Enfermedad Por Reflujo Gastroesof gico

9. El patr�n de sintomas es parecido en pacientes con o sin esofagitis

15. pHmetria de 24 horas Investiga el grado y el momento del reflujo Correlaciona reflujo con sintomas.

17. Endoscopia con Magnificaci�n Permite identificar alteraciones m�nimas en la estructura de la mucosa esof�gica. 12. Patients with ENRD also have minimal and histological changes to the esophagus Despite the absence of definite mucosal breaks or metaplasia that can be seenusing normal endoscopic methods, many patients with ENRD have endoscopically observed minimal changes or histological changes to the esophageal mucosa. These changes, such as histologically observed basal cell hyperplasia of the squamous epithelium and elongation of the papillae10,11 and minimal changes such as triangular indentations and pin-point vessels, have been described both in patients with esophagitis and in patients with ENRD, and may be indicative of acid injury.12 These minimal changes are not included in the LA Classification system because they are not detected consistently using conventional endoscopy.5 The advent of new high-resolution endoscopy techniques that allow more detailed visualisation of the mucosa may, however, make it feasible to use minimal changes in the classification of patients with ENRD in the future.13 5. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 1999;45:172�80. 10. Ismail-Beigi F, Horton PF, Pope CE 2nd. Histological consequences of gastroesophageal reflux in man. Gastroenterology 1970;58:163�74. 11. Vieth M, Haringsma J, Delarive J, Wiesel P, Tam W, Dent J et al. Red streaks in the oesophagus in patients with reflux disease: is there a histomorphological correlate? Scand J Gastroenterol 2001;36:1123�7. 12. Hatlebakk JG, Berstad A. Endoscopic grading of reflux oesophagitis: what observations correlate with gastro-oesophageal reflux? Scand J Gastroenterol 1997;32:760�5. 13. Tam W, Edebo A, Bruno M, Vieth M, Van Berkel A, Lundell L et al. Endoscopy-negative reflux disease (ENRD): high resolution endoscopic and histological signs. Gastroenterology 2002;122 4 Suppl 1:A74.12. Patients with ENRD also have minimal and histological changes to the esophagus Despite the absence of definite mucosal breaks or metaplasia that can be seenusing normal endoscopic methods, many patients with ENRD have endoscopically observed minimal changes or histological changes to the esophageal mucosa. These changes, such as histologically observed basal cell hyperplasia of the squamous epithelium and elongation of the papillae10,11 and minimal changes such as triangular indentations and pin-point vessels, have been described both in patients with esophagitis and in patients with ENRD, and may be indicative of acid injury.12 These minimal changes are not included in the LA Classification system because they are not detected consistently using conventional endoscopy.5 The advent of new high-resolution endoscopy techniques that allow more detailed visualisation of the mucosa may, however, make it feasible to use minimal changes in the classification of patients with ENRD in the future.13 5. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 1999;45:172�80. 10. Ismail-Beigi F, Horton PF, Pope CE 2nd. Histological consequences of gastroesophageal reflux in man. Gastroenterology 1970;58:163�74. 11. Vieth M, Haringsma J, Delarive J, Wiesel P, Tam W, Dent J et al. Red streaks in the oesophagus in patients with reflux disease: is there a histomorphological correlate? Scand J Gastroenterol 2001;36:1123�7. 12. Hatlebakk JG, Berstad A. Endoscopic grading of reflux oesophagitis: what observations correlate with gastro-oesophageal reflux? Scand J Gastroenterol 1997;32:760�5. 13. Tam W, Edebo A, Bruno M, Vieth M, Van Berkel A, Lundell L et al. Endoscopy-negative reflux disease (ENRD): high resolution endoscopic and histological signs. Gastroenterology 2002;122 4 Suppl 1:A74.

30. Hay pocas evidencias de que los h�bitos de vida empeoren los sintomas de la ERGE Obesidad: severidad de la esofagitis asociada al peso solamente cuando el IMC >30 kg/m2 Tabagismo: reduce la presi�n del EEI y el efecto neutralizador de la saliva. Actividad F�sica: La carrera aumenta los RTEEI.

31. Algunos factores diet�ticos poder�n agravar los sintomas de ERGE Jugos y frutas c�tricas Bebidas gaseosas Cafe�na Comidas muy elaboradas Alimentos grasosos Alimentos condimentados Alcohol

32. Medicamentos pueden empeorar los sintomas Empeora de la funci�n del EIE Agonistas beta-adren�rgicos Teofilina Anticolin�rgicos Antidepresivos tric�clicos Progesterona Antagonistas alfa-adren�rgicos Diazepam Bloqueadores de los canales del c�lcio. Lesi�n de la mucosa esof�gica AAS y otros AINES Tetraciclina Quinidina Bisfosfatos.

36. Anti�cidos

37. Anti�cidos

38. ACCIONES DE LOS ANTI�CIDOS

42. Procin�ticos

43. Procin�ticos

44. Procin�ticos

47. Qu�micamente parecidos: Cimetidina Ranitidina Famotidina Nizatidina Inibici�n reversible de duraci�n variada Moderadamente efectivos en la supresi�n �cida, en el alivio de los sintomas y cicatrizaci�n de las lesiones

50. Bloq H2 son efectivos solamente en las esofagitis leves

51. Doblar la dosis es ineficaz en pacientes refractarios a los Blq H2

52. Cu�ndo usarlos ? Doubling the dose is ineffective in patients refractory to H2RAs One approach that has been used in an attempt to improve treatment outcomes in patients refractory to H2RAs is doubling of the dose. The data shown here demonstrate that this approach is ineffective. Kahrilas et al. gave 481 GERD patients with moderate or severe heartburn a standard dose of an H2RA for 6 weeks (1). They then randomized patients who were still symptomatic (n = 271) to receive standard- or double-dose treatment with the same H2RA for a further 8 weeks. As shown on the slide, the proportion of these patients with mild or no heartburn after 4 or 8 weeks was no greater with the double dose than with the standard dose. This proportion was less than 40% in both treatment groups after 4 weeks and less than 50% in both groups after 8 weeks. (1) Kahrilas et al. Am J Gastroenterol 1999; 94: 92�7. Reproduced with permission from the American College of Gastroenterology.Doubling the dose is ineffective in patients refractory to H2RAs One approach that has been used in an attempt to improve treatment outcomes in patients refractory to H2RAs is doubling of the dose. The data shown here demonstrate that this approach is ineffective. Kahrilas et al. gave 481 GERD patients with moderate or severe heartburn a standard dose of an H2RA for 6 weeks (1). They then randomized patients who were still symptomatic (n = 271) to receive standard- or double-dose treatment with the same H2RA for a further 8 weeks. As shown on the slide, the proportion of these patients with mild or no heartburn after 4 or 8 weeks was no greater with the double dose than with the standard dose. This proportion was less than 40% in both treatment groups after 4 weeks and less than 50% in both groups after 8 weeks. (1) Kahrilas et al. Am J Gastroenterol 1999; 94: 92�7. Reproduced with permission from the American College of Gastroenterology.

53. C�mo usarlos en las esofagitis erosivas leves ?

56. IBPs controlan la secreci�n del �cido inhibiendo directamente la bomba de protones

58. Inhibidores de las Bombas de Protones

60. IBPs son los medicamentos m�s eficaces para el tratamiento inicial de la ERGE

69. Helicobacter pylori

70. Helicobacter pylori en la ERGE Infecci�n por H. pylori puede causar un rango de enfermedades g�stricas En el contexto de la ERGE, el H. pylori podr� tener algunos efectos ben�ficos

71. H. pylori � protecci�n contra esofagitis por reflujo?

72. S�NDROMES EXTRADIGESTIVOS

73. COMPLICACIONES

74. TRATAMENTO CIR�RGICOIndicaciones