Transcript GERD Seminar

GERD Seminar
Sally Bowa, RN, MSN, FNP-C
Dr. Hass Jassim,
Objectives:
• Examine general GERD overview,
pathophysiology and disease progression
• GERD symptoms-typical versus atypical
• Comprehensive Diagnosis of GERD
• Our current medical options for treatment
• Current surgical options for treatment
• Surgical interventions-what to expect
What is
GastroEsophogeal
Reflux Disease?
(GERD)
GERD
• It is a chronic, often
progressive disease
• Caused by a weak Lower
Esophageal Sphincter (LES)
• LES is the body’s natural
Lower
barrier to reflux
Esophageal
Esophagus
Sphincter
Duodenum
Stomach
Weak Sphincter (LES)?
•
•
•
•
Unknown
Weakens over time
Family history
Association with hiatal hernias
Hiatal hernia
-Upper part of stomach can
herniate into the chest
cavity
-Can contribute to GERD
symptoms
-If the LES is functioning
normally (barrier), a hiatal
hernia alone does not
necessarily cause GERD
Picture obtained from Medicine Net, Inc.
GERD
SYMPTOMS
Common (typical) Symptoms
•
•
•
•
Heartburn
Regurgitation
Mild dysphagia
Chest pain
Atypical Symptoms
•
•
•
•
•
•
•
•
•
Chronic cough
Hoarseness
Chronic sore throat
Dental problems
Recurrent (aspiration) pneumonia
Worsening asthma
Sleep disturbances
Globus sensation
Bad breath
Complications of GERD
• Esophagitis
• Stricture
Complications of GERD (cont’d)
• Pulmonary
-Poor asthma control
-Cough
-Aspiration pneumonia
-pulmonary fibrosis
• ENT
-Hoarseness
-Voice changes
-Chronic ear infections
-Chronic sinusitis
-Sore throat
-Globus sensation
Complications of GERD (cont’d)
• Barrett’s esophagus
Barrett’s Esophagus cont’d
Esophageal Cancer
• Incidence of adenocarcinoma arising out of
Barrett’s esophagus is rising dramatically
(Uptodate, 2015).
• Risk factors:
–
–
–
–
Long standing GERD (>20 years)
Severe symptoms
Smoking
Obesity
Comprehensive evaluation of GERD
• Patient visit
• Arrange for endoscopic
evaluation
• Additional testing if needed
• Esophageal manometry
• Barium esophogram
Upper endoscopy
-VISUAL Evalution
-Rule out significant lesion
-Obtain biopsies (microscopic evaluation)
-Rule out Barrett’s esophagus, EoE,
candida, adenocarcinoma
-Placement of pH monitor
Indications for EGD
•
•
•
•
•
•
Breakthrough symptoms on PPIs
Long-standing GERD (>5 years)
Rule out other pathology
Dysphagia
Barrett’s surveillance
Screening
– Male, smoker, obese, >50 yrs
Ambulatory pH testing
-PHYSIOLOGIC evaluation
-Most accurate test to
establish diagnosis of GERD
-
Case Study #1
Patient #1
Case Study #2
Patient #2
Esophageal Manometry
• Functional evaluation of
esophagus and LES
Case study #1 cont’d
Case study #2 cont’d
Barium Esophogram
• Visualizes the swallowing
mechanism, esophagus
• Contrast study using barium
• Radiopaque
• Appears white on the film
Symptom Management &
Treatment Options
Dietary Modification
• Avoid trigger foods
–
–
–
–
–
–
Fatty, spicy or fried foods
Tomato based products
Caffeine
Chocolate
Alcohol
Carbonated beverages
Lifestyle Modifications
•
•
•
•
Bed blocks
Avoid overeating
Lose excess weight
Avoid postprandial
recumbency
Medical Therapy
Antacids
H2 Blockers
Proton Pump Inhibitors
Mylanta
Pepcid
Aciphex
Pepto-Bismol
Tagamet
Nexium
Rolaids
Zantac
Prevacid
Tums
Prilosec
Medical therapy
BENEFITS
► Reduces the amount of acid in the stomach
► May reduce inflammation of esophageal
lining
► Provides symptom relief for many patients,
but relief can be temporary
LIMITATIONS
► DOES NOT affect the cause of reflux (LES)
► DOES NOT prevent reflux
► May require life-long use and dose escalation
PPI side effects
• Common side effects:
– Diarrhea or constipation
– Nausea
– Headache
•
•
•
•
Decreased calcium absorption
Increased pneumonia risk
Decreased Plavix efficacy
Decreased magnesium absorption
Potential Risks of Long
term PPI use
• FDA alerts
FDA: Possible Fracture Risk with High Dose,
Long-term Use of Proton Pump Inhibitors
May 25, 2010
Labeling changes will include new safety information
The U.S. Food and Drug Administration today warned consumers
and health care professionals about a possible increased risk of
fractures of the hip, wrist, and spine with high doses or long-term
use of a class of medications called proton pump inhibitors. The
product labeling will be changed to describe this possible increased
risk.
FDA Drug Safety Communication: Low magnesium
levels can be associated with long-term use of
Proton Pump Inhibitor drugs (PPIs)
March 2, 2011
Safety Announcement
The U.S. Food and Drug Administration (FDA) is informing the public that
prescription proton pump inhibitor (PPI) drugs may cause low serum
magnesium levels (hypomagnesemia) if taken for prolonged periods of time
(in most cases, longer than one year). In approximately one-quarter of the
cases reviewed, magnesium supplementation alone did not improve low
serum magnesium levels and the PPI had to be discontinued.
FDA Drug Safety Communication: Clostridium difficile-associated
diarrhea can be associated with stomach acid drugs known as proton
pump inhibitors (PPIs)
February 8, 2012
Safety Announcement
The U.S. Food and Drug Administration (FDA) is informing the public that the use of stomach acid drugs
known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–
associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop
diarrhea that does not improve. Patients should immediately contact their healthcare professional and seek
care if they take PPIs and develop diarrhea that does not improve.
Antisecretory Medications
Percentage of patients experiencing
breakthrough symptoms while on a PPI
(among all patients)
62%
NO
Breakthrough
Symptoms
Why might medication not be effective?
•
Disease is progressing – sphincter
is getting worse and medication no
longer is enough
•
They have symptoms that do not
respond well to medication
ie: regurgitation, chronic cough,
hoarseness or asthma
•
Reflux is not the primary cause of
their symptoms – need to see
Reflux Specialist for testing
38%
Breakthrough
Symptoms
Patient profile with
Progressive disease
• Family history of GERD
• Takes PPIs with complusive regularity
• Has increased symptom severity after 1
year of PPI therapy
• Requires dose escalation of PPIs to
control symptoms
• Esophagitis on baseline endoscopy
• Esophagitis remaining unhealed after PPI
therapy
• Barrett’s esophagus
Surgical Options for GERD
•
•
•
•
•
•
•
Medically refractory GERD
Esophagitis despite meds
History of Barrett’s
Concerned with PPI side effects
Intolerant of meds/side effects
Interest in alternative options
Concern/awareness of Barrett’s esophagus
or esophageal cancer
• QOL
• Hiatal hernia
Surgery options
Nissen fundoplication
LINX-magnetic sphincter
augmentation
• Dr. Jassim’s presentation