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Upper GI Disorders

Upper GI Disorders. Jonathan P Kushner, MD Associate Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine February 2018.

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Upper GI Disorders

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  1. Upper GI Disorders Jonathan P Kushner, MD Associate Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine February 2018

  2. A 25 year old male medical student complains of frequent awakening over the past few months due to burning regurgitant in his chest and mouth; he is overweight but otherwise healthy and on no medication. All of the following are likely contributors to his presentation except: • He gets home from the hospital around 9 PM, eats a quick dinner and goes to bed • He has developed a small hiatal hernia • His regular consumption of orange juice each morning • His lower esophageal sphincter relaxes frequently between meals

  3. GERD • When the reflux of stomach contents causes troublesome symptoms and/or complications (esophagitis, bleeding, strictures, aspiration, Barrett’s/esophageal adenocarcinoma) • 10-20% in Western world • Typical symptoms (heartburn, regurgitation); 25% monthly; 12% weekly; 5% daily; unreliable predictors of erosive disease • Most GERD is non erosive (NERD); more severe acid exposure results in erosive esophagitis (LA classification) Montreal definition and classification of gastroesophageal reflux disease (Vakil, Am J Gastro 2006)

  4. GERD determined by: frequent LES relaxation (TLESR’s); weak LES; hiatal hernia; increased intraabdominal pressure; impaired gastric emptying; position, refluxate (acid, pepsin, bile); esophageal clearance; saliva, tissue resistance

  5. Pathophysiology of GERD Foods that increase reflux: beer, chocolate, coffee, peppermint, fatty food Meds that may increase reflux: nitrates, progesterone, calcium channel blockers, beta agonists, anticholinergics, diazepam, alpha agonists

  6. GERD Atypical symptoms: • dyspepsia • chest pain - GERD #1 esophageal cause of non cardiac chest pain PPI test showed diagnostic utility (vs EGD/probes) functional chest pain (Rome): non burning; no evidence GERD or dysmotility • asthma • enamel changes • cough (recumbent) • hoarseness • sore throat/throat clearing ? symptoms of laryngopharyngeal reflux (LPR); • globus , VCD exam non specific; heartburn only in 40%/ less esophagitis; more UES issues; ? sensitive laryngeal tissue

  7. GERD Diagnosis • PPI trial • EGD indications: alarm symptoms, Barrett’s screen, ???refractory disease • Ambulatory measure of pH (implanted capsule) or pH and impedance by probe on or off medication • Esophagram shows reflux in 25% of normals

  8. GERD Therapy • Lifestyle measures (little data) • H2 blockers (50% healing and maintenance); PPIs 90% healing/80% maintenance (take 30-60 mins ac); PPI OK with clopidogrel (Consensus, 2010). • PPI’s - ? infection (pneumonia/C diff); fractures; B12/Mg absorption, renal disease, dementia; AGA Mar 2017 use at lowest effective dose in complicated GERD; attempt reduction/stop in uncomplicated GERD • Antireflux surgery (fundoplication) in good responders, large hiatal hernia, predominant regurgitation; caution in others; ? magnetic sphincter augmentation system

  9. GERD Refractory reflux : • wrong diagnosis (cardiopulmonary, chest wall) • more severe anatomy (large hernia, extremely low LES barrier) • compliance, dosing, rapid metabolizer • hyperacidity (ZES) • primary dysmotility (achalasia) • impaired gastric emptying • functional heartburn/chest pain (treat antidepressants, CBT)

  10. Upper GI Disorders A 25 year old male medical student complains of frequent awakening over the past few months due to burning regurgitant in his chest and mouth; he is overweight but otherwise healthy and on no medication. All of the following are likely contributors to his presentation except: • He gets home from the hospital around 9 PM, eats a quick dinner and goes to bed • He has developed a small hiatal hernia • His regular consumption of orange juice each morning • His lower esophageal sphincter relaxes frequently between meals

  11. Upper GI Disorders A 25 year old male medical student complains of frequent awakening over the past few months due to burning regurgitant in his chest and mouth; he is overweight but otherwise healthy and on no medication. All of the following are likely contributors to his presentation except: • He gets home from the hospital around 9 PM, eats a quick dinner and goes to bed • He has developed a small hiatal hernia • His regular consumption of orange juice each morning • His lower esophageal sphincter relaxes frequently between meals

  12. A 25 year old male medical student complains of frequent awakening due to regurgitant in his chest and mouth; he feels difficulty swallowing both liquids and solids in the mid chest. Which of the following descriptions seems least likely? • The student in case 1 with GERD left untreated over an additional 6 months • A patient whose manometric swallow study will show a non relaxing lower esophageal sphincter and aperistalsis • A patient whose endoscopy will reveal many coarse rings and who will respond to swallowed topical steroids? • A patient whose hands reveal sclerodactyly and telangiectasias.

  13. Dysphagia Oropharyngeal (transfer) • Cough/choke/aspiration/nasal regurgitation; solid and liquids • Neuromuscular causes (eg myasthenia, stroke) • Structural (osteophyte, thyroid, Zenckerdiverticulum) • SLP evaluates with MBS or FEES

  14. Dysphagia Esophageal Mechanical – Solids before liquids Ring, tumor; eosinophilicesophagitis (EoE); proximal web (Plummer Vinson/; iron deficiency); strictures (reflux, neoplasm, EoE, caustic ingestion); extrinsic compression Dysmotility – • Spasm - chest pain; precipitated by extreme temperature/ carbonation treat underlying GERD; warm liquids, calcium ch blockers, nitrates, sildenafil, trazadone/imipramine; Botox/dilation/surgery • Scleroderma (low LES) • Achalasia • Other – aperistalsis, jackhammer, ineffective motility

  15. Normal high resolution contraction Achalasia – progressive liquid/solid; regurgitation; “heartburn”. Rule out secondary achalasia. Treatment: Botox; serial pneumatic dilation ~ myotomy (ACG 2013); POEM/stents/esophagectomy

  16. Eosinophilic Esophagitis (EoE) • Increasing incidence; 15 % of EGD for dysphagia; M >> F; increased eotaxin 3 response to IL-13 (Th2) • Requires symptoms, > 15 eos/hpf; absence of other conditions • Atopy in 50%; peripheral eos in 30% • PPI responsive > 30% • Topical swallowed steroids - complete histo response 60-70% • Elemental diet 90% effective; SFED 70% (especially milk/wheat in adults) • Cautious dilation successful in > 85%, with low perforation rate • ? endpoints in adults

  17. Odynophagia Inflammation/infections • Infections mostly in immunocompromised • Candida >> viral HSV/CMV • Pill esophagitis – cyclines, KCl, bisphosphonate, vit C; take all pills upright

  18. Upper GI Disorders A 25 year old male medical student complains of frequent awakening due to regurgitant in his chest and mouth; he feels difficulty swallowing both liquids and solids in the mid chest. Which of the following descriptions seems least likely? • The student in case 1 with GERD left untreated over an additional 6 months • A patient whose manometric swallow study will show a non relaxing lower esophageal sphincter and aperistalsis • A patient whose endoscopy will reveal many coarse rings and who will respond to swallowed topical steroids? • A patient whose hands reveal sclerodactyly and telangiectasias.

  19. Upper GI Disorders A 25 year old male medical student complains of frequent awakening due to regurgitant in his chest and mouth; he feels difficulty swallowing both liquids and solids in the mid chest. Which of the following descriptions seems least likely? • The student in case 1 with GERD left untreated over an additional 6 months • A patient whose manometric swallow study will show a non relaxing lower esophageal sphincter and aperistalsis • A patient whose endoscopy will reveal many coarse rings and who will respond to swallowed topical steroids? • A patient whose hands reveal sclerodactyly and telangiectasias.

  20. Upper endoscopic esophageal screening should be performed in which patient? • A 20 year old African American male with nightime regurgitation about once a month after late dinner/work conferences • An asymptomatic 49 year old Caucasian bus driver who achieved excellent control of longstanding nighttime reflux after starting a once daily PPI 3 years ago. • A 30 year old alcoholic Caucasian female with a normal CBC • A 25 year old Haitian man whose dyspepsia has resolved after recent therapy for H pylori found on stool testing

  21. Biopsy if > 1 cm Z line variability (ACG Guidelines 2015)

  22. Barrett’s esophagus • 600 fold increase in adenoCA of esophagus over 25 years; ? increased GERD, refined food, ? hr – HPV; decreased H pylori • Barrett’s 1.5- 7% of Western populations • Risk estimates of CA in non dysplastic Barrett’s have declined to 0.12% (? predictors may include hr HPV, p16/p53 inactivations, long segment Barrett’s) • Screen Males with chronic(> 5 yr) frequent (weekly) GERD and 2 or more risks (> 50, Caucasian, smoker, waist > 102 cm (abd adiposity); family hx (ACG 2015); ?? hiatalhernia Females only if multiple risks

  23. Barrett’s esophagus Survey Barrett’s metaplasia at 1 year, then every 3-5 yrs; low grade dysplasia every 6-12 months. Therapy GERD/PPI; ? roles for ASA/NSAIDs/statins Growing evidence for radiofrequency ablation (RFA) of LGD (Phoa, JAMA 2014, reduced progression from 26 to < 2%); and HGD. EMR and RFA in intramucosal CA above the m. mucosa

  24. Esophageal Cancer • Adenocarcinoma superseded squamous cell cancer in the past 2 decades in the US • Risks for squamous cell CA – achalasia/stasis, tylosis, PVS, lye ingestion, radiation, smoking, alcohol, HPV

  25. Esophageal Cancer • Esophageal CA staging after biopsy confirmation • CT scan +/- PET scanning to exclude metastatic disease, then EUS for local staging • More than half of patients present with at least locally advanced disease precluding initial surgical cure, and impacting prognosis

  26. Upper GI Disorders Upper endoscopic esophageal screening should be performed in which patient? • A 20 year old African American male with nightime regurgitation about once a month after late dinner/work conferences • An asymptomatic 49 year old Caucasian bus driver who achieved excellent control of longstanding nighttime reflux after starting a once daily PPI 3 years ago. • A 30 year old alcoholic Caucasian female with a normal CBC • A 25 year old Haitian man whose dyspepsia has resolved after recent therapy for H pylori found on stool testing

  27. Upper GI Disorders Upper endoscopic esophageal screening should be performed in which patient? • A 20 year old African American male with nightime regurgitation about once a month after late dinner/work conferences • An asymptomatic 49 year old Caucasian bus driver who achieved excellent control of longstanding nighttime reflux after starting a once daily PPI 3 years ago. • A 30 year old alcoholic Caucasian female with a normal CBC • A 25 year old Haitian man whose dyspepsia has resolved after recent therapy for H pylori found on stool testing

  28. A 28 year old computer programmer born in Bellevue, Washington, complains of a mild epigastric fullness, intermittently since college, particularly when eating out. He denies typical GERD symptoms. He also denies regular NSAID use or other medications. He has gained about 5 pounds this year due to reduced physical activity. He wants to know if an upper endoscopy should be done. You suggest: • Stool antigen test for H pylori with treatment if positive • Gastric emptying study at Nuclear Medicine • Reassurance, a diet diary and a follow up visit in 3 months to evaluate further diagnostic/therapeutic options • Start PPI acid suppression twice per day with an upper endoscopy next week to exclude peptic ulcer

  29. Dyspepsia • Symptoms attributed to the luminal upper GI tract, often related to ingestion – discomfort/pain; fullness/satiety; (bloating, nausea); affects up to 40% of population • Clinically exclude carbohydrate intolerance, SIBO, malabsorption/celiac, ischemia/vascular disease, pancreatic/biliary disease, aortic aneurysm, cardiopulmonary disease • Majority is functional dyspepsia (FD); less commonly attributed to non erosive GERD, peptic ulcer disease, medication induced dyspepsia, gastroparesis, neoplasm, infiltrative diseases, metabolic • Alarm symptoms – anemia, vomiting, weight loss and/or age > 55 should prompt upper GI imaging (EGD)

  30. Dyspepsia Management options: (in absence of red flags or < 55 yo) • Investigate/imaging • Test and treat H pylori; NNT = 17 for response; cost effective if > 12% prevalence • PPI’s/acid suppression • Buspirone, low dose nortriptyline, mirtazepine • Psychology, reassurance

  31. Nausea/Vomiting in Adults(differentiate vomiting from free regurgitation, rumination) Common Uncommon CNS stroke, seizure, mass, pseudotumor, Meniere’s, meningitis, hydrocephalus, trauma GI adhesions, hernia, obstruction, ischemia, peritonitis, dysmotility Infections CNS (abscess, encephalitis, meningitis), pneumonia Metabolic adrenal, parathyroid, thyroid CNS • Benign Positional Vertigo • Migraine • Motion Sickness • Cyclic Vomiting Syndrome/Cannabis Hyperemesis GI • GERD • PUD/gastritis • Gastroparesis • Biliary/pancreatic • Appendicitis Infections • Bacterial/viral gastroenteritis/Foodborne • Pyelonephritis Metabolic • DKA, pregnancy, uremia Other: kidney stones, myocardial infarction, glaucoma medications/toxins/withdrawal, pain, psych

  32. Nausea and Vomiting Classes of antiemetic agents: Anticholinergic: Scopolamine Antihistamine: Meclizine, hydroxyzine Phenothiazine: Prochlorperazine,promethazine Benzamide: Trimethobenzamide, metoclopramide Butyrophenone: Droperidol Serotonin (5-HT3) antagonist: Ondansetron, granisetron Neurokinin-1 antagonist: Aprepitant Corticosteroid: Dexamethasone Benzodiazepine: Lorazepam, diazepam Cannabinoid: Dronabinol

  33. Gastroparesis • Nausea/satiety/fullness; vomiting, bloating, pain in more severe (overlap with dyspepsia); bezoars • Idiopathic > diabetes > other etiologies • EGD/imaging to exclude obstruction • Diagnosis: Gastric emptying study > 60% retention at 2 hrs; > 10% at 4 hours (other: capsule, sonography, MRI, 13C breath tests) adjust meds, glucose control • Symptom correlation with gastric emptying studies poor

  34. Gastroparesis Treatment (2013 ACG): - diet (liquid predominant !) - glucose control - antiemetics - prokinetics (metoclopramide OK) - gastric electrical stimulation (diabetics) - acupuncture - Botox (not routinely recommended) - feeding tubes/surgery

  35. Gastritis/H.Pylori • Autoimmune (type A) gastritis; gastric body predominant; associated pernicious anemia, hypochlorhydria, type I carcinoids, adenocarcinoma • H Pylori • Type B, antral predominant. • H pylori prevalence in West 20%; decreasing • Assess H pylori status in documented PUD, MALT B cell lymphoma, early gastric CA, pre ASA/NSAID use; ? in IDA, FD, ITP, chronic urticaria • False negative (stool, breath) testing possible with PPI or antibiotic use; active bleed • Serology does not reflect persistent infection

  36. H.Pylori Therapy: • Amoxicillin, tetracycline, bismuth do not develop resistance • If no macrolide exposure and clarithramycin resistance < 15%: amoxicillin/clarithramycin/PPI for 14 days • Otherwise: Tetracycline/Bi+/Flagyl/PPI; or sequential amox 5d, then clarith/flagyl 5d; or amox + levo or amox + cipro+ rifabutin (Toronto/AGA 2016; ACG 2017)

  37. Upper GI Disorders A 28 year old computer programmer born in Bellevue, Washington, complains of a mild epigastric fullness, intermittently since college, particularly when eating out. He denies typical GERD symptoms. He also denies regular NSAID use or other medications. He has gained about 5 pounds this year due to reduced physical activity. He wants to know if an upper endoscopy should be done. You suggest: • Stool antigen test for H pylori with treatment if positive • Gastric emptying study at Nuclear Medicine • Reassurance, a diet diary and a follow up visit in 3 months to evaluate further diagnostic/therapeutic options • Start PPI acid suppression twice per day with an upper endoscopy next week to exclude peptic ulcer

  38. Upper GI Disorders A 28 year old computer programmer born in Bellevue, Washington, complains of a mild epigastric fullness, intermittently since college, particularly when eating out. He denies typical GERD symptoms. He also denies regular NSAID use or other medications. He has gained about 5 pounds this year due to reduced physical activity. He wants to know if an upper endoscopy should be done. You suggest: • Stool antigen test for H pylori with treatment if positive • Gastric emptying study at Nuclear Medicine • Reassurance, a diet diary and a follow up visit in 3 months to evaluate further diagnostic/therapeutic options • Start PPI acid suppression twice per day with an upper endoscopy next week to exclude peptic ulcer

  39. Your patient’s colleague also presents for an evaluation. He has missed work 6 times in the past year for periods of severe nausea, mild abdominal discomfort and emesis with volume depletion. The episodes last around a week; when they resolve he feels fairly normal, eats regularly again, and regains weight lost. • Ask if anyone in his family suffers from migraine headaches • Send HLA typing to exclude celiac disease • Inquire as to any use of marijuana • Discuss a trial of amitriptyline at bedtime

  40. Upper GI Disorders Your patient’s colleague also presents for an evaluation. He has missed work 6 times in the past year for periods of severe nausea, mild abdominal discomfort and emesis with volume depletion. The episodes last around a week; when they resolve he feels fairly normal, eats regularly again, and regains weight lost. You might do all but the following: • Ask if anyone in his family suffers from migraine headaches • Send HLA typing to exclude celiac disease • Inquire as to any use of marijuana • Discuss a trial of amitriptyline at bedtime History very suggestive of Cyclic Vomiting Syndrome

  41. Upper GI Disorders A 59 year old male undergoes an upper endoscopy for persistent dyspeptic symptoms and mild microcytic anemia. He had a normal colonoscopy last year. He takes low dose aspirin daily for known coronary artery disease and admits to using Advil at least 4 days a week for right knee pain. The EGD reveals a 1.5 clean based ulcer in the duodenal sweep. You should: • Admit him directly for IV PPI therapy • Begin oral PPI therapy to continue indefinitely • Schedule a follow up EGD for 8 weeks to assess ulcer resolution • Omit H pylori testing in this case since he admitted to NSAID use

  42. Peptic Ulcer Disease • Prevalence remains high as H pylori declines, NSAID use rises (> 70% over 65 at least weekly); OTC’s. • Idiopathic (20%) increasing; recheck drug history/H pylori; consider Crohn’s, CMV, ischemia/cocaine, Zollinger Ellison, infiltrative, neoplasm • 80% of NSAID ulcer complications present without warning symptoms • H pylori eradication heals DU, GU and prevents recurrence

  43. NSAID Co Protection

  44. Upper GI Bleeding - Etiology • Peptic ulcer • Mucosal lesion/erosion • Portal HTN/varices • Mallory Weiss • Gastritis/esophagitis/erosive gastropathy • Dieulafoy lesion • Neoplasm • GAVE • Angiodysplasia • Aortoenteric fistula • Hemobilia

  45. UGI bleeds(ASGE guidelines 2012) • Mortality unchanged ~ 10% • Bright red hematochezia from upper source only if hemodynamically unstable • First steps; IV access/resuscitation, cardiac assessment, ? intubation • Intervention – for high Blatchford score vs risk factors of cirrhosis/malignancy/red hematemesis, hypotension/tachycardia/Hb < 8

  46. UGI bleeds(ASGE guidelines 2012) • For PUD, PPI started before endoscopy reduces intervention; use octreotide/antibiotics in suspected portal HTN • IV prokinetics 20-120 min before endoscopy decreases need for 2nd look • Early EGD (24 hrs) reduces LOS/transfusions; rebleeding reduced to < 20% with endotherapy, < 10% with concomitant PPI therapy, especially if continued for 72 hrs; 2nd look beneficial for rebleeding • ICU stress ulcers: prophylax ventilated/anticoagulated patients

  47. Stigmata of Ulcer Hemorrhage Prediction of Rebleeding Visible Vessel (22%) 50-70% rebleed Arterial Bleeding (16%) 88% rebleed Adherent Clot (15%) 9-36% rebleed Flat pigmented spot (15%) 0-10% rebleed Clean base (33%) 3% rebleed

  48. A 59 year old male undergoes an upper endoscopy for persistent dyspeptic symptoms and mild microcytic anemia. He had a normal colonoscopy last year. He takes low dose aspirin daily for known coronary artery disease and admits to using Advil at least 4 days a week for right knee pain. The EGD reveals a 1.5 clean based ulcer in the duodenal sweep. You should: • Admit him directly for IV PPI therapy • Begin oral PPI therapy to continue indefinitely • Schedule a follow up EGD for 8 weeks to assess ulcer resolution • Omit H pylori testing in this case since he admitted to NSAID use

  49. Upper GI Disorders A 59 year old male undergoes an upper endoscopy for persistent dyspeptic symptoms and mild microcytic anemia. He had a normal colonoscopy last year. He takes low dose aspirin daily for known coronary artery disease and admits to using Advil at least 4 days a week for right knee pain. The EGD reveals a 1.5 clean based ulcer in the duodenal sweep. You should: • Admit him directly for IV PPI therapy • Begin oral PPI therapy to continue indefinitely • Schedule a follow up EGD for 8 weeks to assess ulcer resolution • Omit H pylori testing in this case since he admitted to NSAID use

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