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Putting Out the Fire: Prevention & Treatment of Acid Reflux & Ulcers. William J. Salyers, Jr., MD, MPH Division Chief/Medical Director KU Wichita gastroenterology Associate Program Director Internal Medicine Residency. Goals. Discuss the causes and treatments of ulcer-related disease.

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Putting out the fire prevention treatment of acid reflux ulcers

Putting Out the Fire: Prevention & Treatment of Acid Reflux & Ulcers

William J. Salyers, Jr., MD, MPH

Division Chief/Medical Director

KU Wichita gastroenterology

Associate Program Director

Internal Medicine Residency


Goals
Goals & Ulcers

Discuss the causes and treatments of ulcer-related disease.

Discuss the causes and treatments of GERD.

Review the long-term consequences of GERD.

Review the use of endoscopy in management of ulcers and complications of GERD.


Peptic Ulcer & Ulcers

Disease


What causes an ulcer
What Causes an Ulcer? & Ulcers

Ulcers occur when acid eats away the lining of the esophagus, stomach, or small intestine.


How does this happen
How Does This Happen? & Ulcers

  • Medications

    • Pain Relievers: Ibuprofen , Aspirin, Naproxen

    • Bisphosphonates: Fosamax, Actonel

  • Helicobacter pylori bacteria

  • High Acid States: Gastrinoma



Yes no
Yes & No & Ulcers

  • Stress alone does NOT cause ulcers.

  • Uncontrolled high stress conditions may:

    • Burns

    • Physical trauma

    • Surgery



Helicobacter pylori
Helicobacter Pylori & Ulcers

30 – 40% of the US population is estimated to be infected with HP.

The majority of individuals acquire HP during childhood.


What are the symptoms
What Are the Symptoms? & Ulcers

  • Pain.

    • May be worse when your stomach is empty.

  • Bleeding.

  • Nausea & Vomiting.

  • Unexplained weight loss.


Complications of ulcers
Complications of Ulcers & Ulcers

GI Bleeding.

Perforation.

Scarring.


Treatment
Treatment & Ulcers

Medications to suppress acid production.

Medications that neutralize acid or protect the stomach lining.

Antibiotics for H. pylori infection.

Endoscopic therapy.


Endoscopy & Ulcers


What is endoscopy
What is Endoscopy & Ulcers

  • Examination of the gastrointestinal tract using long, thin flexible scopes.

    • EGD

    • Colonoscopy

    • Enteroscopy

      • Capsule Endoscopy

  • Used for diagnostic and therapeutic purposes.

    • Colon cancer screening

    • Evaluation of abdominal pain

    • Management of swallowing difficulty

    • Management of bleeding


Acid reflux & Ulcers

Disease


What is gerd
What is GERD? & Ulcers

  • Gastroesophageal Reflux Disease.

  • Backwash of acid into the esophagus.

    • Irritates the lining of the esophagus.

    • Occasionally caused by bile.

    • Due to relaxation of the lower esophageal sphincter.


What are the symptoms1
What Are the Symptoms? & Ulcers

Heartburn.

Metal or sour taste in mouth.

Chest pain.

Chronic dry cough.

Regurgitation of food or sour liquid.

Difficulty swallowing.

Lump in the throat.


Risk factors
Risk Factors & Ulcers

Smoking.

Obesity.

Connective tissue disease.

Hiatal hernia.

High output acid disorders.

Diabetes.

Pregnancy.


Treatment1
Treatment & Ulcers

  • Lifestyle measures.

    • Avoid trigger foods.

    • Don’t eat 3 hours before bedtime.

    • Keep head of bed elevated at night.

    • Lie on your left side at night.

    • Don’t smoke.

    • Maintain a healthy weight.

    • Don’t wear tight clothing.

  • Acid suppressing medications.

  • Anti-reflux surgery / procedures.


When should you see your doctor
When Should You See Your Doctor? & Ulcers

  • Symptoms of chest pain.

  • Symptoms that occur > 2 x weekly.

    • Taking OTC acid medications > 2 x weekly.

  • Symptoms that interfere with your daily activities.

  • Difficulty swallowing.

  • Unintentional weight loss.

  • GI bleeding.


What are the complications of gerd
What Are the Complications of GERD? & Ulcers

Peptic strictures.

Esophageal ulcers.

Pre-cancerous changes of the esophagus (Barrett’s).

Esophageal cancer.


Peptic stricture
Peptic Stricture & Ulcers

Reversible inflammation & edema

irreversible scarring.

Heartburn often decreases w/ worsening dysphagia.

Dysphagia usually limited to solids.


Esophageal cancer adenocarcinoma
Esophageal Cancer: & UlcersAdenocarcinoma

  • Related to heartburn & Barrett’s esophagus.

  • Barrett’s Screening

    • Highest Yield – White Males > 50 w/ longstanding GERD.

    • Consider all pts w/ GERD > 5 yrs & all pts age > 50.


Barrett’s & Ulcers

Esophagus


Epidemiology
Epidemiology & Ulcers

  • Barrett’s Esophagus

    • Premalignant lesion assoc w/ Adenocarcinoma of esophagus & GE jct.

      • Increasing incidence of Esophageal AdenoCa in US over past 2 decades.

      • AdenoCa accounting for > 50% esophageal cancers in US.

      • Annual incidence of AdenoCa in BE is < 0.5% in US.

      • Poor 5-year survival – only 13%.

    • BE - Dx in 10 -15% pts w/ reflux undergoing EGD.

    • Prevalence reported as high as 5.6% in pts w/o chronic reflux symptoms.


Therapy
Therapy & Ulcers

  • PPI to control GERD symptoms.

  • NissenFundoplication may be considered for pt’s w/ controlled GERD on PPI.

  • PPI tx &/or surgery do not reverse BE.

  • No role for pH monitoring.

    • Tx goal is symptom control, not pH level.

  • Endoscopic therapy.


2011 aga guidelines
2011 AGA Guidelines & Ulcers

  • High-Grade Dysplasia

    • RFA, EMR, & PDT recommended.

    • 70-80% can be successfully tx w/ endoscopic tx alone.\

  • Low-Grade Dysplasia

    • “RFA should also be a therapeutic option for treatment”.

    • >90% reversion to normal-appearing squamous epithelium.


2011 aga guidelines1
2011 AGA Guidelines & Ulcers

  • Nondysplastic

    • “RFA, with or wthout EMR, should be a therapeutic option for select individuals with nondysplastic Barrett’s esophagus who are judged to be at increased risk for progression to high-grade dysplasia or cancer”.



Screening
Screening & Ulcers

  • ACG: No recommendation – individualized in high risk patients.

  • ASGE: “may be appropriate in selected pts w/ frequent (e.g., several times/wk), chronic, long-standing GERD (> 5 yrs).”

    • If negative screening exam, no further screening indicated.


Questions? & Ulcers


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