the esophagus is
    exposed to refluxed gastric juice.
    • Mucosal defense also has 3 arms
    I. Mucosal blood flow
    II. Growth factors
    III. Protective mucus
    Summary of Pathogenesis of
    GERD
    1. impaired lower esophageal
    sphincter-low pressures or
    frequent transient lower
    esophageal sphincter relaxation.

    2. hypersecretion of acid

    3. decreased acid clearance resulting


    from impaired peristalsis or abnormal
    saliva production

    4. delayed gastric emptying or


    duodenogastric reflux of bile
    salts and pancreatic enzymes.
    Dr. K. Sendhil Kumar.
    Surgical gastroenterologist
    Gateway clinics & hospital
    SYMPTOMS
    • There are 2 typical or classical symptoms of GERD
    Heartburn (Pyrosis)
    Regurgitation
    Symptoms:
    HEARTBURN

    - retrosternal burning pain


    - may start in abdomen and
    extend up into the neck
    • Regurgitation: is the
    perception of flow of
    refluxed gastric content
    into the mouth or
    hypopharynx.
    The Montreal Definition of GERD
    • At initial presentation, it is important to consider a patients age and
    presence of “alarm signs”.
    • The presence of any alarm sign necessitates the evaluation of GERD
    symptoms with an upper endoscopy or imaging modality.
    • Atypical manifestation of GERD refer to symptoms that are
    extraoesphageal, including pulmonary, ear, nose and throat
    manifestation as well as a non cardiac chest pain.
    Alarming Signs & Symptoms
    • Age > 45 years
    • Dysphagia
    • Early satiety
    • GI bleeding
    • Odynophagia
    • Vomiting
    • Weight loss
    • Iron deficiency anemia
    Alarm Symptoms/Signs contd
    • Family history of GIT cancer
    • Previous esophagogastric malignancy
    • Previous documented PUD
    • Lymphadenopathy
    • Abdominal mass
    • Unintended Weight Loss
    • Jaundice
    Risk factors
    • Race • Cigarette
    • Sex • Smoking
    • Age • consumption of coffee and cola
    • Obesity • connective tissue disease
    • Alcohol consumption • chronic obstructive airway
    • Hiatus hernia disease
    • Pregnancy
    Certain foods can be associated with reflux events
    • Citrus fruits
    • Chocolate
    • Drinks with caffeine
    • Fatty and fried foods
    • Garlic and onions
    • Mint flavorings
    • Spicy foods
    • Tomato-based foods, like spaghetti sauce, chili, and pizza
    GERD Diagnostic Approach

    History typical for uncomplicated


    GERD…
    Absence of alarm features…
    Typical reflux syndrome can be diagnosed
    Initial trial of empiric PPI therapy appropriate
    Response to therapy require no further diagnostic testing.

    From Kahrilas PJ et al. Gastroenterology 2008;135:1392-1413


    • Classic GORD/GERD can be diagnosed by taking a thorough symptom
    history and confirmed b a complete response to medical therapy. (A
    “PPI” test)
    • In general, diagnostic testing is reserved for patients who fail to
    respond to a trial of adequate medical therapy or for patients who
    have alarm symptoms.
    Diagnostic Tests for GERD
    • Barium swallow
    • Endoscopy
    • Ambulatory pH monitoring
    • Impedance-pH monitoring
    • Esophageal manometry
    • Bernstein test
    Barium swallow
    • Radiologic studies are of limited use in the management of GERD due
    to poor sensitivity in milder forms of GERD, but they can detect
    moderate to severe oesophagitis, strictures, hiatus hernia and
    tumours. Barium studies can also demonstrate hiatus hernia and
    refux.
    • The primary utility of radiologic studies in GERD is to rule out other
    diseases like peptic ulcer and tumours as a cause of patients
    symptoms
    UPPER ENDOSCOPY
    • In addition to excluding the presence of other disease such as tumour
    and peptic ulcers, upper endoscopy can detect and grade
    oesophagitis and extent and severity of mucosal injuries.
    • Upper endoscopy also allows the evaluation of any complication of
    the disease like strictures and Barrett oesophagus. It is therefore the
    test of choice in patients with alarm signs. It also has a therapeutic
    value.
    Ambulatory pH monitoring
    Esophageal manometry
    Bernstein Test
    Potential GERD management pathway

    1. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux
    disease. Gastroenterology, 2008;135:1383–1391.
    Lifestyle modifications

    • Avoid large meals

    • Avoid acidic foods (citrus/tomato), alcohol, caffeine, chocolate,


    onions, garlic, peppermint

    • Decrease fat intake

    • Avoid lying down within 3-4 hours after a meal

    • Avoid medicines that may potentiate GERD (CCB, alpha


    agonists, theophylline, nitrates, sedatives, NSAIDS)
    Lifestyle Modifications
    • Weight reduction if overweight
    • Avoid clothing that is tight around the waist
    • Modify diet
    • Eat more frequent but smaller meals
    • Avoid fatty/fried food, peppermint, chocolate,
    alcohol, carbonated beverages, coffee and tea,
    onions, garlic.
    • Stop smoking
    • Elevate head of bed 4-6 inches
    • Avoid eating within 2-3 hours of bedtime
    Pharmacotherapy
    • The following medications are used
    • H2 receptor antagonists (eg, cimetidine, famotidine,
    nizatidine)
    • Proton pump inhibitors (eg, omeprazole, lansoprazole,
    rabeprazole, esomeprazole, pantoprazole)
    • Prokinetic agents (eg, Domperidone,
    metoclopramide)
    • Antacids (eg, aluminum hydroxide, magnesium
    hydroxide)
    Surgical options
    • Transthoracic and transabdominal fundoplications are performed
    • Open and laparoscopic techniques may be used.
    • Placement of a device to augment the lower esophageal sphincter is
    another surgical option.
    Indications for fundoplication include the
    following
    • Patients with symptoms that are not completely
    controlled by proton pump inhibitors
    • Patients with well-controlled reflux disease who desire
    definitive, one-time treatment
    • The presence of Barrett esophagus
    • The presence of extraesophageal manifestations
    • Young patients
    • Poor patient compliance with medications
    • Postmenopausal women with osteoporosis
    • Medical complications attributable to a large hiatal hernia
    • Cost of medical therapy
    Treatment
    • Antireflux surgery
    • Failed medical management
    • Patient preference
    • GERD complications
    • Medical complications attributable to a large hiatal hernia
    • Atypical symptoms with reflux documented on 24-hour pH monitoring
    Complications of GERD
    • Erosive/ulcerative esophagitis

    • Bleeding from esophageal erosion

    • Esophageal (peptic) stricture

    • Barrett’s esophagus

    • Adenocarcinoma
    Complications
    • Erosive esophagitis
    • Responsible for 40-60% of GERD symptoms
    • Severity of symptoms often fail to match severity of erosive esophagitis
    Complications
    • Esophageal stricture
    • Result of healing of erosive esophagitis
    • May need dilation
    Complications
    • Barrett’s Esophagus

    • Columnar metaplasia of the esophagus


    • Associated with the development of adenocarcinoma

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