GASTROINTESTINAL SYSTEMANDSLEEP

Oya tilDE Medical Faculty Dept. Of Respiratory MedicineZMR

Sleep Disorders and GIS SymptomsDisturbed sleep is common among patients with GI symptoms.Chicken, egg or vicious cycle ?Sleep disturbance is commonly reported by GER sufferers.

There is an association between irritable bowel syndrome and sleep disorders. Waking up at least four times a month has been found to be associated with a variety of GI symptoms like pain and diarrhea.

Sleep disorders can lead to changes in visceral sensations. Sleep deprivation hyperalgesia M. Maneerattanaporn. Neurogastroenterol Motil 2009;21:97-99

GER

Passive transition of gastric content into the oesophageus due to the transient or chronic relaxation of lower oesophageal sphincter

Retrosternal burning sensation and / or painRegurgitation of gastric contentBitter taste in moutherozive oesophagitis ( stricture, Barrett metaplasia, adenocarcinoma )May be asymptomatic

Nonerosive form 60 %Erosive form 35 %Complicated erosive cases 5 %

Extraoesophageal Manifestatons of GERPulmonaryAsthmaAspiration pneumoniaChronic bronchitisPulmonary fibrosis

Cardiac Chest painENTHoarsnessLaryngitisPharyngitisChronic coughGlobus sensationDisphoniaSinusitisSubglottic stenosisLaryngeal cancer

GER- related oral and laryngopharyngeal manifestationsLarynx oedema and hyperemiaVocal cord erythema, polyps, granulomas, ulcersHyperemia of posterior pharynx and lymphoid hyperplasiaInterarytenoid changesDental erosionSubglottic stenosisLaryngeal cancerVaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.

OdontologiaDental erosionPchyatricSleep disordersSexual disordersAnxietyPediatricRecurrent pneumoniaSudden infant deathOtitis mediaOtherBad odor in the mouthDry mouth

Sleep-related GEROesophagitisBarrett oesophagusOesphageal adenocarcinomaArousalsPoor sleep qualityExcessive daytime sleepinessDeteoriation in quality of lifeGER- related exstraoesophageal manifestations

UES in proximality18-22 cm. LES in distality3 types of contraction primary secondary non-peristaltic

Transient LES relaxations occur without swallowingResponsible of 63 % -74 % of GER episodes

Increase in gastric acid secretions Delay in gastric emptying Increase in gastric pressure

GER

Large pleural-abdominal pressure gradientsObesityOesophageal dysmotilityLES hypotensionHiatal hernia

GER

Mechanisms of GER-related respiratory symptoms Nocturnal ascit reflux microaspiration exudative mucosal reactionAscid reflux esophagus vagus nerve bronchoconstriction

Respiration is not a static process. Body position changes pressure conditions.In some respiratory diseases, subatmospheric intrathoracic pressure increases with volume increase as the result of the increase in respiratory resistance GER

GER AND SLEEPSleep-related GER in patients with GER 79 %Sleep Heart Health Study 25 % BMIConsumption of carbonated drinkssnoringSleepinessnsomniaBenzodiazepinesHT and asthma

Fass R. Chest 2005;127:1658-66

Physiology of sleep-related GERBasal gastric ascite secretion peaks between 20.00 pm - 1.00 am.Gastric emptying delays.No saliva productionNo swallowing during stable sleepUES pressure drops from 44 mm Hg to 10 mm Hg.During REM sleep UES reflex persists.

LES pressure doesnt change.No transient LES relaxations during stable sleepEsophagus ascite clearance significantly delays during sleep and requires arousal for clearance. Esophageal ascite migrates toward proximal. Harding SM. Sleep Medicine Clinics 2007; 2:1

Sleep PositionGastric ascite is very close to the esophagus due to the posterior position of the oesophagus.

GER events in wakefulness are frequent but short.Less frequent in sleep but long . because of the increase in esophageal clearance durationEating within the two hours before sleep

Sleep is a risk factor for GER.No difference between REM and NREMMore frequent in the first half of sleepMore frequent in lateral decubitus position

Demeter P, Pap A. J Gastroenterol 2004;39:815-20Demeter P, Pap A. J Gastroenterol 2004;39:815-20Hila A. J Clin Gastroenterol 2005; 39:579-83

Ascite production increases in wakefulness.LES pressure decreases as sleep deepens in healthy volunteers.

Kahrilas PJ,et.al. Gastroenterology 1987;92:466-71Stacher G,et al. Gastroenterology ; 1975;68:1449-55

Diaphragma is related with LES through PEL .Respiratory work of diaphragma increases during OSACardia is affected due to frequent changes in PEL position cardia insufficiencyDeteoriation in swallowing

Obesity and alcohol abuse increase intraabdominal pressure and decrease in oesophageal clearance

Sleep-related GER and OSASObstructive apnea episodes in parallel with the increase in intrathoracic pressure transdiaphragmatik pressure increases effect on phrenooesophagealPressure changes cardia insufficiency

gastric volume clearance LES insufficiency GER

Serious respiratory symptoms without typical upper GIS complaintsAwakening at sleep with panic choking and ascitic burning

2000 adults, 20-44 ageSnoring in 5 % of males and 2 % of femalesApneas in patients with GER

GER symptoms are more frequent in older patients with OSA than without OSA.

Teramoto et al. J Am Geriatr Soc 1999; 116: 17-21

OSAS + GER CPAP decrease in reflux eventsOSA, may be a causal factor for GER.

Green BT. Arch Intern Med 2003;13:41-5

Refl Arousal GER causes OSA OSA + GER , 20 mg omeprazol 2x1Improvement in AHI in 30 % of the cases

Kerr P. Chest 1992;101:1539-44

10 cases with OSASOSAS + GER in 820 mg omeprazol 2x1, 2.7 months + dietSignificant improvement in EDS

Demeter P, Pap A. J Gastroenterol 2004;39:815-20

CPAP, can decrease GER in cases with OSAS by increasing intraoesophageal pressure.Seropositivity for Helicobacter pylori has been found to be significantly high in patients with OSAS.

nal M. Clin Otolaryngol 2003;28:100-2

OSA

Dph (-) pTh PEL pTD

TLESR (n) GER

Oesophageal and tracheal ascit affects airway reactivity and peak expiratory flow rates during sleep.In patients with GER + nocturnal asthma, when oesophageal pH drops, PEFR 8 L/m in the monitorization of oesophageal and tracheal pHWhen tracheal pH drops , PEFR 84 L/m

Diagnosis of Sleep-Related GERCareful historyOesophageal pH testEndoscopy PSG

Esophageal pH monitorization24 hourspH < 4 GERDistal esophagus probe is placed 5 cm above the LES. Manometric determination of LES is gold standard for the placement of pH probe.

A reference lead is placed on the anterior chest wall and the esophageal pH probe is then connected to a portable data acquisition device that has an event marker that the patient pushes to note when symptoms occur.

Wireless, Catheter-Free Esophageal pH Monitoring

Improved patient comfort and acceptance Continued normal work, activities and diet study Longer reporting periods possible (48 hours) Maintain constant probe position relative to SCJ

Potential Advantages

63 pts with OSA ( AHI > 15 )41 controls47% of GER events has no relation with apneas11 % were preceded within 1 minute of apneic events30 % were followed by apneic events12 % occurred simultaneously

TreatmentConservative measuresMedical treatmentProton pump inhibitorsH2 receptor antagonists, prokinetic agentsSurgical treatmentFundoplication

ClassDoseAdverse effectsMylantaAntascite2-4 mL DiareGaviscon powder/LiquidAntascite1p/120 mL 5 mL/120 mLConstipationRanitidine (Zantac)CimetidineNizatidineFamotidineH2 receptor antagonist4-8 mg/kg/gdBitter taste, lethargyNo use with antascites , folic ascit, B12, Fe, Mg absorption, NECOmeprazole(Prilosec)PantoprazoleProton Pump Inhibitor (PPI)0.7-3 mg/k/dBitter taste, B12 ,NaMetoklopramide(Reglan)Prokinetic0.5 mg/k/dLethargy,DiareErithromycinProkinetic20 mg/k/dAllergic liver enz, rash, pyloric stenosisLansoprazol(Prevacid)PPI0.5 mg/k/dfatigue, nausea, BP, diare,theo levels

Future medicationsGABA antagonistsBaclofen

Open and laparoscopic Nissen fundoplicationSymptom resolution in 80 % to 90 % of GER patientsComplicationsDysphagiaChest herniationVagal nerve damage

62 % of surgically treated patients still require GER medication postoperatively.Endoscopic fundoplication is considered experimental.

Rothstein R. Gastroenterology 2006;131:704-12

Management strategy for sleep-related GERConservative measures + PPI (30-60 min before dinner)

prokinetic agent

esophageal pH testing

Weight lossSleep in left lateral decubitus positionCPAP if OSAS is present

CONCLUSIONBoth diseases are common and share similar risk factors.Both of them disrupt sleep and sleep architecture.Future research may clarify the association between OSA and sleep-related GER.

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