Acid Peptic DisordersAcid Peptic Disorders

Acid peptic disorders include a number of Acid peptic disorders include a number of diseases, whose etiology can be linked to diseases, whose etiology can be linked to gastric secretions.gastric secretions.

Gastroesophageal reflux disease, and Gastroesophageal reflux disease, and peptic ulcer disease, are two most peptic ulcer disease, are two most common and well-defined disease states. common and well-defined disease states.

GERD is defined as chronic symptoms or mucosal GERD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric damage produced by the abnormal reflux of gastric contents into the esophagus.contents into the esophagus.

Reflux esophagitis refers to a subgroup of GERD Reflux esophagitis refers to a subgroup of GERD patients with histopathologically demonstrated patients with histopathologically demonstrated characteristic changes in the esophageal mucosa characteristic changes in the esophageal mucosa

Nonerosive reflux disease, also know as endoscopy-Nonerosive reflux disease, also know as endoscopy-negative reflux disease, refers to patients with typical negative reflux disease, refers to patients with typical GERD symptoms caused by intraesophageal acid who GERD symptoms caused by intraesophageal acid who do not have visible mucosal injury at endoscopy. do not have visible mucosal injury at endoscopy.

PrevalencePrevalence

Heartburn is a common problem in the United States and in Heartburn is a common problem in the United States and in the Western world, since many individuals control symptoms the Western world, since many individuals control symptoms with over-the-counter medications and without consulting a with over-the-counter medications and without consulting a physician, the condition is likely underreported.physician, the condition is likely underreported.

Approximately 7% of the population experience symptoms of Approximately 7% of the population experience symptoms of heartburn daily. 20-40% of the people who experience heartburn daily. 20-40% of the people who experience heartburn do indeed have GERD heartburn do indeed have GERD

No sexual predilection exists. GERD is as common in men No sexual predilection exists. GERD is as common in men as in women as in women GERD occurs in all age groups. GERD occurs in all age groups. The prevalence of GERD increases in people older than 40 The prevalence of GERD increases in people older than 40 years.years.

EtiologyEtiology

Lower esophageal sphincter incompetence. Lower esophageal sphincter incompetence.

Transient lower esophageal sphincter Transient lower esophageal sphincter relaxation.relaxation.

Hiatal hernia Hiatal hernia

Obesity: contributing factor in GERDObesity: contributing factor in GERD

Typical FeaturesTypical Features

HeartburnHeartburn

RegurgitationRegurgitation

Atypical FeaturesAtypical Features

Coughing and/or wheezing Coughing and/or wheezing Hoarseness Hoarseness Pneumonia Pneumonia Belching Belching LaryngitisLaryngitis Otitis mediaOtitis media Enamel decay. Enamel decay.

DifferentialsDifferentials

AchalasiaAchalasia CholeithiasisCholeithiasis Coronary Artery AtherosclerosisCoronary Artery Atherosclerosis Esophageal SpasmEsophageal Spasm Esophageal CancerEsophageal Cancer EsophagitisEsophagitis Chronic GastritisChronic Gastritis Irritable bowel syndromeIrritable bowel syndrome Peptic Ulcer DiseasePeptic Ulcer Disease

WORKUPWORKUP

Barium EsophagogramBarium Esophagogram EsophagogastroduodenoscopyEsophagogastroduodenoscopy Esophageal manometry Esophageal manometry Radionuclide measurement of gastric emptying Radionuclide measurement of gastric emptying Ambulatory 24-hour pH monitoringAmbulatory 24-hour pH monitoring Empiric trial of proton pump inhibitorEmpiric trial of proton pump inhibitor Multichannel intraluminal impedanceMultichannel intraluminal impedance Bravo systemBravo system

Medical TreatmentMedical Treatment

Lifestyle ModificationsLifestyle Modifications Losing weight (if overweight) Losing weight (if overweight) Avoiding alcohol, chocolate, citrus juice, Avoiding alcohol, chocolate, citrus juice,

and tomato-based products and tomato-based products Avoiding large meals Avoiding large meals Waiting 3 hours after a meal before lying Waiting 3 hours after a meal before lying

down down Elevating the head of the bed 8 inchesElevating the head of the bed 8 inches

Treatment Cont.Treatment Cont.

Pharmacologic Therapy Pharmacologic Therapy AntacidsAntacids

Prokinetic agents: Prokinetic agents: metoclopramide hydrochloride metoclopramide hydrochloride

H2 receptor antagonists: H2 receptor antagonists: Ranitidine, Cimetidine, Famotidine. Ranitidine, Cimetidine, Famotidine.

Nizatidine Nizatidine

Proton pump inhibitors: Proton pump inhibitors: Omeprazole, Rabeprazole, Esomeprazole,Omeprazole, Rabeprazole, Esomeprazole,

Treatments Cont.Treatments Cont.

AntacidsAntacids Prompt but temporary reliefPrompt but temporary relief No objective proof of superiority to placeboNo objective proof of superiority to placebo

ProkineticsProkinetics Improvement of symptoms in mild GERDImprovement of symptoms in mild GERD Effective for healing only mild erosive esophagitisEffective for healing only mild erosive esophagitis Can be useful in a select patient populationCan be useful in a select patient population

HH22RAsRAs Relief of symptoms in ~50% of patientsRelief of symptoms in ~50% of patients Effective for healing only mild erosive esophagitisEffective for healing only mild erosive esophagitis

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Antacids may be no more Antacids may be no more effective than placeboeffective than placebo

Chiba et al. Gastroenterology 1997

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PPIs are the most effective drugs PPIs are the most effective drugs for the initial treatment of GERDfor the initial treatment of GERD

Complications.Complications.

Esophagitis Esophagitis

StricturesStrictures

Barrett esophagusBarrett esophagus

AdenocarcinomaAdenocarcinoma

Respiratory complications: Respiratory complications: pneumonia, asthma, and pneumonia, asthma, and interstitial lung fibrosis.interstitial lung fibrosis.

Complications cont.Complications cont.

Complications cont.Complications cont.

Points to RememberPoints to Remember

Endoscopy reveals that 50% of patients do not Endoscopy reveals that 50% of patients do not have esophagitis. have esophagitis.

The only way to determine if abnormal reflux is The only way to determine if abnormal reflux is present and if symptoms are actually caused by present and if symptoms are actually caused by GERD is through pH monitoring. GERD is through pH monitoring.

Achalasia can present with heartburn. Only Achalasia can present with heartburn. Only esophageal manometry and pH monitoring can esophageal manometry and pH monitoring can be used to distinguish achalasia from GERD. be used to distinguish achalasia from GERD.

Peptic Ulcer DiseasePeptic Ulcer Disease

Peptic ulcers are defects in the Peptic ulcers are defects in the gastrointestinal mucosa that extend gastrointestinal mucosa that extend through the muscularis mucosa. through the muscularis mucosa.

PrevalencePrevalence

Lifetime prevalence is approximately 11-Lifetime prevalence is approximately 11-14% for men. 14% for men.

Lifetime prevalence is approximately 8-Lifetime prevalence is approximately 8-11% for women. 11% for women.

Age trends for ulcer occurrence reveal Age trends for ulcer occurrence reveal declining rates in younger men, declining rates in younger men, particularly for duodenal ulcer, and particularly for duodenal ulcer, and increasing rates in older women. increasing rates in older women.

EtiologyEtiology

Helicobacter pyloriHelicobacter pylori infection infection

Consumption of NSAIDSConsumption of NSAIDS

Severe physiologic stressSevere physiologic stress

Hypersecretory states Hypersecretory states

SymptomsSymptoms

Epigastric painEpigastric pain Nausea Nausea VomitingVomiting DyspepsiaDyspepsia HeartburnHeartburn Chest discomfortChest discomfort Anorexia, weight lossAnorexia, weight loss Hematemesis or melena Hematemesis or melena

SignsSigns

Epigastric tendernessEpigastric tenderness

Epigastric painEpigastric pain

Guaiac-positive stool Guaiac-positive stool

Succussion splashSuccussion splash

DifferentialsDifferentials Biliary Colic Biliary Colic Cholecystitis Cholecystitis Cholelithiasis Cholelithiasis Gastritis, Acute Gastritis, Acute Gastritis, Chronic Gastritis, Chronic Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease Mesenteric Artery Ischemia Mesenteric Artery Ischemia Myocardial Ischemia Myocardial Ischemia Pancreatic Cancer Pancreatic Cancer Pancreatitis, Acute Pancreatitis, Acute Pancreatitis, Chronic Pancreatitis, Chronic

WORKUPWORKUP

Double-contrast radiography Double-contrast radiography

Detection of Detection of H pyloriH pylori infection infection

Endoscopic testsEndoscopic tests

Serum gastrin Serum gastrin

Medical TreatmentMedical Treatment

H. pylori H. pylori eradication: Dual/Triple therapyeradication: Dual/Triple therapy Cessation of NSAIDsCessation of NSAIDs H2-receptor antagonists H2-receptor antagonists Proton Pump InhibitorsProton Pump Inhibitors Prostaglandins Prostaglandins misoprostol misoprostol

SucralfateSucralfate sucrose-aluminum complex promotes ulcer healing sucrose-aluminum complex promotes ulcer healing

FDA-Approved Treatment FDA-Approved Treatment Regimes Regimes

for for H. pyloriH. pylori Infection Infection Omeprazole 20 mg BID + Clarithromycin Omeprazole 20 mg BID + Clarithromycin

500 mg BID + Amoxicillin 1 g BID for 10 days500 mg BID + Amoxicillin 1 g BID for 10 days Lansoprazole 30 mg BID +Clarithromycin Lansoprazole 30 mg BID +Clarithromycin

500 mg BID + Amoxicillin 1 g BID for 10 days500 mg BID + Amoxicillin 1 g BID for 10 days Bismuth subsalicylate (Pepto Bismol) 525 mg Bismuth subsalicylate (Pepto Bismol) 525 mg

QID + Metronidazole 250 mg QID + QID + Metronidazole 250 mg QID + Tetracycline 500 mg QID X 14 days + HTetracycline 500 mg QID X 14 days + H22

receptor antagonist x 4 wksreceptor antagonist x 4 wks

Adjunctive TreatmentAdjunctive Treatment

Caffeine and AlcoholCaffeine and Alcohol - Both of these stimulate - Both of these stimulate the secretion of stomach acid and should be the secretion of stomach acid and should be avoided in the acute phase of an ulcer. avoided in the acute phase of an ulcer.

CigarettesCigarettes - Nicotine will delay the healing of an - Nicotine will delay the healing of an ulcer.ulcer.

AntacidsAntacids - These agents, can be used for relief - These agents, can be used for relief of peptic ulcer symptoms. Except for bismuth of peptic ulcer symptoms. Except for bismuth (Pepto Bismol),- they do not help heal ulcers. (Pepto Bismol),- they do not help heal ulcers.

ComplicationsComplications

HemorrhageHemorrhage Confined Perforation Confined Perforation Open PerforationOpen Perforation Gastric outlet obstructionGastric outlet obstruction RecurrenceRecurrence Stomach cancer:Stomach cancer: Adenocarcinoma, Gastric/MALT Adenocarcinoma, Gastric/MALT

lymphomaslymphomas

Clean Ulcer Induced by AspirinClean Ulcer Induced by Aspirin

Gastric Ulcer H.Pylori & AspirinGastric Ulcer H.Pylori & Aspirin

MCQSMCQS

1) Gold standard for investigating GERD?1) Gold standard for investigating GERD?A) Endoscopic TestsA) Endoscopic Tests

B) Esophageal manometerB) Esophageal manometer

C) Multichannel intraluminal impedanceC) Multichannel intraluminal impedance

D) Bravo SystemD) Bravo System

E) None of the aboveE) None of the above

2) Which of the following statements is false?2) Which of the following statements is false?

A) Antacids are not clearly superior to placebosA) Antacids are not clearly superior to placebos

B) NSAIDS most common cause of PUD B) NSAIDS most common cause of PUD

C) Dysphagia is an alarm symptomsC) Dysphagia is an alarm symptoms

D) H2RA Effective healing only mild esophagitisD) H2RA Effective healing only mild esophagitis

E) Nicotine delays healing of an ulcerE) Nicotine delays healing of an ulcer

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