PATHOPHYSIOLOGY AND DIAGNOSIS OF GERD

1. PATHOPHYSIOLOGY AND DIAGNOSIS OF GERD Doc. dr med. sc. Zoran Mavija Klinika za unutra�nje bolesti Odjeljenje gastroenterologije i hepatologije KC Banja Luka

3. Epidemiology of GERD Highly prevalent in Western countries Relatively low developing country from Africa or Asia 7% of the individulas in US experinece heartburn daily 14% have heartburn once a week Approximately 20�40% of the adult population suffer from heartburn, the principal symptom of GERD In the new millenium the disease is becoming progressively more commom

4. Author: Bardhan KD Topic: Duodenal ulcer and gastroesophageal reflux disease today: long-term therapy-a sideways glance Source: Yale J Biol Med; 69: 211-224 1996 It is common experience that reflux disease is seen more frequently. The figure shows the number of new patients seen in the Rotherham center each year from 1976 to 1994 with GERD (erosive and non-erosive disease), duodenal and gastric ulcer. The rising numbers of patients with GERD is striking. As this was not a formal epidemiological study, conclusions on changing prevalence have to be tentative and limited. The annual number of endoscopies since 1980 has not changed, so the rise cannot be entirely explained by increasing use of diagnostic methods. Greater awareness of GERD, particularly of non-erosive disease, presumably contributes. However, it is difficult to avoid the possibility that at least a part of the rising numbers results from a true increase in prevalence.Author: Bardhan KD Topic: Duodenal ulcer and gastroesophageal reflux disease today: long-term therapy-a sideways glance Source: Yale J Biol Med; 69: 211-224 1996 It is common experience that reflux disease is seen more frequently. The figure shows the number of new patients seen in the Rotherham center each year from 1976 to 1994 with GERD (erosive and non-erosive disease), duodenal and gastric ulcer. The rising numbers of patients with GERD is striking. As this was not a formal epidemiological study, conclusions on changing prevalence have to be tentative and limited. The annual number of endoscopies since 1980 has not changed, so the rise cannot be entirely explained by increasing use of diagnostic methods. Greater awareness of GERD, particularly of non-erosive disease, presumably contributes. However, it is difficult to avoid the possibility that at least a part of the rising numbers results from a true increase in prevalence.

5. Definition Sve osobe izlo�ene riziku nastanka organskih promjena (o�tecenja) jednjaka zbog refluksa �elucanog sadr�aja i/ili osobe koje osjecaju da im je zbog refluksnih simptoma bitno poremecena kvaliteta �ivljenja (quality of life), nakon �to je objektivno ocijenjeno da se radi o benignoj prirodi tegoba Dent et al; 1999 Genval statement Sve osobe izlo�ene riziku nastanka organskih promjena (o�tecenja) jednjaka zbog refluksa �elucanog sadr�aja i/ili osobe koje osjecaju da im je zbog refluksnih simptoma bitno poremecena kvaliteta �ivljenja (quality of life), nakon �to je objektivno ocijenjeno da se radi o benignoj prirodi tegoba Dent et al; 1999 Genval statement

6. Pathophysilogy

7. Pathophysiology Disfunction of the lower esophageal sphincter (LES) Transient LES relaxations (TLESR) Cholinergic hypothesis Nitric oxide - induces TLESRs

8. Pathophysiology Gastric acid Pepsin Bile salts, lecithin Pancreatic enzymes

9. Patofiziologija ezofagitisa na razini tkiva - agresivni cinioci o�tecuju sluznicu i prirodne barijere...Patofiziologija ezofagitisa na razini tkiva - agresivni cinioci o�tecuju sluznicu i prirodne barijere...

10. Pathophysiology Hiatus hernia Helicobacter pylori (negative association) Intraabdominal pressure Habit (smoking, drinking alcohol, coffee, life habits, etc.) Medicines (NSAIDs, theophyline, calcium chanell blockers, alendronate) Stress

11. Diagnosis History Upper GI endoscopy Barium esophagogram 24- hours esophageal pH monitoring Esophageal manometry Perfusyng the esophagus with 0,1 N HCl Radionuclide imaging EUS (endosonography)

12. SYMPTOMS TYPICAL SYMPTOMS Heartburn (pyrosis) Regurgitation ALARM SYMPTOMS Dysphagia GI hammorrhage Iron deficiency anemia Nausea and/or vomiting Weight loss Family history of cancer

13. CLINICAL MANIFESTATIONS OF GERD - CURRENT STATUS

14. Vi�e od 60% oboljenih ima NERD, ikap ostatak ima endoksopski razvijenu sliku ili vec i komplikacijeVi�e od 60% oboljenih ima NERD, ikap ostatak ima endoksopski razvijenu sliku ili vec i komplikacije

15. Endoscopy �Gold standard� �Best tool� Best method for detection of complications Multiple biopsies The first approach in patients over 40 years with alarm symptoms

16. Savary- Miller classification of GERD Grade I: Erosive esophagitis with a non-circumferential solitary ulcerla Grade II: Erosive esophagitis with multiple and confluent non-circumferential ulcers Grade III: Erosive esophagitis with confluent and circumferential ulcers Grade IV: Barrett�s esophagus

17. �L.A.� (Los Angeles ) criteria for endoscopic assessment of GERD Lundell et al, 1999 6. The LA Classification system for the endoscopic assessment of reflux esophagitis Under the LA Classification system, endoscopically visible esophagitis is classified as follows:5 Grade A � one (or more) mucosal break, no longer than 5 mm, that does not extend between the tops of two mucosal folds Grade B � one (or more) mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds Grade C � one (or more) mucosal break that is continuous between the tops of two or more mucosal folds, but which involves less than 75% of the circumference Grade D � one (or more) mucosal break that involves at least 75% of the esophageal circumference. Lundell et al, 1999 6. The LA Classification system for the endoscopic assessment of reflux esophagitis Under the LA Classification system, endoscopically visible esophagitis is classified as follows:5 Grade A � one (or more) mucosal break, no longer than 5 mm, that does not extend between the tops of two mucosal folds Grade B � one (or more) mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds Grade C � one (or more) mucosal break that is continuous between the tops of two or more mucosal folds, but which involves less than 75% of the circumference Grade D � one (or more) mucosal break that involves at least 75% of the esophageal circumference.

18. Lundell et al 1999, published with permission from professor G Tytgat and professor J. DentLundell et al 1999, published with permission from professor G Tytgat and professor J. Dent

19. Lundell et al 1999, published with permission from professor G Tytgat and professor J. Dent Lundell et al 1999, published with permission from professor G Tytgat and professor J. Dent

22. Grade of GERD El-Serag & Johanson 2002 11. LA Grade B is the most prevalent grade of esophagitis The majority of patients with GERD with esophagitis have mild erosions that are graded as A or B according to the LA Classification system. In this study, in which 6709 patients with esophagitis were screened for entry into acid-suppressive clinical trials, LA Grade A esophagitis was present in 34% of patients, LA Grade B in 39%, LA Grade C in 20% and LA Grade D in 7%.9 El-Serag & Johanson 2002 11. LA Grade B is the most prevalent grade of esophagitis The majority of patients with GERD with esophagitis have mild erosions that are graded as A or B according to the LA Classification system. In this study, in which 6709 patients with esophagitis were screened for entry into acid-suppressive clinical trials, LA Grade A esophagitis was present in 34% of patients, LA Grade B in 39%, LA Grade C in 20% and LA Grade D in 7%.9

23. Endoscopy-new imaging techniques Narrow-Band Imaging (NBI):This works on the principle that since the penetration depth of light depends on its wavelength, by using a narrow band filter in the endoscopic system, superficial tissue can be visualized better using blue light, which has a shorter wavelength Video autofluorescence imaging (AFI). Magnification endoscopy Chromoscopy in endoscopy (2,5 %Lugol) Capsule endoscopy

24. Endoscopic images of the same area within a) Barrett�s esophagus using high-resolution endoscopy with optical zoom b) Narrow-band imaging. c) Chromoscopy with indigo carmine. d) Application of acetic acid.

25. An example of Barrett�s esophagus imaged with light-induced fluorescence endoscopy. Left: the image obtained with the system�s white-light mode, showing no visible abnormalities. Right: The LIFE image of the same area, with a visible discoloration corresponding to early cancer.

28. Esophageal pH recording Indications Confirm diagnosis of gastro-esophageal reflux disease in endoscopy �negative patients Atypical and extra-esophageal manifestations of gastro-esophageal reflux disease Selection of patients undergoing antireflux surgery Evolution of antireflux treatment failure

29. 24 h esophageal pH monitoring

30. pH monitoring Wireless pH metry for 48 hours Multi-chanell intraluminal impedance (MII) testin to measure non-acid refluks

31. Esophageal manometry Measurement of LES pressure Esophageal peristaltic amplitude Can help to detect systemic disease Prior to antireflux surgery

32. Esophageal manometry

33. Conclusion GERD is becoming one of the leading disease of the upper GI tract with a global distribution Motor/mechanical abnormalities are mostly responsible for exposing the delicate esophageal mucosa to irritant gastroenteric contens. The Los Angeles (LA) system is increasingly used for grading erosive damage

34. Thank you for your attention