Gastroenterology Lecture (GERD + Barret's) Lecture Notes PDF

GASTROENTEROLOGY LECTURE INTRODUCTION  Team.. Daniela Dobru - course coordinator Danusia Onisor Adina Andone Crina Pop Andrei Ioanovici REFERENCES FINAL EVALUATION GASTROESOPHAGEAL REFLUX DISEASE ...

GASTROENTEROLOGY LECTURE INTRODUCTION  Team.. Daniela Dobru - course coordinator Danusia Onisor Adina Andone Crina Pop Andrei Ioanovici REFERENCES FINAL EVALUATION GASTROESOPHAGEAL REFLUX DISEASE  Ben A 22- year-old student with heartburn and acid regurgitation more frequent after spicey food and drinking. The symptoms have improved every time after antiacids. No important family history After attending the GERD lecture he was concerned about the risk of developing Barrett esophagus.  David A 55-year-old obese man with longstanding heartburn complained that he was experiencing more frequent breakthrough symptoms than in the past. He also indicated that he felt fluid in the back of his throat at night He was taking esomeprazole 40 mg twice daily but expressed frustration about both the need for and cost of daily medication. He was concerned about PPIs long therapy  John A 6o-year-old man with longstanding heartburn( 20 y) Past smoker 20 c/day 25 ys He also indicated that he felt acid regurgitation at night and in the last month he has difficulty in swallowing the solid food. He was taking esomeprazole 40 mg twice daily for the last 5 y.  Q..... What’s next ? What are the most important informations from the medical history ? Whom do we have to investigate ? Diagnosis ? Treatment ? Prognosis ? Complications ? DIFFERENCES BETWEEN THE 3 PTC....  Definitions Gastro-esophageal reflux = condition in which the content of stomach return into the esophagus GERD = refers to reflux that produces frequents simptoms and results in demage of the es.mucosa or in the respiratory sistem.  Etiology A functional or mechanical problem of the LES Excessive retrograde movement of acid- containing gastric secretions or bile from the duodenum and stomach into the esophagus Foods (coffee, alcohol, chocolate, fatty meals) Medications (beta-agonists, nitrates, calcium channel blockers, anticholinergics), hormones (eg, progesterone), and nicotine.  Aditional Factors that lead to symptoms or injury of the mucosa of the esophagus or the airway include : transient lower esophageal sphincter relaxations (TLESRs), hiatal hernia, poor acid clearance from the esophagus, diminished salivary flow, reduced mucosal resistance to injury, increased acid production, delayed gastric emptying of solids, obstructive sleep apnea Causes of increased exposure of the esophagus to gastric refluxate. The distal esophageal high-pressure zone (HPZ)  Hiatal Hernia HH may contribute to reflux via a variety of mechanisms: The LES may migrate proximally into the chest and lose its abdominal high-pressure zone (HPZ) The length of the HPZ may decrease The diaphragmatic hiatus may be widened by a large hernia Gastric contents may be trapped in the hernial sac  Mechanism of action of refulate in GERD The steps which lead to tissue damage and sypmtoms The mechanism for extraesophageal manifestations  The mechanism for extraesophageal manifestations 1.direct aspiration or damage of mucosa in the respiratory tract 2.vagally mediated reflex triggered by acidification of the distal esophageal mucosa Subglottic stenosis and granuloma of the vocal cords are very serious consequences of reflux caused by direct contact injury of the delicate mucosa of the airway, resulting in stridor, cough, or dysphonia  Epidemiology 40% of the adult population in the United States report heartburn monthly and 18% report it weekly GERD becomes more common with increasing age Of patients who have endoscopy for GERD : 10% have benign strictures 3% to 4% have Barrett’s esophagus an extremely small number have adenocarcinoma Text  Simptoms Heartburn (defined as retrosternal burning ascending toward the neck) Acid regurgitation (the unpleasant return of sour or bitter gastric contents to the pharynx) Patient symptoms of “GERD,” “reflux,” and “heartburn” should be differentiated from the burning epigastric sensation of dyspepsia ( site ! ) patients may use different and imprecise terms to describe their symptoms, such as “indigestion,” “stomach upset,” and “sour stomach”  Heatburn , regurgitation Reflux is more common after meal (1 to 3 hours after eating) Reflux may occur also at night or in suspine Meals and beverages that increase reflux Smoking  Extraesophageal Symptoms cough, wheeze, hoarseness, sore throat, repetitive throat clearing, postnasal drip, neck or throat pain, globus, apnea, or otalgia.  Atypical Symptoms of Gastroesophageal Reflux Disease GERD may cause many different clinical syndromes: angina -like sy. respiratory sys The more common or dangerous causes of these syndromes should be evaluated first.  Angina-like chest pain GERD is the most common esophageal cause of noncardiac chest pain. It may be indistinguishable from cardiac pain. Because of the potential fatal significance of cardiac pain, it is imperative that cardiac investigation precede esophageal investigation  According to the guidelines: patients with symptoms and history consistent with uncomplicated GERD=>the diagnosis of GERD may be assumed => empirical therapy patients who show signs of GERD complications or other illness or who do not respond to therapy should be considered for further diagnostic testing.  DIAGNOSTIC TESTS FOR GASTROESOPHAGEAL REFLUX DISEASE Diagnostic tests are unnecessary for most persons with GERD Investigations should be conducted in : patients who have alarm symptoms, equivocal results on a treatment trial, atypical symptoms those undergoing surgical or endoscopic therapy for GERD.  The association of chronic GERD with Barrett esophagus and the inherent risk of progression from Barrett esophagus to adenocarcinoma of the esophagus have been established. Consequently, any patient aged 50 years or older, male or female, with a history of chronic GERD should have at least a 1-time upper endoscopy to screen for Barrett esophagus  DIAGNOSTIC TESTS Mandatory tests : upper GI endoscopy confirm the diagnosis of reflux by demonstrating complications of reflux (esophagitis, strictures, Barrett esophagus) evaluate the anatomy (eg, hiatal hernia, masses, strictures). manometry helps surgical planning by determining the LES pressure and identifying any esophageal motility disorders.  DIAGNOSTIC TESTS Optional studies : 24-hour pH probe test - INDICATIONS : confirm the diagnosis in patients in whom the history is not clear, atypical symptoms dominate the clinical picture, endoscopy shows no complications of reflux disease. upper GI series - INDICATIONS : delineate the anatomy inadequate gastric emptying  Endoscopic Examination allows direct visualization of the esophageal mucosa. characteristic finding : linear erosions in the distal esophagus. ).  Esophagus Barium Upper Gastrointestinal Tract Series It is of limited usefulness in the evaluation of patients with GERD. Its major indication in GERD is to identifying strictures and large hiatal hernias.  Ambulatory Esophageal pH Monitoring The test is performed with a probe that has a pH sensor at its tip. The tip is placed 5 cm above the proximal border of the lower esophageal Reflux of acid is defined as a sudden decrease in intraesophageal pH 70 yo of patients younger than 39 yo More likely to develop severe disease More likely to be poorly diagnosed or underdiagnosed Due to atypical symptoms Always look for medication causes  GERD in the elderly Alarm symptoms : Dysphagia Vomiting Weight loss Anemia Anorexia Typical symptoms are less frequent  GERD in the Elderly Diagnosis should always include endoscopy Prokinetic agents should be avoided PPI’s are medications of choice for acute episodes and prevention of recurrence due to efficacy, safety, and tolerability Step down approach is preferred – more clinically effective and more cost effective  Refractory Reflux Definition : symptoms of GERD that are refractory to treatment with regular dosages of proton pump inhibitors.  Surgical treatment. For many years, antireflux surgery was performed through a transabdominal or transthoracic approach, with considerable morbidity. laparoscopic antireflux procedure : With well-chosen patients and experienced surgeons, an 80% to 90% success rate is expected The success rate decreases : if the patients have symptoms refractory to PPI poorly documented reflux disease if the procedure is performed by less experienced surgeons Laparoscopic Nissen fundoplication.  ENDOSCOPIC VIEW Part of the esophagus is wrapped around the esophagus BARRETT’S ESOPHAGUS AND ESOPHAGEAL CANCER  Definition -ESGE statement The diagnosis of BE is made if the distal esophagus is lined with columnar epitelium with a minimum length of 1 cm ( tongue or circular )containing specialized intestinal metaplasia at histopathological examination  Definitions Barrett’s esophagus is the strongest risk factor known for esophageal adenocarcinoma Endoscopic and pathologic criteria need to be met to make the diagnosis of Barrett’s esophagus. Endoscopy must demonstrate salmon-colored mucosa in the tubular distal esophagus Biopsy specimens must show intestinal metaplasia with goblet cells (so-called specialized intestinal metaplasia).  short-segment Barrett’s esophagus :salmon- colored epithelium less than 3 cm in length seen at endoscopy long-segment Barrett’s esophagus : salmon- colored segment of specialized intestinal metaplasia > 3 cm long. Intestinal metaplasia of the cardia refers to intestinal metaplasia with goblet cells at a normally located and normal appearing squamocolumnar junction (the so-called zig-zag line, or Z line) intestinal metaplasia of the cardia is not classified as Barrett’s esophagus  risk factors : reflux symptoms, advancing age, male sex , white race. alcohol use and exposure to nicotine The role of genetics and obesity is being investigated  2.Cancer risk in Barrett‘s Esophagus Different reports on cancer incidence ranging between 0.2% ~ 1.9% Meta analysis from 57 studies resulted in 0.33% incidence in all BE patients 0.19% incidence in short-segment BE if nondysplastic B at index endoscopy Desai et al. Gut. 2012 Jul;61(7):970-6.  Cancer Risk The risk of developing cancer is higher among patients with dysplasia at index endoscopy compared to patients with non-dysplastic BE. non-dysplastic BE -the annualy incidence of EAC is 0,12%-0,43 % low grade dysplasia BE :the risk of progression to high grade dysplasia or EAC is estimated at 4.7%-13.4%/patient/year BE-associated dysplasia is an important marker for risk of progression to esophageal adenocarcinoma and an indication for non-invasive endoscopic therapy. Endoscopic surveillance for dysplasia and intramucosal adenocarcinoma is the gold standard for the management of BE patients and represents an opportunity for curative therapy.  CANCER RISK Barrett’s Esophagus annually, esophageal adenocarcinoma develops in 0.5% of patients with Barrett’s esophagus a 50-year-old man with Barrett’s esophagus and otherwise normal life expectancy has a 3% to 10% lifetime risk (cumulative incidence) of developing esophageal adenocarcinoma The most important risk factor for predicting neoplastic progression is the degree of dysplasia  Prevalence of Barrett’s Esophagus Minesotta study The number of new cases of long-segment Barrett’s esophagus diagnosed per 100,000 population per year increased from 0.37 in 1965- 1969 to 10.5 in 1995-1997, a 28-fold increase  The increase can be explained by two phenomenons: increased recognition by physicians, especially of short-segment Barrett’s esophagus, increased detection because of increased use of diagnostic endoscopy  Pathophysiology Barrett’s esophagus is an acquired disorder in which columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus. occur in response to years of reflux of gastric contents into the distal esophagus  History and Physical Examination The classic history for a patient with Barrett esophagus : a middle-aged white man with a chronic history of gastroesophageal reflux +/- obesity  Endoscopy + biopsy = goldstandard dg The risk of progression from Barrett esophagus to adenocarcinoma of the esophagus have been established. =>any patient aged 50 years or older + history of chronic GERD should have at least a 1-time upper endoscopy to screen for Barrett esophagus.  SURVEILLANCE GUIDE -lines The ESGE / AGA recommend : biopsy specimens are to be collected from every quadrant at 2cm intervals along the length of the segment + focal lesions :nodules, raised edges of an ulcer, or stricture. dysplasia is the best indicator of cancer risk.  High-Grade Dysplasia If at least two gastrointestinal pathologists agree on the presence of HGD four major options are available: 1) observation ( PPI regimen + endoscopy will be performed every 3 months, 2) endoscopic mucosal resection, followed by photodynamic therapy; 3) photodynamic therapy alone 4) esophagectomy. Patient with early malignant changes in Barrett‘s Esophagus Pa ge 98 Pa ge 99 Pa ge 100 DBE  Mucosal pattern irregular patterns Vascular pattern vessels not following normal architecture of the mucosa  Treatment PPI? Radiofrequency Ablationan Cryotherapy Endoscopic Mucosal Resection (EMR): a specialized endoscopic technique used to remove large areas of early cancers Esophagectomy: a major surgical procedure that involves removing the esophagus and top part of the stomach, and creating a new esophagus from remaining healthy stomach and esophagus or pharynx  Radiofrequency Ablationan -electrode, mounted either on a balloon catheter or an endoscope, delivers heat energy to the diseased lining of the esophagus 105  Cryotherapy : Barrett’ esophagus tissue is exposed to very cold temperatures, leading to the tissue’s destruction Endoscopic image showing an area just treated with cryotherapy. The white area is frozen Barrett's mucosa  Endoscopic mucosal resection ESGE guideline Indication : patients with high-grade dysplasia or early cancer in a nodule that is less than 2 cm in diameter and T1a (intramucosal) in depth. Pa ge 109 Indication :