WILLIAM J. SALYERS, JR. , MD, MPH

D I V I S I O N C H I E F / M E D I C A L D I R E C T O RKU W I C H I TA G A S T R O E N T E R O L O G Y

A SS O C I AT E P R O G R A M D I R E C T O R I N T E R N A L M E D I C I N E R E S I D E NC Y

Putting Out the Fire: Prevention & Treatment of

Acid Reflux & Ulcers

Goals

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 ULCERDISEASE

What Causes an Ulcer?

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

How Does This Happen?

Medications Pain Relievers: Ibuprofen , Aspirin, Naproxen Bisphosphonates: Fosamax, Actonel

Helicobacter pylori bacteria

High Acid States: Gastrinoma

Does Stress Cause Ulcers?

Yes & No

Stress alone does NOT cause ulcers.

Uncontrolled high stress conditions may: Burns Physical trauma Surgery

HELICOBACTER PYLORI

Helicobacter Pylori

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?

Pain. May be worse when your stomach is empty.

Bleeding.Nausea & Vomiting.Unexplained weight loss.

Complications of Ulcers

GI Bleeding.

Perforation.

Scarring.

Treatment

Medications to suppress acid production.

Medications that neutralize acid or protect the stomach lining.

Antibiotics for H. pylori infection.

Endoscopic therapy.

ENDOSCOPY

What is Endoscopy

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 REFLUXDISEASE

What is GERD?

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 Symptoms?

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

Smoking.Obesity.Connective tissue disease.Hiatal hernia.High output acid disorders.Diabetes.Pregnancy.

Treatment

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?

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?

Peptic strictures.

Esophageal ulcers.

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

Esophageal cancer.

Peptic Stricture

Reversible inflammation & edema irreversible scarring.

Heartburn often decreases w/ worsening

dysphagia.

Dysphagia usually limited to solids.

Esophageal Cancer: Adenocarcinoma

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’SESOPHAGUS

Epidemiology

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

PPI to control GERD symptoms.Nissen Fundoplication 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

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 Guidelines

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”.

Radiofrequency Ablation

Screening

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?