slide1
Download
Skip this Video
Download Presentation
GASTROESOPHAGEAL REFLUX DISEASES

Loading in 2 Seconds...

play fullscreen
1 / 49

GASTROESOPHAGEAL REFLUX DISEASES - PowerPoint PPT Presentation


  • 198 Views
  • Uploaded on

CHRONIC COUGH. due to. GASTROESOPHAGEAL REFLUX DISEASES. MÜNEVVER ERDİNÇ Department of Chest Diseases Ege University Faculty of Medicine. A cute Cough lasting less than 3 weeks Subacute Cough lasting 3 to 8 weeks. Chronic Cough. Lasting more than 8 weeks.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'GASTROESOPHAGEAL REFLUX DISEASES' - bill


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1
CHRONIC COUGH

due to

GASTROESOPHAGEAL

REFLUX DISEASES

MÜNEVVER ERDİNÇ

Department of Chest Diseases

Ege University Faculty of Medicine

slide2
Acute Cough

lasting less than 3 weeks

Subacute Cough

lasting 3 to 8 weeks

Chronic Cough

Lasting more than 8 weeks

Morice AH.Eur Respir J 2004 :24:481-492

Fontana GA.Thorax 2003;58:1092-1095

Irwin RS.NEJM 343(23): 1715-1721,2000

Irwin RS. Chest 1998; 114(suppl1) :133S-181S

slide3
PNDS

12

ASTHMA

16

13

12

6

4

10

GERD

1.Gastroesophageal reflux disease(21-41%)

2. Cough variant asthma (24-59%)

3.Postnasal drip syndrome(41-58%)

Chest 1999;116:279-284

slide5
Asthma and/or GERD, PNDS

responsible for 93.6% of the cases

of chronic cough

  • İmmunocompetent patients
  • Not exposed to enviromental irritants
  • Chest radiograph is normal
  • Not taking an ACE inhibitor
  • Nonsmoker

Harding SM .Chest 2003;123:659-660

slide6
Cough

the most common complaint for seeking medical care

In the USA  Ist (1993)

GERD

the most common chronic disease

ın the USA!

R. C. Orlando

slide8
GASTROESOPHAGEAL REFLUX

The backflow of stomach contentsinto the esophagus

(gastric acid, pepsin, bile, pancreatic enzymes)

Heartburn (pyrosis) and regurgitation

At least weekly symptoms

manifested by either by

extraesophageal reflux symptoms

and/or esophageal mucosal damage

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Irwin SR. Chest 2006:129:80S-94S

slide9
What happens during nonpathologic reflux?

Kahrilas PJ.CCJM 70(5):S4-19,2003

slide10
ANTIREFLUX BARRIERS

Diaphragma

Intrathoracic

-5 mmHg

Intraabdominal

+5 mmHg

LES +25mmHg

Expiration

Inspiration

slide11
GERD ?

Decreased saliva

Impaired esophageal clearance

Functional defect in LES syphincter

Hiatal hernia

Delayed gastric emptying

İncreased intra-abdominal pressure

Katzka & DiMarino 1995

slide12
Causative Factors in GERD

1.Gastroesophageal barrier function impairment

Hiatal hernia

İmpaired diyaphragmatic crus

Transient LES relaxations

2.Delayed esophageal clearance

Low amplitude or simultaneous contractions

Reduced salivation

3.Exogen factors

Alcohol, smoking, drugs, hot drinks , hypertonic foods, aging

4.Gastric factors

Acid hypersecretion ?

Delayed gastric emptying

Abnormal antropyloroduodenal motility (Alkalen reflux)

5.Impaired mucosal resistance

slide13
Izmir, Türkiye (630) S.Bor et al. DDW 2000

Olmsted, USA (2073) Locke et al. Gastroenterology,1997

Gastroesophageal Reflux Diseasesİzmir - Olmsted Prevalance

20

18

16

14

12

15.6

10

20

17.8

19.8

Weekly symptoms %

8

10

6

4

6.3

2

0

Heartburn

Regurgitation

Pyrozis/

Regurgitation

slide14
Menderes (Ege ÜTF)

Olmsted (Mayo)

Symptom

GERD (+)%

GERD (-) %

GERD (+) %

GERD (-) %

Dysphagia

35,7

7,9 *

29,4

13,5 *

NCCP

44,4

18,7 *

37

23,1 *

Odynophagia

10,3

2,4 *

Globus

23,8

8,1 *

14,2

10,6 *

Regurgitation

24,6

13,8 *

Hiccup

9,5

2,4 *

Cough

19,8

10,3 *

Hoarseness

28,6

13,1 *

Asthma

0,8

2,2

11,6

9,3

GERD Related Symptoms

slide15
GERD SPECTRUM

Physiologic

Typical

Extraesophageal

NERD

Atypical

Complications

Chronic cough

Hoarseness

Asthma

Laryngitis

Aspiration pneumonia

Dental erosions

Snoring

Noncardiac chest pain

Chest pain

Hiccup

Dyspepsia

Night sweats

Globus

Sleep

disturbances

Stricture

Bleeding

Barrett

Adenocarcinoma

Esophagitis

slide16
Edema and hyperemia of larynx
  • Vocal cord erythema, polyps, granulomas, ulcers
  • Hyperemia and lymphoid hyperplasia
  • of posterior pharynx
  • Interarytenoid changes
  • Subglottic stenosis

FLR

Signs

slide17
GERD-related cough incidence

5 - 41%

ARRD 1981;123:413-417

Arch Intern Med 1996;156:997

Chest 1993;104:1511-1517

Irwin RS. Chest 2006;129:80S-94S

May be the sole presenting symptom

Association between cough andreflux is important

  • Esophageal-tracheal-bronchial reflex
  • Microaspiration

Pathogenesis

Nonacid factors?

Esophageal dysmotility?

Thorax 2003:58;1092-1095)

Chest 1997; 111: 1389-1402

Irwin RS. Chest 2006;129:80S-94S

slide18
Central

Nervous

System

Esophagus

Tracheobronchial Tree

Airway

REFLUX

Microaspiration

.Mediator

Release

. Inflammation

. Edema

.Mucus

. Smooth

Muscle

Airway Vagal

Afferents

Esophageal

Vagal

Afferents

CNS

Airway Vagal

Efferents

Bronchial Hyperreactivity

Stein MR.Am J Med 2003

Chest 1997;111: 1389-1402

diagnostic tests in gerd

Diagnostic TestsinGERD

History

PPI test

Impedans

Endoscopy

Bernstein test

Bilier scintigraphy

Esophagography

Aspiration methods

Bilier scintigraphy

Reflux scintigraphy

Esophageal biopsy

Esophageal manometry

Standardized acid reflux test

High magnificated endoscopy

24-h intraesophageal impedance and pH

Telemetric esophageal pH monitorization

24-h intraesophageal pH monitoring

slide20
Oesophagus

Stomach

slide21
The most sensitive and specific test for GERD is

24-h esophageal pH monitoring

DeMeester score

Distal

DeMeester score >14.7

-Total time below pH 4

- Fractional of total time 4.2% 

- Fractional time of upright position 6.3% 

- Fractional time of supine position 1.2% 

-Total reflux events 50 

- Length of time 9.2 min. 

-Total time below pH 4

- Fractional of total time 1.1% 

- Fractional time of upright position 1.7% 

- Fractional time of supine position 0.6% 

-Total reflux events 5

- Length of time 3 min. 

Proximal

Richter JE, DeMeester TR.Gastroenterology 1990;98:122

slide22
Causes of chronic cough

Ayık SÖ, Başoğlu ÖK, Erdinç M.

Respir Med Vol. 97 (2003) 695-701

slide23
Reflux symptoms in chronic cough patients are associated with pathologic reflux in proximal esophagus

Ayık SÖ,Erdinç M,Bor S

slide24
Esophageal-pulmonary Reflux
  • Lipid-laden macrophages in BAL
  • Adding indicators to feedings
  • Glucose oksidase test
  • Scintigraphic monitoring
  • Exhaled breath condensate (EBC)
  • Esophageal pH monitoring
  • Symptoms
  • Empiric PPI therapy

Effros RM.Am J Med 2003;115:137S-143S

slide25
90

30

28

DLCO ml/min/mmHg

85

FEV1/FVC %

26

80

24

22

75

20

70

18

GER (-)

Grade 1

İntermittent

GER Grade 2

Severei GER

Grade 3

GER (-)

Grade 1

İntermittent

GER Grade 2

Severei GER

Grade 3

GER severity

GER severity

DLCO decrease in severe GER

Schachter LM.Chest 2003;123:1932-38

slide26
The empiric trial of medical therapy

is appropiate when pHmonitoring cannot

be done or is not available

American College of Chest Physicians

Chest 1998; 114(suppl1) :133S-181S

The empiric trial of medical therapy

should be considered even in cases pHmonitoring can be done

Thorax 2003 ;58:901-907

Poe RH.Chest 2003;123:679-684

Chest 2003 ;123:650-660

slide27
24 hour pHmetry

Empiric PPI therapy

  • GERD the most common cause of chronic cough
  • Empiric PPI therapy is not only practical
  • but is also ‘cost-effective’
  • 3. Consensus should be reconsidered
  • 4. pHmetry should be done in nonresponsive
  • to empiric therapy

Harding SM. Chest 2003 ;123:650-660

slide28
pHmetry,

High sensitive in typical symptoms

however diagnostic value

in extraesophageal symptoms

50 - 80%

Symptom / reflux association

is more important in atypical symptoms

Empiric PPI therapy sensitivity  62.5 - 81%

-Patients presented with laryngeal symptoms and cough-

slide29
Respiratory symptoms

prevalance

with GERD symptoms

Roka R.Digest.2005:92-96

slide30
17 cm

15 cm

9 cm

7 cm

pH - 5 cm

5 cm

6 impedance channels

3 cm

+

1 pH electrode

Multichannel intraluminal

impedance-pH catheter

Adult Standard

Model ZAN-S61C01E

slide31
Symptoms

No symptoms

50

40

Percentage of subjects

30

Oesophageal

dysmotility ?

20

10

0

Abnormal

Manometry

alone

Abnormal

manometry

and 24-h pH

Abnormal

24-h pH

alone

Normal

investigations

Results of oesophageal manometry and 24 hour ambulatory pH monitoring

in patients with chronic cough with (n=34)

and without (n=9) symptoms of gastro-oesophageal reflux

Kastelik JA. Thorax 2003;58:699-702

slide32
Weakly acidic reflux with chronic cough

Sifrim D.Gut 2005;54:449-54

slide33
In patients with chronic cough who had failed

to respond very intensive medical therapy,

the improvement or elimination of cough in

all subjects 12 months following surgery

Irwin RS.Chest 2002;121:1132-1140

The term acid reflux disease when applied

to chronic cough due to GERD, can be misnomer

Irwin RS. Chest 2006;129:80S-94S

slide34
Therapetic Options

Antacids/

alginates

Life-styles

PPIs

H2RB

GERD

Prokinetic agents

Fundoplication

Endoscopic

Hatlebakk & Berstad, Clin Pharmacokinet 1996; 31: 386–406.

slide35
Pharmacological Therapy in GERD
  • 1) Acid inhibition / neutralization
  • Antascides
  • H2 receptor blockers
      • Ranitidin
      • Famotidin
      • Nizatidin
  • Proton pump inhibitors
      • Omeprazol
      • Lansoprazol
      • Pantoprazol
      • Rabeprazol
      • Esomeprazol

2) Barrier

Alginic acid

3) Cytoprotectives

Sucralfat

Mizoprostol

4) Prokinetics

Cisapride

Domperidon?

Metoclopramid?

slide36
Comparison of H2B with PPI

Metaanalysis

Study

Risk ratio (95% CI)

% Weight

Bardhan 1995

0.26 (0.15,0.46)

5.0

Klinkenberg-Knol 1987

0.33 (0.16,0.69)

3.3

Havelund 1988*

0.42 (0.28,0.62)

7.1

Sandmark 1988

0.48 (0.33,0.69)

7.8

Bate 1990

0.59 (0.48,0.73)

11.1

Dehn 1990*

0.60 (0.37,0.98)

5.9

Bianchi Porro 1992

0.63 (0.42,0.94)

7.1

Koop 1995

0.72 (0.54,0.95)

9.5

IROSG 1991

0.61 (0.38,0.99)

5.9

Robinson 1995

0.37 (0.24,0.57)

6.6

Vantrappen 1988*

0.26 (0.10,0.67)

2.2

Farley 2000

0.64 (0.52,0.79)

11.0

Jansen 1999

0.35 (0.21,0.59)

5.5

Armbrecht 1997

0.59 (0.29,1.20)

3.5

Van Zyl 2000

0.52 (0.36,0.76)

7.6

Soga 1999

0.09 (0.01,0.62)

0.6

Overall (95% CI)

0.50 (0.43,0.58)

.012003

1

83.3135

Risk ratio

PPI H2RA

Moayyedi. Health Care Needs Assessment, 2002

slide37
Therapy in Esophageal-pulmonary reflux
  • Conservative and lifestyle measures
  • Pharmacological therapy: Proton pump inhibitors

PPI x 2 / 3 months

  • Therapy failure  24 hour intraesophageal pHmetry

( pharyngeal pHmetry)

GERD (+)

High dose PPI

Surgery, + H2 blocker agent

Pulmonary and Crit Care Update 1994;Vol 9

Morice AH. ERJ 2004;24:481-492

slide39
Esophagus

PPI

PPI

Stomach

slide40
Specific therapy

for diagnosis and treatment

Results of therapy

in treating cough

due to GERD

Poe RH.Chest 2003;123:679-684

slide41
Cumulative Response to GERD Therapy

Weeks of antireflux therapy Patients responded

No No (%)

2 16 (41)

4 38 (86)

6 42 (95)

8 43 (99)

12 44 (100)

Poe RH.Chest 2003;123:679-684

slide42
Effect of the GABAB agonist baclofen

on symptoms in patients with GERD

Ciccaglione AF.Gut 2003;52:464-470

slide43
Anti-Reflux Surgery

Restore Intraabdominal esophagus

Reduce Hiatal Hernia

Approximate Diaphragmatic crurae

Perform Fundoplication

slide44
Preop

pH <4: %23.6

De Meester: 85

Postop

pH <4: %2.4

De Meester: 9.9

slide45
Preop

pH <4: %14.5

De Meester: 52.9

Postop

pH <4: %3.8

De Meester: 14.2

slide46
Clinical Profile That Chronic

Cough İs Likely Due To‘Silent GERD’

1.Chronic cough for at least 2 months

2. Immunocompetent patients

3. Chest radiograph is normal

4. Not exposed to enviromental irritants nor a present smoker

5. Not taking an ACE inhibitor

6. Symptomatic asthma has been ruled out

7. Rhinosinus diseases has been ruled out:

8. ‘Silent sinusitis’ has been ruled out

9. Nonasthmatic eosinophilic bronchitis

has been ruled out:

BPT is negative

Cough has not improved

with asthma therapy

1st generation H1

antagonists has been used

Eo 3%

in induced sputum

Cough has not improved

with steroids

Irwin RS. Chest 2006;129:80S-94S

İrwin RS. AJRCCM Vol 165; 1469-1474, 2002

slide47
Chronic Cough

History and

Physical

Avoid irritants

Discontinue ACE ihibitors

Smoking cessation

normal

abnormal

Chest radiograph

Sputum cytology,

HRCT scan

Bronchoscopy

Esophagography

Cardiac evaluation

GERD symptoms

(-) (+)

Ampiric PPI

Three months b.i.d.

Asthma, PNDS

Spirometry (BPT)

ENTevaluation

Spesific diagnosis

and treatment

Spesific diagnosis

and treatment

Cough persists

pHmetry ( surgery?)

Psychogenic cough(?)

Cough persists

Cough persists

slide48
Pharyngeal pHmetry

-

+

Increase dose PPI

+ alginate

Not GERD

Clinical GERD symptoms ?

Nonacid, weakly acid reflux?

Not improved

İmproved

Consider

Simultaneously

dual probes

24 hours pHmonitoring

and

intraesophageal impedance

pHmetry

under treatment

Continue

Irwin RS.AJRCCM 165:1469-74,2002

McGarvey LPA.Thorax 59:342-346,2004

slide49
EGE REFLUX WORKING GROUP

KBB

Faringolaringeal

reflü

Gastroenteroloji

Erişkin-Çocuk

Göğüs,

Pulmoner reflü

Kardiyoloji

NCCP

Psikiyatri, Halk sağlığı

Patoloji

Diş Hek.

Cerrahi

Erişkin, Çocuk

www.gerd-turkey.org

ad