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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.


Putting out the fire prevention treatment of acid reflux ulcers

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.


Putting out the fire prevention treatment of acid reflux ulcers

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


Putting out the fire prevention treatment of acid reflux ulcers

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.


Putting out the fire prevention treatment of acid reflux ulcers

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.


Putting out the fire prevention treatment of acid reflux ulcers

Questions? & Ulcers