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UPDATES on Acid-Related Digestive Disorders. Disorders that are characterized by an imbalance between mucosal defense mechanisms And gastric acid secretion. DEFINITION OF ACID RELATED DISORDERS. Peptic ulcer disease gastroesophageal reflux disease.

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definition of acid related disorders

Disorders

that are characterized

by an imbalance between

mucosal defense mechanisms

And gastric acid secretion

DEFINITION OF ACID RELATED DISORDERS
  • Peptic ulcer disease
  • gastroesophageal reflux disease
common features gerd and peptic ulcers
COMMON FEATURES GERD and PEPTIC ULCERS
  • High prevalence
  • Variable presentation
  • High economic cost
high prevalence
High prevalence
  • 14% of adults have GERD symptoms on weekly basis, and 6% on a daily basis.
  • Similarly in peptic ulcer disease, the lifetime prevalence is 5 -10%,whileinH pylori-infected subjects, it is (10 - 20%).
  • During statistics In February 2008, the world\'s general population is believed to have reached over 6.60 billions.
  • From this new population,924 millions will suffer symptoms of GERD , and another 660 millions will have peptic ulcers.
  • In H pylori infected population, the number of ulcers will be double (1.32 billion).

These figures will definitely make a big burden on health resources on most countries

variable presentation
Variable presentation
  • Typical presentation as heartburn at nighttime occurs in nearly 80% of patients, but the atypical presentation as asthma or chronic cough has been only seen in 20-25 percent of adults.
  • On the other hand, Peptic ulcers can cause a variety of symptoms which may vary from patient to patient, some patients have minimal, unusual, or even no symptoms at all.

Both disorders could present in a variable ways that force us to remember these diseases, specially in risk group populations

high economic cost
High economic cost
  • in 2000, statistics In USA, showed that treatments for GERD disease have coasted over 24 billions USD.
  • Again, from statistics in USA, ulcers have caused an estimated 1 million hospitalizations and 6500 deaths per year, and the cost for health care of peptic ulcer disease have been estimated at nearly $6 billion per year.

These costs has limited the planning of an effective treatments and preventive programs which need very high budgets which is beyond facilities of many countries

slide8
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
slide9
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
size of problem
SIZE OF PROBLEM
  • The size is huge.
  • GERD may start as early as first year of life.
  • Simple heartburn may occur normally at least once every month in about 40% of the general population, this usually can be controlled by life style measures only.
  • When the symptoms happen more than twice a week, this is then called (GERD).
  • GERD will be more serious when it is associated with esophageal erosions, and here is the importance of doing early endoscopy.
  • Some GERD patients are asymptomatic and diagnosed by chance during endoscopy, this will cause some patients to present for the first time with complications in the absence of heartburns.
  • Untreated erosive GERD may lead to complications of serious nature.
slide11
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
presentations of gerd
PRESENTATIONS OF GERD
  • TYPICAL PRESENTATION :

Chief symptoms include heartburn, food regurgitation into the throat, occasional difficult or painful swallowing, and occasional chest pain.

  • ATYPICAL PRESENTATION :

symptoms include cough, and wheezing,or vocal cord inflammation leading to hoarseness of voice, and other ENT symptoms.

typical presentation
TYPICAL PRESENTATION
  • Heartburn is the whole mark of the typical GRED presentation, constitute 70-80% of GERD cases.
  • Almost everyone has infrequently experienced some extent of heartburn some time during his life.
  • About 25% of pregnant women may suffer from frequent heartburns.
  • Temporary heartburn is very commonly seen with certain foods, alcohol, and with some medications.
  • Frequent or severe symptoms can limit daily activities and productivity.
  • Erosive GERD may lead to serious complications.
atypical presentation
ATYPICAL PRESENTATION

* atypical symptoms are predominant in up to

27% of GERD patients.

* in onestudy, the frequency of symptoms :

  • 1% as sialorrhea.
  • 4.5% as hiccups.
  • 15.5% as chest pain.
  • 23% as hoarseness.
  • 24.4% as cough.
  • 38% as globus sensation.
slide15
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
diagnosis of typical gerd
DIAGNOSIS OF TYPICAL GERD
  • Young patients when present with classical heartburn have a strait forward diagnosis and doesn’t need endoscopic confirmation.
  • This approach of course will miss the diagnosis of erosions, but it will cut costs.
  • Using this approach, treatment should be planned according to the severity of symptoms.
when we investigate atypical gerd
WHEN WE INVESTIGATE ATYPICAL GERD ?

Accordingly

more accurate tests are needed

to confirm atypical reflux

therefore, ambulatory pH monitoring, has

been unable to confirm all cases of atypical GERD

  • Investigations should be done only after failure of a therapeutic trial with twice daily high dose of PPI.
  • Using the barium swallow for diagnosis, has fallen out of favor because of poor sensitivity since it may help diagnosis in only 25-35% of patients.
  • Value of endoscopy in the evaluation of patients with suspected atypical reflux is limited also by a low sensitivity (the likelihood of detecting endoscopic esophagitis is only 25%), against (70% of GERDs who have a normal looking esophagus).
  • Ambulatory pH monitoring used to measure esophageal acidity for confirmation of reflux, is also not sensitive and can’t detect all cases of GERD

(the possibility of recording abnormal acid exposure is 70-80% by the distal esophageal probe , but only 50-55% in the proximal probe).

new emmerging more accurate diagnostic test
NEW EMMERGING MORE ACCURATE DIAGNOSTIC TEST

for patients with persistent symptoms

despite full acid suppression therapy

MII-pH shows a promise

to become an important clinical tool

particularly to assess atypical GERD

  • Combined, Multichannel Intraluminal Impedance (MII) with pH testing presents a new approach to confirm atypical reflux, it’s distribution, and it’s clearing from esophagus.
  • MII can primarily detect the reflux and classify it as liquid, gas or mixed, then the acid probe can tell the reflux as acid or non-acid based on adjoined pH meter.
  • MII can therefore determine the refluxate clearance time, while the pH meter measures the acid clearance time.
slide19
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
gerd and hiatus hernia
GERD and HIATUS HERNIA

BMC Gastroenterol. 2005; 5: 2

impact of hiatal hernia on histological pattern of non-erosive reflux disease, Anthie Gatopoulou, etal,

1. In erosive disease :

HH was usually correlated with more

severe endoscopic erosions.

2. In non erosive disease :

HH is also correlated with severe biopsy

histological abnormality.

what is the clinical value of this study
what is the clinical value of this study ?

when GERD symptoms doesn’t respond

to usual therapeutic measures, and associated with large Hiatus Hernia, surgery will be then advisable

sleep disorder in gerd sleep heart health study may 2005 done by johns hopkins health alert program
SLEEP disorder in GERD Sleep Heart Health Study (May 2005 ) done by Johns Hopkins Health Alert program

overweight

or drink a lot of carbonated beverages

or snore

or experience daytime sleepiness

or have insomnia

or use anti-anxiety medications

CONCLUSIONS FROM STUDY

15,314

enrolledpeople

79% of patients with early (GERD)

suffer from reflux symptoms

that awakens them during night

Without clear symptoms of heatburn

People with nighttime heartburn

are at greater risk of developing

serious esophageal complications

And have a frequent

heartburns in past year

25% (3,806)

reported sleep problems

at least twice a month

gerd and barrett s
GERD and Barrett\'s
  • Barrett’s is probably the most serious complication of GERD.
  • It is estimated that 6% - 12% of patients undergoing endoscopy for follow up of GERD will show Barrett\'s esophagus.
  • The serious thing about Barrett\'s esophagus is , it’s potential to develop esophageal adenocarcinoma in about 0.5% of cases annually.
  • the earliest sign of change to cancer is development of dysplasia in the Barrett\'s mucosa.
  • Therefore endoscopic surveillance should be done annually to detect early dysplasia in Barrett\'s mucosa in order to prevent progression to esophageal adenocarcinoma.
  • Recently, Biomarkers and genomic profiles have raised promise in detecting early dysplasia.
slide25
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
biomarkers and genomic profiles for detection of early esophageal cancer
Biomarkers and genomic profiles for detection of early esophageal cancer
  • esophageal carcinomas complicating GERD can only be detected at an advanced stage, and when diagnosed have an overall 5-year survival rate of 10–20%.
  • Moreover, esophageal cancer treated by surgery, is associated with a very high morbidity and mortality.
  • Depending on endoscopic surveillance programs in GERD patients will also bring diagnosis in a late stage.
  • Therefore trials on early detection of cancer at its pre-malignant stage is likely to carry a significant survival benefits.
  • This may be possible when we detect dysplasia in the Barrett’s mucosa.
  • Alternatively, better hopes for earlier detection of these cancers lies with the identification of biomarkers that can be assayed in serum or urine samples from patients who are considered as high risk groups in GERD patients.
what are these biomarkers
What are these biomarkers
  • A biomarker may be defined as a characteristic that is evaluated as an indicator of pathological processes or a response to a therapeutic intervention.
  • An ideal biomarker of malignancy will be detectable early in a pre-malignant phase.
  • Currently the evaluation of cancer biomarkers is a very complex task.
  • The National Cancer Institute has recently formed the Early Detection Research Network to facilitate this process.
types of biomarkers
TYPES OF BIOMARKERS
  • Endoscopic Biomarkers: Endoscopic ultrasound, and methylene blue staining or fluorophores.
  • Tissue Biomarkers : cyclin D1, p53, and markers of cell proliferation.
  • Serum and Urine Biomarkers : villin protein detection, detection of Mutations of the p53 gene, and The APC gene detection.
slide31
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
gerd and surgery
GERD AND SURGERY

INDICATIONS OF SUREGERY IN GERD

1.persistence of erosive esophagitis, one year after adequate medical

therapy is the most accepted indication for surgery.

2. But, severe symptoms, even after improvement of erosions, and in spite

of adequate medical treatment is a relative indication.

  • Large hiatal hernia.
  • Barrett\'s esophagus.
  • Recurrent esophageal strictures.
  • Severe pulmonary complications.
  • Noncompliance.
  • Inability to afford medications.

Associated Complications is a strong indication for surgery

Failure of medical therapy is a relative indication for surgery

suitable surgical candidates
SUITABLE SURGICAL CANDIDATES
  • Patients showing severe endoscopic erosive esophagitis one year after starting treatment, in spite of high-dose PPI therapy.
  • Patients presenting with a predominant nocturnal regurgitation symptoms, which are associated with chest complications.
  • patient with typical symptoms that responds completely to PPI therapy but he is unhappy about the cost of treatment, or worried about the potential adverse effects of long-term PPI therapy.
slide34
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
outcomes of gerd therapies
OUTCOMES OF GERD THERAPIES
  • Most patients achieve adequate symptom control and esophageal healing of lesions through a combination of lifestyle measures with or without drug therapies in 90% of cases, usually within 2-3 months.
  • In a significant number of cases, symptoms will recur after stopping PPI therapy, which need to be continued for a longer period.
  • patients who are well controlled on PPI therapy may consider step-down therapy to a H2-receptor blocker.
  • Surgical or laparoscopic Nissen fundoplication should be considered in patients not responding to long treatment, and usually this has a cure rate of up to 90 percent.
slide36
SIZE OF GERD PROBLEM
  • PRESENTATIONS OF GERD
  • DIAGNOSIS OF GERD
  • ASSOCIATED GERD PROBLEMS
  • BIOMARKERS IN GERD
  • GERD AND SURGERY
  • OUTCOMES OF GERD THERAPIES
  • NEW THERAPEUTIC MODALITIES
new therapeutic modalities to replace surgery
NEW THERAPEUTIC MODALITIES TO REPLACE SURGERY
  • several endoscopic therapies for the treatment of GERD have been approved recently by the FDA.
  • These include endoscopic suturing, radiofrequency ablation, and bulking techniques.
  • Currently there are only few controlled clinical trials on efficacy and safety of these techniques.
  • Thus, until further information’s regarding these procedures will be available, they should all be considered investigational and used only in the setting of a clinical trials.
slide39
SIZE OF PEPTIC ULCER PROBLEM
  • CAUSES AND PRESENTATIONS OF ULCERS
  • DIAGNOSIS AND TREATMENTS FOR ULCERS
  • H PYLORI AND PEPTIC ULCERS
  • ULCERS AND NSAIDs
  • WHAT IS NEW ?
size of peptic ulcer problem
SIZE OF PEPTIC ULCER PROBLEM
  • 10-15% of people will get a peptic ulcer some time during their lifetime.
  • Ulcer can occur at any age, but it often seen more with ageing.
  • Ulcers in the old are more likely to present with complications.
  • Most patients with duodenal ulcers are infected by H. pylori, but not all people with H pylori develop ulcers.
  • Management was revolutionised in 1982 by the discovery of Helicobacter pylori which is currently affecting more than 50% of some societies over the age of 50.
slide41
SIZE OF PEPTIC ULCER PROBLEM
  • CAUSES AND PRESENTATIONS OF ULCERS
  • DIAGNOSIS AND TREATMENTS FOR ULCERS
  • H PYLORI AND PEPTIC ULCERS
  • ULCERS AND NSAIDs
  • WHAT IS NEW ?
causes of peptic ulcers
CAUSES OF PEPTIC ULCERS
  • H pylori antral gastritis, and Non-steroidal anti-inflammatory drugs cause the vast majority of ulcers.
  • Cohn\'s disease

Hypergastrinaemia

Hyperparathyroidism

may cause ulcers only in rare cases

presentation of ulcers
PRESENTATION OF ULCERS
  • The most common presentation of ulcer disease is dyspepsia.
  • Ulcer Can also be suspected by eliciting unusual epigastric tenderness during physical examination of abdomen.
  • It should be suspected in all patients discovered to have H Pylori infection.
  • Some cases may be diagnosed by chance during gastric endoscopy done for any reason.
  • It should be strongly suspected when a patient present with GIT bleeding.
slide44
SIZE OF PEPTIC ULCER PROBLEM
  • CAUSES AND PRESENTATIONS OF ULCERS
  • DIAGNOSIS AND TREATMENTS FOR ULCERS
  • H PYLORI AND PEPTIC ULCERS
  • ULCERS AND NSAIDs
  • WHAT IS NEW ?
diagnostic tests for ulcers
DIAGNOSTIC TESTS FOR ULCERS
  • Until early 1900s, the diagnosis was suspected only on clinical grounds.
  • Until 1925, fractional test meal was being widely used, and confirmed by the rigid gastroscope.
  • After1925,Barium contrast studies were started to replace the rigid gastroscopes.
  • After 1950 flexible fibro-optic endoscopy has revolutionized the diagnosis and direct visualization of the ulcer was then possible.
  • Till now flexible video-endoscopy is regarded as the gold standard diagnostic test for ulcers.
how to manage dyspepsia
HOW TO MANAGE DYSPEPSIA
  • In patients presenting with alarm symptoms or signs for malignancy, such as weight loss, GIT bleeding, severe vomiting, and in old age dyspepsia (more than 50), endoscopy should be done as the best approach to exclude gastric neoplasia.
  • There is no longer any role for barium radiography in the evaluation of dyspepsia because of its poor sensitivity and specificity.
how to treat dyspepsia
HOW TO TREAT DYSPEPSIA
  • Nowadays, conducting non-invasive tests for H. pylori detection followed by antibiotic triple therapy is the most accepted approach in young poeple.
  • Empirical treatment of dyspeptic patients with antibiotics for suspected H. pylori infection is not accepted, even when serology was positive.
  • Positive serology should be confirmed by urea breath test.
  • For serologically negative cases, starting a short trial of PPI therapy is considered as reasonable, in absence of alarm signs.
management of asymptomatic ulcers
MANAGEMENT OF ASYMPTOMATIC ULCERS
  • H. pylori testing is essential following discovery of any ulcer, since such infection will be the cause in more than 80% of cases.
  • When H Pylori is absent, we should look for other causes, chief of them is the use of NSAIDs.
  • Other causes are rare, but should be looked for in doubtful cases.
slide49
SIZE OF PEPTIC ULCER PROBLEM
  • CAUSES AND PRESENTATIONS OF ULCERS
  • DIAGNOSIS AND TREATMENTS FOR ULCERS
  • H PYLORI AND PEPTIC ULCERS
  • ULCERS AND NSAIDs
  • WHAT IS NEW ?
h pylori and peptic ulcers
H PYLORI AND PEPTIC ULCERS

beginning in 1958 John Lykoudis, a general practitioner in Greece, was treating his patients for peptic ulcer disease with antibiotics, long before H pylori and it’s relation to ulcers was recognized.

discovery of h pylori
DISCOVERY OF H PYLORI

Helicobacter pylori was then discovered in

1982 by two Australian scientists, J. Robin

Warren and Barry J. Marshall as a

causative factor for peptic ulcers.

early doubts about discovery of h pylori
EARLY DOUBTS ABOUT DISCOVERY OF H PYLORI

H. pylori discovery was poorly accepted in the beginning, so in an act of removing doubts by self-experimentation, Marshall Barry drank a Petri dish containing a culture of H P organisms extracted from infected patient, and he soon developed severe H P gastritis. His symptoms disappeared then after two weeks, following being forced to take antibiotics to kill the ingested bacteria at the urge of his wife, since he got severe halitosis, which is one of the symptoms of H Pylori gastric infection.

experiment was published in 1984 in the Australian Medical Journal

nobel prize
NOBEL PRIZE

In 2005, the Karolinska Institute in Stockholm awarded the Nobel Prize in Physiology of Medicine to Dr. Marshall Barry and his long-time collaborator Dr. Warren "for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease".

do we need to follow patients after eradication of h pylori
DO WE NEED TO FOLLOW PATIENTS AFTER ERADICATION OF H PYLORI
  • Post treatment testing for H Pylori is only preferable in H Pylori gastritis.
  • But testing will be mandatory in patients with peptic ulcers, specially when complicated by bleeding, perforation, or obstruction.
  • Confirmatory testing for eradication should not be done until 4 weeks after completion of therapy by UBT or Endoscopy.
slide55
SIZE OF PEPTIC ULCER PROBLEM
  • CAUSES AND PRESENTATIONS OF ULCERS
  • DIAGNOSIS AND TREATMENTS FOR ULCERS
  • H PYLORI AND PEPTIC ULCERS
  • ULCERS AND NSAIDs
  • WHAT IS NEW ?
ulcers due to nsaids
ULCERS due to NSAIDs
  • Between 15% and 25% of NSAIDs users, will have evidence of gastric ulcers, but in most cases ulceration is mild.
  • There is a 3.5 fold risk of ulcer formation in NSAIDs users in the following group :

1. Old People over 65.

2. People with history of ulcers or upper GI bleeding.

3. Those with heart disease.

4. Users of certain medications, such as the anticoagulants,

corticosteroids, or alendronate.

5. Alcohol users.

6. H. pylori infected people.

Given the widespread use of these factors, however, the total number of people with confirmed disease is considerable

slide57
SIZE OF PEPTIC ULCER PROBLEM
  • CAUSES AND PRESENTATIONS OF ULCERS
  • DIAGNOSIS AND TREATMENTS FOR ULCERS
  • H PYLORI AND PEPTIC ULCERS
  • ULCERS AND NSAIDs
  • WHAT IS NEW ?
what is new
WHAT IS NEW ?
  • Recent studies indicate that existing H pylori infection can significantly adds to the risk in NSAID users.
  • Therefore screening and treatment for H. pylori infection before initiating long-term NSAID therapy has been suggested to reduce risk for ulcers.
recent trial on use of nsaids in h pylori infected patients
RECENT TRIAL ON USE OF NSAIDs IN H PYLORI INFECTED PATIENTS

investigators from Hong Kong randomized 100 arthritic patients with confirmed H. pylori infection to receive either one week of :

1. standard triple eradication therapy

2. omeprazole alonewithout antibiotics.

slide60

100

Arthritis

+

H Pylori

One week triple therapy

Two groups

One week omeprazol only

All given 100 mgs Dicofenac for 6 months

ENDOSCOPY

ULCERS

PATIENTS

FOUND BY

ENDOSCOPY

In 10% of antibiotic and PPI recipients

P=0.0085

In 30% of omepazol only recipients

conclusions of the study
CONCLUSIONS OF THE STUDY

The investigators concluded that treatment for H. pylori infection before initiating NSAID therapy will reduce the risk for developing peptic ulcers.

conclusions on gerd
CONCLUSIONS ON GERD
  • GERD is a common chronic problem with variable presentation and high economic cost.
  • Heartburn is the chief presenting symptom of typical GERD.
  • Atypical presentation is very common also, usually causing ENT symptoms.
  • Simple therapies and lifestyle modifications can control half of patients.
  • Neglected severe erosive disease can lead to serious complications.
  • New therapeutic modalities are under active assessment as alternatives for surgery.
conclusions about pud
CONCLUSIONS ABOUT PUD
  • PUD will continue to be with us for more time to come.
  • We will expect to see more ulcers that are caused by other factors than H pylori infection in the future.
  • Such ulcers will be due to aspirin or other NSAIDs.
  • Non H pylori ulcers have a higher tendency to bleed.
  • Currently management of such bleeding ulcers can mainly be done by therapeutic endoscopic means.
  • management of such bleeding episodes by IV PPI therapy is recommended, but it’s definite value remains to be confirmed.
slide64

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