acid peptic disorders

2. Acid Peptic DisordersAcid Peptic Disorders
Acid peptic disorders include a number of Acid peptic disorders include a number of
diseases, whose etiology can be linked to diseases, whose etiology can be linked to
gastric secretions.gastric secretions.
Gastroesophageal reflux disease, and Gastroesophageal reflux disease, and
peptic ulcer disease, are two most peptic ulcer disease, are two most
common and well-defined disease states. common and well-defined disease states.

4. GERD is defined as chronic symptoms or mucosal GERD is defined as chronic symptoms or mucosal
damage produced by the abnormal reflux of gastric damage produced by the abnormal reflux of gastric
contents into the esophagus.contents into the esophagus.
Reflux esophagitis refers to a subgroup of GERD Reflux esophagitis refers to a subgroup of GERD
patients with histopathologically demonstrated patients with histopathologically demonstrated
characteristic changes in the esophageal mucosa characteristic changes in the esophageal mucosa
Nonerosive reflux disease, also know as endoscopy-Nonerosive reflux disease, also know as endoscopy-
negative reflux disease, refers to patients with typical negative reflux disease, refers to patients with typical
GERD symptoms caused by intraesophageal acid who GERD symptoms caused by intraesophageal acid who
do not have visible mucosal injury at endoscopy. do not have visible mucosal injury at endoscopy.

5. PrevalencePrevalence
Heartburn is a common problem in the United States and Heartburn is a common problem in the United States and
in the Western world, since many individuals control in the Western world, since many individuals control
symptoms with over-the-counter medications and without symptoms with over-the-counter medications and without
consulting a physician, the condition is likely consulting a physician, the condition is likely
underreported.underreported.
Approximately 7% of the population experience Approximately 7% of the population experience
symptoms of heartburn daily. 20-40% of the people who symptoms of heartburn daily. 20-40% of the people who
experience heartburn do indeed have GERD experience heartburn do indeed have GERD

No sexual predilection exists. GERD is as common in No sexual predilection exists. GERD is as common in
men as in women men as in women
GERD occurs in all age groups. GERD occurs in all age groups.
The prevalence of GERD increases in people older than The prevalence of GERD increases in people older than
40 years.40 years.

6. EtiologyEtiology
Lower esophageal sphincter incompetence. Lower esophageal sphincter incompetence.
Transient lower esophageal sphincter Transient lower esophageal sphincter
relaxation.relaxation.
Hiatal hernia Hiatal hernia
Obesity: contributing factor in GERDObesity: contributing factor in GERD

7. Typical FeaturesTypical Features
HeartburnHeartburn
RegurgitationRegurgitation

8. Atypical FeaturesAtypical Features
Coughing and/or wheezing Coughing and/or wheezing
Hoarseness Hoarseness
Pneumonia Pneumonia
Belching Belching
LaryngitisLaryngitis
Otitis mediaOtitis media
Enamel decay. Enamel decay.

10. DifferentialsDifferentials
AchalasiaAchalasia
CholeithiasisCholeithiasis
Coronary Artery AtherosclerosisCoronary Artery Atherosclerosis
Esophageal SpasmEsophageal Spasm
Esophageal CancerEsophageal Cancer
EsophagitisEsophagitis
Chronic GastritisChronic Gastritis
Irritable bowel syndromeIrritable bowel syndrome
Peptic Ulcer DiseasePeptic Ulcer Disease

11. WORKUPWORKUP
Barium EsophagogramBarium Esophagogram
EsophagogastroduodenoscopyEsophagogastroduodenoscopy
Esophageal manometry Esophageal manometry
Radionuclide measurement of gastric emptying Radionuclide measurement of gastric emptying
Ambulatory 24-hour pH monitoringAmbulatory 24-hour pH monitoring
Empiric trial of proton pump inhibitorEmpiric trial of proton pump inhibitor
Multichannel intraluminal impedanceMultichannel intraluminal impedance
Bravo systemBravo system

15. Medical TreatmentMedical Treatment
Lifestyle ModificationsLifestyle Modifications
Losing weight (if overweight) Losing weight (if overweight)
Avoiding alcohol, chocolate, citrus juice, Avoiding alcohol, chocolate, citrus juice,
and tomato-based products and tomato-based products
Avoiding large meals Avoiding large meals
Waiting 3 hours after a meal before lying Waiting 3 hours after a meal before lying
down down
Elevating the head of the bed 8 inchesElevating the head of the bed 8 inches

16. Treatment Cont.Treatment Cont.
Pharmacologic Therapy Pharmacologic Therapy
AntacidsAntacids
Prokinetic agents: Prokinetic agents: metoclopramide hydrochloride metoclopramide hydrochloride
H2 receptor antagonists: H2 receptor antagonists: Ranitidine, Cimetidine, Famotidine. Ranitidine, Cimetidine, Famotidine.
Nizatidine Nizatidine
Proton pump inhibitors: Proton pump inhibitors: Omeprazole, Rabeprazole, Esomeprazole,Omeprazole, Rabeprazole, Esomeprazole,

17. Treatments Cont.Treatments Cont.

AntacidsAntacids

Prompt but temporary reliefPrompt but temporary relief

No objective proof of superiority to placeboNo objective proof of superiority to placebo
ProkineticsProkinetics

Improvement of symptoms in mild GERDImprovement of symptoms in mild GERD

Effective for healing only mild erosive esophagitisEffective for healing only mild erosive esophagitis

Can be useful in a select patient populationCan be useful in a select patient population
HH
22RAsRAs

Relief of symptoms in ~50% of patientsRelief of symptoms in ~50% of patients

Effective for healing only mild erosive esophagitisEffective for healing only mild erosive esophagitis

18. Placebo
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19. Chiba et al. Gastroenterology 1997
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PPIs are the most effective drugs PPIs are the most effective drugs
for the initial treatment of GERDfor the initial treatment of GERD

20. Complications.Complications.
Esophagitis Esophagitis
StricturesStrictures
Barrett esophagusBarrett esophagus
AdenocarcinomaAdenocarcinoma
Respiratory complications: Respiratory complications: pneumonia, asthma, and pneumonia, asthma, and
interstitial lung fibrosis.interstitial lung fibrosis.

21. Complications cont.Complications cont.

22. Complications cont.Complications cont.

23. Points to RememberPoints to Remember
Endoscopy reveals that 50% of patients do not Endoscopy reveals that 50% of patients do not
have esophagitis. have esophagitis.
The only way to determine if abnormal reflux is The only way to determine if abnormal reflux is
present and if symptoms are actually caused by present and if symptoms are actually caused by
GERD is through pH monitoring. GERD is through pH monitoring.
Achalasia can present with heartburn. Only Achalasia can present with heartburn. Only
esophageal manometry and pH monitoring can esophageal manometry and pH monitoring can
be used to distinguish achalasia from GERD. be used to distinguish achalasia from GERD.

24. Peptic Ulcer DiseasePeptic Ulcer Disease
Peptic ulcers are defects in the Peptic ulcers are defects in the
gastrointestinal mucosa that extend gastrointestinal mucosa that extend
through the muscularis mucosa. through the muscularis mucosa.

25. PrevalencePrevalence
Lifetime prevalence is approximately 11-Lifetime prevalence is approximately 11-
14% for men. 14% for men.
Lifetime prevalence is approximately 8-Lifetime prevalence is approximately 8-
11% for women. 11% for women.
Age trends for ulcer occurrence reveal Age trends for ulcer occurrence reveal
declining rates in younger men, declining rates in younger men,
particularly for duodenal ulcer, and particularly for duodenal ulcer, and
increasing rates in older women. increasing rates in older women.

26. EtiologyEtiology
Helicobacter pyloriHelicobacter pylori infection infection
Consumption of NSAIDSConsumption of NSAIDS
Severe physiologic stressSevere physiologic stress
Hypersecretory states Hypersecretory states

27. SymptomsSymptoms
Epigastric painEpigastric pain
Nausea Nausea
VomitingVomiting
DyspepsiaDyspepsia
HeartburnHeartburn
Chest discomfortChest discomfort
Anorexia, weight lossAnorexia, weight loss
Hematemesis or melena Hematemesis or melena

28. SignsSigns
Epigastric tendernessEpigastric tenderness
Epigastric painEpigastric pain
Guaiac-positive stool Guaiac-positive stool
Succussion splashSuccussion splash

29. DifferentialsDifferentials
Biliary Colic Biliary Colic
Cholecystitis Cholecystitis
Cholelithiasis Cholelithiasis
Gastritis, Acute Gastritis, Acute
Gastritis, Chronic Gastritis, Chronic
Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease
Mesenteric Artery Ischemia Mesenteric Artery Ischemia
Myocardial Ischemia Myocardial Ischemia
Pancreatic Cancer Pancreatic Cancer
Pancreatitis, Acute Pancreatitis, Acute
Pancreatitis, Chronic Pancreatitis, Chronic

30. WORKUPWORKUP
Double-contrast radiography Double-contrast radiography
Detection of Detection of H pyloriH pylori infection infection
Endoscopic testsEndoscopic tests
Serum gastrin Serum gastrin

31. Medical TreatmentMedical Treatment
H. pylori H. pylori eradication: Dual/Triple therapyeradication: Dual/Triple therapy
Cessation of NSAIDsCessation of NSAIDs
H2-receptor antagonists H2-receptor antagonists
Proton Pump InhibitorsProton Pump Inhibitors
Prostaglandins Prostaglandins misoprostol misoprostol
SucralfateSucralfate sucrose-aluminum complex promotes ulcer healing sucrose-aluminum complex promotes ulcer healing

32. FDA-Approved Treatment FDA-Approved Treatment
Regimes Regimes
for for H. pyloriH. pylori Infection Infection
Omeprazole 20 mg BID + Clarithromycin Omeprazole 20 mg BID + Clarithromycin
500 mg BID + Amoxicillin 1 g BID for 10 days500 mg BID + Amoxicillin 1 g BID for 10 days
Lansoprazole 30 mg BID +Clarithromycin Lansoprazole 30 mg BID +Clarithromycin
500 mg BID + Amoxicillin 1 g BID for 10 days500 mg BID + Amoxicillin 1 g BID for 10 days
Bismuth subsalicylate (Pepto Bismol) 525 mg Bismuth subsalicylate (Pepto Bismol) 525 mg
QID + Metronidazole 250 mg QID + QID + Metronidazole 250 mg QID +
Tetracycline 500 mg QID X 14 days + HTetracycline 500 mg QID X 14 days + H
22
receptor antagonist x 4 wksreceptor antagonist x 4 wks

33. Adjunctive TreatmentAdjunctive Treatment
Caffeine and AlcoholCaffeine and Alcohol - Both of these stimulate - Both of these stimulate
the secretion of stomach acid and should be the secretion of stomach acid and should be
avoided in the acute phase of an ulcer. avoided in the acute phase of an ulcer.
CigarettesCigarettes - Nicotine will delay the healing of an - Nicotine will delay the healing of an
ulcer.ulcer.
AntacidsAntacids - These agents, can be used for relief - These agents, can be used for relief
of peptic ulcer symptoms. Except for bismuth of peptic ulcer symptoms. Except for bismuth
(Pepto Bismol),- they do not help heal ulcers. (Pepto Bismol),- they do not help heal ulcers.

34. ComplicationsComplications
HemorrhageHemorrhage
Confined Perforation Confined Perforation
Open PerforationOpen Perforation
Gastric outlet obstructionGastric outlet obstruction
RecurrenceRecurrence
Stomach cancer:Stomach cancer: Adenocarcinoma, Gastric/MALT Adenocarcinoma, Gastric/MALT
lymphomaslymphomas

35. Clean Ulcer Induced by AspirinClean Ulcer Induced by Aspirin

36. Gastric Ulcer H.Pylori & AspirinGastric Ulcer H.Pylori & Aspirin

37. MCQSMCQS
1) Gold standard for investigating GERD?1) Gold standard for investigating GERD?
A) Endoscopic TestsA) Endoscopic Tests
B) Esophageal manometerB) Esophageal manometer
C) Multichannel intraluminal impedanceC) Multichannel intraluminal impedance
D) Bravo SystemD) Bravo System
E) None of the aboveE) None of the above

38. 2) Which of the following statements is false?2) Which of the following statements is false?
A) Antacids are not clearly superior to placebosA) Antacids are not clearly superior to placebos
B) NSAIDS most common cause of PUD B) NSAIDS most common cause of PUD
C) Dysphagia is an alarm symptomsC) Dysphagia is an alarm symptoms
D) H2RA Effective healing only mild esophagitisD) H2RA Effective healing only mild esophagitis
E) Nicotine delays healing of an ulcerE) Nicotine delays healing of an ulcer

39. ThanksThanks