GERD solo patologia gastro-esofagea?

Transcription

1 GERD solo patologia gastro-esofagea? Prof. Giancarlo D Ambrosio UNIVERSITÀ DI ROMA LA SAPIENZA Resp. UO Chirurgia Generale ad Indirizzo Colo-Rettale Az. Policlinico Umberto I, Roma

2 Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract.

3 The Montreal definition and classification of GERD a prevalent and chronic condition in which reflux of the stomach contents into the oesophagus causes a range of troublesome symptoms (including heartburn, acid regurgitation and epigastric pain) and complications Vakil et al. The Montreal definition and classification of GERD: a global evidence-based consensus. Am J Gastroenterol. 2006

4 GERD: epidemiology In developed countries, the prevalence of gastro-oesophageal reflux disease (defined by symptoms of heartburn, acid regurgitation, or both, at least once a week) is 10 20%, whereas in Asia the prevalence is roughly less than 5%. El-Serag H, Hill C, Jones R. Systematic review: the epidemiology of gastro-oesophageal reflux disease in primary care, using the UK General Practice Research Database. Aliment Pharmacol Ther 2009; 29: Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2005; 54:

5 GERD: epidemiology In the USA, this disease is the most common gastrointestinal diagnosis to prompt an outpatient clinic visit (8 9 million visits in 2009). The rising prevalence of gastro-oesophageal reflux disease seems to be related to the rapidly increasing prevalence of obesity. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143:

6 GERD: epidemiology incidence of gastro oesophageal reflux disease diagnosis in uk general practice El-Serag H, Hill C, Jones R. Systematic review: the epidemiology of gastro-oesophageal reflux disease in primary care, using the UK General Practice Research Database. Aliment Pharmacol Ther 2009; 29:

7 GERD: Pathophysiology Dysfunction of the oesophagogastric junction Three components make up the oesophagogastric junction: the lower oesophageal sphincter, the crural diaphragm, and the anatomical flap valve. This complex functions as an antireflux barrier.

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9 GERD: Pathophysiology Helicobacter pylori Helicobacter pylori does not have an important role in the pathogenesis of gastrooesophageal reflux disease. Eradication of the microorganism does not lead to an increased chance of development of the disorder

10 Diagnostic investigations The most important diagnostic investigations to prove the presence of GERD are endoscopy long-term impedance ph monitoring (or ph monitoring).

11 Diagnostic investigations Endoscopy can directly evaluate the Esophago-Gastric Junction and make biopsies in order to identificate precancerous lesions (Barrett s Esophagus)

12 GERD: definition Los Angeles classification of reflux oesophagitis grade A, endoscopic abnormalities are restricted to one or more mucosal lesions with a maximum length of 5 mm. In grade B, one or more mucosal breaks are present, with a maximum length of more than 5 mm but non-continuous across mucosal folds. In grade C, mucosal breaks are continuous between at least two mucosal folds, but less than 75% of oesophageal circumference is involved. In grade D, mucosal breaks encompass more than 75% of oesophageal circumference

13 Diagnostic investigations Manometry studies are important prior to any surgical procedure to evaluate motility disorders, especially spastic motility disorders or achalasia

14 GERD: Signs & Symptoms Typical symptoms heartburn (pyrosis) regurgitation.

15 GERD: Signs & Symptoms Although reflux and heartburn happen predominantly during the day, in particular postprandially, both can also occur during sleep. Nocturnal reflux is associated significantly with severe oesophagitis and intestinal metaplasia (Barrett s oesophagus) and can lead to sleep disturbance.

16 Extra-oesophageal (or atypical) symptoms Laryngopharyngeal reflux (LPR) is implicated in the pathogenesis of various upper airway inflammatory diseases as sinusitis or dacryostenosis. 20% of the children with diagnosed LPR showed pepsin in the tears.

17 GERD: Signs & Symptoms Extra-oesophageal (or atypical) symptoms Asthma cough disturbances in cardiac rhythm pharyngitis, sinusitis recurrent otitis media pulmonary fibrosis

18 GERD: Signs & Symptoms Extra-oesophageal (or atypical) symptoms hoarseness sleep apnoea tooth decay difficulty swallowing foreign body sensation in the throat growths on the vocal cords (granulomas)

19 GERD & ASTHMA

20 Asthma causes GERD or GERD causes asthma? GERD present in 30-90% of adults with asthma 80% of asthmatic patients shows ph-metric abnormalities 77% of asthmatic patients show symptoms related to reflux 40% of asthmatic patients suffering from esophagitis In particular, it is unclear which of the two disorders induce the other and vice versa.

21 GERD causes asthma? theory of microaspiration: the aspiration of gastric material refluxed in the tracheobronchial tree causes bronchoconstriction and the onset of chronic bronchitis, asthma attacks and even pneumonia. In the case of asthma, this mechanism is deemed secondary theory of vagal reflex: the stimulation of receptors of the esophageal submucosa induces a reflection of the vagus nerve, which causes a deterioration of respiratory function. This mechanism, which can be demonstrated through the acid perfusion test, is the most likely to explain the onset of chronic cough and asthma.

22 CLINICAL CASE Student 17 year old, non-smoker, no family history of asthma and / or atopy Recurrent episodes of urticaria in anamnesis It refers to a week sense of "tightness" in the epigastric and dyspnoea predominantly postprandial The physical examination of the chest is negative, except for a few hisses and groans expiratory auscultation. spirometry is performed

23 CLINICAL CASE Spirometry revealed an obstructive ventilatory defect of medium severity with a good response to bronchodilator.

24 FURTHER INQUIRIES MADE Prick test for inhalant allergens: Negative PRIST (Total IGE) 36.3: satisfactory ECP (eosinophil cationic protein) 5:32: satisfactory Blood count: the norm CXR: negative THERAPY PRESCRIBED: beta adrenergic bronchodilator + inhaled corticosteroid in combination: 4.5 mcg formoterol / budesonide 160 mcg x 2 / day

25 Discontinued therapy to improved symptoms 13/09/2007 After a month, reappearance of oppression in the epigastric and predominantly postprandial dyspnea, while spirometry again reveals an obstructive ventilatory defect of medium severity. It is again prescribed bronchodilator therapy, increasing the dose of inhaled corticosteroid. 4.5 mcg formoterol / budesonide 160 mcg x 2 / day Budesonide 200 mcg x 2 / day

26 Persists "air hunger" in post-prandial period. This symptom disappears during therapy Formoterol 4.5 mcg / 11/10/07 Budesonide 160 mcg x 2 / day gastroenterological consulting

27 gastroenterological consulting EGDS: gastro esophageal reflux with mild hyperemia of the gastric mucosa and esophageal mucosa. Hp (-) Pantoprazole 40 mg/die

28 23/07/13 Currently, the patient no longer experiences the symptoms and performs maintenance therapy with proton pump inhibitor (pantoprazole 20 mg) It is to check once a year.

29 Therapy Antireflux therapy (both pharmacological and surgical) leads to an improvement in asthma symptoms in 70% of cases. The use of anti-reflux therapy also reduces the use of drugs commonly used in asthma care: Some asthma medications promote reflux. The intensive treatment for GERD is indicated in asthma associated with typical symptoms of reflux, non-allergic asthma, nocturnal asthma, asthma resistant to standard treatments and asthma with onset in adulthood.

30 GERD and COUGH

31 COUGH: HIDDEN EPIDEMIC The incidence of cough symptom is constantly growing and the perception of doctors is that it is not more of a problem mainly seasonal but a symptom that involves them all year.

32 Clinical Practice Guidelines 70-90% of cases seen in clinical practice Upper airway cough syndrome (UACS) GERD Asthma January 2006; 129(1_suppl) Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines

33 chronic cough and GERD prevalence GERD: three prospective studies of Irwin during 17 years 10% (4 th cause) in % (3 rd cause) in % (2 nd cause) in 1998 Jinnai M et al, Cough 2008

34 VICIOUS CIRCLE CRONIC COUGH Cough REFLEX DISTAL ESOPHAGUS TRACHEOBRONCHIAL INCREASED TRANSDIAPHRAGMATIC PRESSURE GASTROESOPHAGEAL REFLUX TRANSITIONAL RELAXATION OF LES RELAXATION OF THE LES IN CONNECTION WITH SWALLOWING

35 GERD and AF

36 Atrial fibrillation in healthy heart 45 ys,, smoker, alcoholic, oveweight; Access to E.R. for prolonged palpitations on waking; Acknowledgement on ECG of atrial fibrillation at 80 / min.

37 Atrial fibrillation in healthy heart Cardiology consult: For several months extra-systolic palpitations mainly in the early hours of the morning; asymptomatic for angina; Echocardiogram: Normal systolic function of the LV and normal size of the left atrium; Infusion of flecainide with restoration of sinus rhythm within one hour; Home tp: flecainide 100 mg 1 tablet x2 / day + Bisoprolol 1.25 mg 1 tablet Holter ECG monitoring to a month.

38 Atrial fibrillation in healthy heart Arrhythmological consulting The patient reported worsening of extra-systolic palpitations morning despite antiarrhythmic tp; an episode of atrial fibrillation after a large meal and liquor abuse and remembers waking up just before a sense of 'weight in the stomach associated with heartburn "; Holter monitoring: "... Several supraventricular extrasystoles, mainly distributed in the night hours of recording, repetitive (many couples and prejudice of max 15 beats)..."; Gastroenterological consulting -> PPI

39 Atrial fibrillation in healthy heart Cardiological examination after a month of PPI: disappearance palpitations Holter ECG monitoring: satisfactory suspension of antiarrhythmic therapy

40 Atrial fibrillation in healthy heart, but not healthy subject 1. Vagal hyperstimulation induced by acid reflux? (It has been seen that treatment with PPI would facilitate the conversion to sinus rhythm) 2. Inflammation district left atrium in patients with esophagitis? 3. Release of pro-inflammatory substances such as interleukin-1β, interleukin-6, CRP (C-reactive protein)? 4. chronic atrial ischemia induced by the reduced coronary flow because of acid reflux? 5. autoimmune mechanisms? (Autoantibodies against myosin heavy chain) 6. genetic factors? (Currently only hypothesised) 7. mechanical or inflammatory effect (linked to distal esophagitis) left atrium by a hiatal hernia? Linz et al. Atrial fibrillation and gastroesophageal reflux disease: the cardiogastric interaction. EUROPACE. 31 May 2016

41 Extra-oesophageal (or atypical) symptoms Pharingo-laryngitis

42 Extra-oesophageal (or atypical) symptoms Hoarseness

43 Extra-oesophageal (or atypical) symptoms Recurrent otitis media

44 Extra-oesophageal (or atypical) symptoms Pulmonary fibrosis

45 Extra-oesophageal (or atypical) symptoms Sleep Apnoea

46 Extra-oesophageal (or atypical) symptoms Tooth decay

47 Extra-oesophageal (or atypical) symptoms Difficulty swallowing

48 Extra-oesophageal (or atypical) symptoms Foreign body sensation in the throat

49 Extra-oesophageal (or atypical) symptoms Growths on the vocal cords (granulomas)

50 dietary and behavioral rules Reduce fat in the diet, Avoid spices, mint, chocolate, carbonated drinks, coffee, tea Stop smoking Avoid excessive alcohol consumption

51 dietary and behavioral rules Avoid those movements that increase abdominal pressure (push-ups on the bust) and too tight clothing Evaluate with the treating physician: Medications that can accentuate Symptoms Eg. Nitrates and calcium channel blockers, antiinflammatory drugs..

52 dietary and behavioral rules Elevate the headboard of the bed by placing cm thick Reduce body weight (If the patient is overweight) Bedtime no earlier than 3 hours between meals. A walk can be helpful

53 Medical therapy The goal of medical therapy in GERD is to: control heartburn, heal gastroesophageal mucosal injuries, improve quality of life. EAES recommendations for the management of gastroesophageal reflux disease Surg Endosc (2014)

54 Medical therapy normalization of ph of gastric juice through the use of alkali salts (weak bases) reduction of acid production administration of protective agents for the gastric mucosa (sucralfate) acceleration of gastric emptying

55 Indication for surgical therapy Prior to the indication for surgery or any other invasive therapy, it must be proven that patients are in need of long- term treatment of GERD. Patients with continuous reduced quality of life, persistent troublesome symptoms, and/or progression of disease despite adequate PPI therapy in dosage and intake should be offered laparoscopic antireflux surgery after proper diagnostic testing. EAES recommendations for the management of gastroesophageal reflux disease Surg Endosc (2014)

56 Indication for surgical therapy There is evidence that laparoscopic antireflux surgery can improve quality of life in patients with altered anatomy, massive acid exposure, nonacid reflux, severe reduction in quality of life, and progressive disease with need to increase PPI dosage over the years EAES recommendations for the management of gastroesophageal reflux disease Surg Endosc (2014)

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58 Indication for surgical therapy Several randomized trials comparing PPI therapy with antireflux surgery have been conducted. Three of these trials showed an advantage for surgical therapy in outcome and cost-effectiveness after a few years, whereas one showed an advantage for PPI therapy after 5 years EAES recommendations for the management of gastroesophageal reflux disease Surg Endosc (2014)

59 Indication for surgical therapy Most frequently mentioned features leading to the indication for antireflux surgery: Typical symptoms for GERD Documented symptom-reflux correlation Year-long reflux history Reduced quality of life Need for PPI dosage increase Hiatal hernia Documented esophagitis (in the past before PPI) Proven LES incompetence Documented acid reflux EAES recommendations for the management of gastroesophageal reflux disease Surg Endosc (2014)

60 Indication for surgical therapy Hiatal Hernia Type I: sliding hiatal hernia Type II: paraesophageal hernia Type III: mixed paraesophageal hernia Type IV: giant hiatal hernia

61 Indication for surgical therapy Hiatal Hernia Type IV: giant hiatal hernia

62 Indication for surgical therapy Most of patients with extra-esophageal signs and symptoms benefits of medical therapy. Several patients with typical symptoms of GERD can benefit of surgical treatment. Patients with documented pathologic laryngopharyngeal reflux (LPR) and positive symptom correlation may benefit from a laparoscopic fundoplication. EAES recommendations for the management of gastroesophageal reflux disease. 2014

63 Surgical therapy Laparoscopic partial and total fundoplications are currently the best available surgical techniques to treat severe GERD.

64 WHICH TECHNIQUE? TOTAL FUNDOPLICATION FLOPPY-NISSEN NISSEN-ROSSETTI PARTIAL FUNDOPLICATION: TOUPET DOR

65 Laparoscopic surgery of gastroesophageal reflux

66 Exposure of the operating region

67 esophagus access: incision of pars condensa and dissection of the right pillar.

68 incision of the phrenoesophageal membrane

69 dissection of the left pillar to the left margin of the esophagus.

70 passage of retro-esophageal webbing

71 Exposure of the hiatus after esophageal mobilization

72 Rapprochement pillars of the diaphragm posteriorly esophagus

73 valve passage posteriorly esophagus

74 Process according Nissen. 360 Process according Toupet 270.

75 Process according Nissen.

76 Robotic Dor Fundoplicatio

77 First the diagnosis (opponent's study) then the strategy (tactics) and then the victory on the field!