Clinical presentation, diagnosis, and management of … · Clinical presentation, diagnosis, and management of ... uncomplicated pyrosis or epigastric pain caused ... highly correlates

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Clinical presentation, diagnosis, Clinical presentation, diagnosis, andand

management of management of gastroesophagealgastroesophagealreflux diseasereflux disease

Mitchell S. Mitchell S. CappellCappell, MD, PhD, FACG, MD, PhD, FACG

Med Med ClinClin N Am 89 (2005) 243N Am 89 (2005) 243––291291胃腸內科胃腸內科陳青富陳青富醫師醫師

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TerminologyTerminology

GERDGERD refers to the pathologic reflux of gastric fluid into refers to the pathologic reflux of gastric fluid into the esophagus through the the esophagus through the gastroesophagealgastroesophageal junction.junction.BelchingBelching, which is reflux of air from the stomach to the , which is reflux of air from the stomach to the esophagus and beyond.esophagus and beyond.VomitingVomiting, which is reflux of digested foods (primarily a , which is reflux of digested foods (primarily a semisolid solution).semisolid solution).Reflux Reflux esophagitisesophagitis have evident esophageal have evident esophageal abnormalities at abnormalities at esophagogastroduodenoscopyesophagogastroduodenoscopy (EGD) (EGD) or at pathologic analysis of or at pathologic analysis of endoscopicendoscopic biopsies.biopsies.

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TerminologyTerminology

NonerosiveNonerosive reflux diseasereflux disease have reflux symptoms and have reflux symptoms and abnormal acid exposure with no evident esophageal abnormal acid exposure with no evident esophageal abnormalities at EGD or at pathologic evaluation of abnormalities at EGD or at pathologic evaluation of endoscopicendoscopic biopsies.biopsies.Although Although gastroesophagealgastroesophageal reflux has been defined as reflux has been defined as reflux of acid (pH<4), reflux of acid (pH<4), gastroesophagealgastroesophageal reflux may reflux may incorporate reflux (regurgitation) of nonacid (neutral or incorporate reflux (regurgitation) of nonacid (neutral or alkaline) fluids.alkaline) fluids.GERD is also used as an allGERD is also used as an all--inclusive term for any inclusive term for any extraesophagealextraesophageal clinical consequences, symptomatic or clinical consequences, symptomatic or anatomic, from reflux.anatomic, from reflux.

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PathogenesisPathogenesis

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PathogenesisPathogenesis

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EpidemiologyEpidemiologyIncidenceIncidence

About 40% of US adults complain of monthly heartburn, About 40% of US adults complain of monthly heartburn, about 20% complain of weekly heartburn, and about 7% about 20% complain of weekly heartburn, and about 7% complain of daily heartburn. complain of daily heartburn. The prevalence of erosive The prevalence of erosive esophagitisesophagitis is, however, less, is, however, less, with estimates of with estimates of 2% to 7%2% to 7% as determined by EGD.as determined by EGD.About 0.25% of adults in the United States develop BE About 0.25% of adults in the United States develop BE as a complication of GERD. as a complication of GERD. The prevalence of The prevalence of gastroesophagealgastroesophageal reflux seems to reflux seems to have increased during the last 30 years.have increased during the last 30 years.

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EpidemiologyEpidemiologyRisk factorsRisk factors

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Clinical presentationClinical presentationSymptomsSymptoms

PyrosisPyrosis is the cardinal symptom. Typically, a burning is the cardinal symptom. Typically, a burning pain arises from the pain arises from the epigastriumepigastrium and radiates and radiates retrosternallyretrosternally to the throat and neck; to the throat and neck; exacerbated by meals, by exacerbated by meals, by recumbencyrecumbency, by bending over, , by bending over, and by ingesting acidic drinks; and is relieved by and by ingesting acidic drinks; and is relieved by ingestion of antacids, milk, or other alkaline foods and ingestion of antacids, milk, or other alkaline foods and by standing up.by standing up.RegurgitationRegurgitation: Patients may complain of bitter or acidic : Patients may complain of bitter or acidic fluid in the fluid in the oropharynxoropharynx from regurgitation.from regurgitation.

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Nausea and vomitingNausea and vomiting is rare in GERD and suggests other is rare in GERD and suggests other diseases. Patients occasionally complain of diseases. Patients occasionally complain of atypical chest atypical chest painpain. . GlobusGlobus is an uncommon symptom that is usually is an uncommon symptom that is usually caused by GERD.caused by GERD.DysphagiaDysphagia suggests luminal obstruction from a refluxsuggests luminal obstruction from a reflux--induced peptic stricture or from esophageal induced peptic stricture or from esophageal adenocarcinomaadenocarcinoma complicating BE, sometimes complicating BE, sometimes uncomplicated erosive uncomplicated erosive esophagitisesophagitis..Involuntary weight lossInvoluntary weight loss with chronic reflux symptoms with chronic reflux symptoms suggests possible esophageal suggests possible esophageal adenocarcinomaadenocarcinoma, , particularly when the patient is elderly and has particularly when the patient is elderly and has dysphagiadysphagia of recent origin.of recent origin.

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Severe erosive Severe erosive esophagitisesophagitis can occasionally cause can occasionally cause odynophagiaodynophagia. . Ulcerative reflux Ulcerative reflux esophagitisesophagitis may present with acute may present with acute gastrointestinal bleeding manifesting as gastrointestinal bleeding manifesting as hematemesishematemesisor or melenamelena..

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Clinical presentationClinical presentationSignsSigns

GERD without esophageal complications and without GERD without esophageal complications and without extraesophagealextraesophageal symptoms rarely produces signs. symptoms rarely produces signs. Signs may occur with esophageal complications or Signs may occur with esophageal complications or with with extraesophagealextraesophageal disease.disease.Hemorrhagic Hemorrhagic esophagitisesophagitis may produce pallor from may produce pallor from acute GI bleeding, whereas esophageal ulcerations or acute GI bleeding, whereas esophageal ulcerations or adenocarcinomaadenocarcinoma may produce fecal occult blood with may produce fecal occult blood with chronic GI bleeding.chronic GI bleeding.Esophageal Esophageal adenocarcinomaadenocarcinoma from BE may cause from BE may cause cancer cancer cachexiacachexia..

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Clinical presentationClinical presentationLaboratory testsLaboratory tests

Routine blood tests are characteristically normal with Routine blood tests are characteristically normal with uncomplicated GERD.uncomplicated GERD.Complicated GERD can cause abnormal blood tests. Complicated GERD can cause abnormal blood tests. Hemorrhagic reflux Hemorrhagic reflux esophagitisesophagitis may cause anemia.may cause anemia.Patients with esophageal Patients with esophageal adenocarcinomaadenocarcinoma may have may have hypoalbuminemiahypoalbuminemia from malnutrition.from malnutrition.

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Differential diagnosisDifferential diagnosis

The D/D of The D/D of epigastricepigastric painpain includes includes cholelithiasischolelithiasis, , choledocholithiasischoledocholithiasis, acute viral hepatitis, alcoholic , acute viral hepatitis, alcoholic hepatitis, acute hepatitis, acute pancreatitispancreatitis, PUD, gastritis, , PUD, gastritis, pyelonephritispyelonephritis, , nephrolithiasisnephrolithiasis, shingles, and , shingles, and mesenteric ischemia.mesenteric ischemia.The D/D of The D/D of atypical chest painatypical chest pain includes angina, includes angina, myocardial infarction, and diffuse esophageal spasm.myocardial infarction, and diffuse esophageal spasm.

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Differential diagnosisDifferential diagnosis

DysphagiaDysphagia may be caused by esophageal obstruction may be caused by esophageal obstruction from esophageal s.c.c, large polyps, webs, radiationfrom esophageal s.c.c, large polyps, webs, radiation--induced stricture, foreign body ingestion, or lye induced stricture, foreign body ingestion, or lye ingestion; extrinsic compression, or ingestion; extrinsic compression, or paraesophagealparaesophagealhernia.hernia.OdynophagiaOdynophagia suggests infectious suggests infectious esophagitisesophagitis caused caused by Candida, herpes simplex, cytomegalovirus, or by Candida, herpes simplex, cytomegalovirus, or primary HIV infection; pill primary HIV infection; pill esophagitisesophagitis or radiationor radiation--induced esophageal injury.induced esophageal injury.

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DiagnosisDiagnosisTrial of empiric therapyTrial of empiric therapy

A 6A 6--week trial of empiric acidweek trial of empiric acid--suppressive (PPI) therapy, suppressive (PPI) therapy, without performing EGD, for patients who present with without performing EGD, for patients who present with uncomplicated uncomplicated pyrosispyrosis or or epigastricepigastric pain caused by pain caused by suspected GERD. suspected GERD. Symptom resolution with therapy initiation and Symptom resolution with therapy initiation and recurrence with therapy cessation provides presumptive recurrence with therapy cessation provides presumptive evidence of GERD. evidence of GERD. Sensitivity: 75% and specificity : 80% for GERD, Sensitivity: 75% and specificity : 80% for GERD, using a 50% improvement in using a 50% improvement in pyrosispyrosis as the therapeutic as the therapeutic end point.end point.

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DiagnosisDiagnosisEsophagramEsophagram

Barium studies are used to evaluate a patient with Barium studies are used to evaluate a patient with suspected GERD to document the reflux; detect refluxsuspected GERD to document the reflux; detect reflux--induced mucosal injury; identify an associated sliding induced mucosal injury; identify an associated sliding hiatalhiatal hernia; exclude complications, such as BE, peptic hernia; exclude complications, such as BE, peptic stricture, or stricture, or adenocarcinomaadenocarcinoma. . the sensitivity : 60% for singlethe sensitivity : 60% for single--contrast contrast

90% for double90% for double--contrast studies contrast studies for moderate to severe reflux for moderate to severe reflux esophagitisesophagitis..

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DiagnosisDiagnosisEsophagogastroduodenoscopyEsophagogastroduodenoscopy

with with endoscopicendoscopic biopsiesbiopsiesEGD is the standard clinical test for GERD, EGD is the standard clinical test for GERD, evaluates the evaluates the severity and extent of mucosal injury, and detects the severity and extent of mucosal injury, and detects the presence of complications from GERD.presence of complications from GERD.Severity of Severity of esophagitisesophagitis is is endoscopicallyendoscopically graded graded according to one of three systems. ( the Los Angeles, according to one of three systems. ( the Los Angeles, SavarySavary--Miller grading system or the Miller grading system or the HetzelHetzel classification )classification )In the Los Angeles grading system, In the Los Angeles grading system, esophagitisesophagitis is graded is graded from A, where mucosal breaks are confined to folds and from A, where mucosal breaks are confined to folds and no longer than 5 mm, to D, where mucosal breaks are no longer than 5 mm, to D, where mucosal breaks are circumferential.circumferential.

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Grade A, LA classification Grade A, LA classification

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Grade B, LA classification Grade B, LA classification

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Grade C, LA classificationGrade C, LA classification

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Grade D, LA classificationGrade D, LA classification

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with with endoscopicendoscopic biopsiesbiopsiesEGD cannot detect abnormal acid reflux without mucosal EGD cannot detect abnormal acid reflux without mucosal injury (injury (nonerosivenonerosive reflux diseasereflux disease).).It misses about 40% of acid reflux determined by pH It misses about 40% of acid reflux determined by pH monitoring, but such reflux tends to be mild and monitoring, but such reflux tends to be mild and uncomplicated. uncomplicated. EGDEGD often fails to diagnose clinically significant often fails to diagnose clinically significant extraesophagealextraesophageal manifestations of GERD, which often manifestations of GERD, which often occur without occur without esophagitisesophagitis. . When When extraesophagealextraesophageal manifestations of GERD are manifestations of GERD are suspected, normal findings at EGD should prompt 24suspected, normal findings at EGD should prompt 24--hour ambulatory pH monitoring.hour ambulatory pH monitoring.

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with with endoscopicendoscopic biopsiesbiopsies

GERD is associated with a sliding GERD is associated with a sliding hiatalhiatal hernia.hernia.EGD reveals a small pouch between the tubular EGD reveals a small pouch between the tubular esophagus and the baggy stomach; the pouch is lined by esophagus and the baggy stomach; the pouch is lined by gastric mucosa and covered by gastric gastric mucosa and covered by gastric rugaerugae that extend that extend several centimeters above the diaphragmatic hiatus.several centimeters above the diaphragmatic hiatus.A stricture associated with reflux A stricture associated with reflux esophagitisesophagitis may be may be benign from peptic injury, or malignant from benign from peptic injury, or malignant from adenocarcinomaadenocarcinoma, should be extensively , should be extensively biopsiedbiopsied..

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HiatalHiatal herniahernia

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Esophageal Peptic Strictures Esophageal Peptic Strictures

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Esophageal Cancer Esophageal Cancer

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DiagnosisDiagnosisAmbulatory pH monitoringAmbulatory pH monitoring

2424--hour ambulatory pH monitoring is the most hour ambulatory pH monitoring is the most sensitive test, but cannot detect reflux of sensitive test, but cannot detect reflux of nonacidicnonacidicfluids and cannot assess mucosal damage from the fluids and cannot assess mucosal damage from the refluxaterefluxate..Indicated for pts with typical reflux symptoms Indicated for pts with typical reflux symptoms refractory to conventional therapy who have refractory to conventional therapy who have nonerosivenonerosive reflux disease; for pts presenting with reflux disease; for pts presenting with extraesophagealextraesophageal symptoms of undetermined etiology symptoms of undetermined etiology and before and before antirefluxantireflux surgery.surgery.

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DiagnosisDiagnosisAmbulatory pH monitoringAmbulatory pH monitoring

The acid exposure time is defined as the percentage of The acid exposure time is defined as the percentage of time that the esophageal pH is less than 4. ( normal time that the esophageal pH is less than 4. ( normal upper limit : 6.3% in the supine and 1.2% in the upright upper limit : 6.3% in the supine and 1.2% in the upright position).position).GastroesophagealGastroesophageal reflux is most simply defined as an reflux is most simply defined as an abnormally high acid exposure time. abnormally high acid exposure time. An abnormal result at ambulatory 24An abnormal result at ambulatory 24--hour pH monitoring hour pH monitoring highly correlates with the diagnosis of reflux highly correlates with the diagnosis of reflux esophagitisesophagitisat EGD.at EGD.Between 84% and 96% of patients with reflux Between 84% and 96% of patients with reflux esophagitisesophagitis at EGD have abnormal esophageal acid at EGD have abnormal esophageal acid exposure times.exposure times.

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Medical therapyMedical therapyLifestyle and dietary modificationsLifestyle and dietary modifications

Factors that promote or exacerbate Factors that promote or exacerbate gastroesophagealgastroesophagealreflux should be avoided.reflux should be avoided.Obese patients should lose weight and avoid heavy or Obese patients should lose weight and avoid heavy or fatty meals.fatty meals.Patients should avoid late night snacks and Patients should avoid late night snacks and recumbencyrecumbencysoon after eating.soon after eating.The head of the bed should be elevated.The head of the bed should be elevated.Patients should avoid Patients should avoid midabdominalmidabdominal tighttight--fitting clothes fitting clothes or belts.or belts.Patients should eliminate smoking and restrict alcohol Patients should eliminate smoking and restrict alcohol intake.intake.

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Medical therapyMedical therapyLifestyle and dietary modificationsLifestyle and dietary modifications

Foods that exacerbate symptoms should be avoided; Foods that exacerbate symptoms should be avoided; these foods often include citrus drinks, spicy foods, these foods often include citrus drinks, spicy foods, coffee, tea, cola beverages, and chocolate.coffee, tea, cola beverages, and chocolate.Medications known to lower the LES pressure, such as Medications known to lower the LES pressure, such as calcium channel blockers or nitrates, and that can calcium channel blockers or nitrates, and that can exacerbate esophageal injury, such as exacerbate esophageal injury, such as NSAIDsNSAIDs, should , should be avoided if possible.be avoided if possible.Avoidance of Avoidance of psychologicpsychologic stress at home and work is stress at home and work is advisable.advisable.

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Medical therapyMedical therapyMedicationsMedications

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Medical therapyMedical therapyγγ--AminobutyricAminobutyric acid agonistsacid agonists

A major current focus of research is to develop A major current focus of research is to develop tLESRtLESRinhibitors that may effectively prevent GERD with inhibitors that may effectively prevent GERD with minimal side effects.minimal side effects.γγ --AminobutyricAminobutyric acid is a powerful CNS inhibitory acid is a powerful CNS inhibitory neurotransmitter. neurotransmitter. BaclofenBaclofen is a is a γγ--aminobutyricaminobutyric acidacidBBreceptor agonist blocks receptor agonist blocks tLESRtLESR relaxation in laboratory relaxation in laboratory animals and in humans.animals and in humans.BaclofenBaclofen reduced the frequency of reflux episodes and of reduced the frequency of reflux episodes and of tLESRstLESRs by 40by 40-- 60% as compared with placebo.60% as compared with placebo.

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EndoscopicEndoscopic therapytherapy

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Surgical therapySurgical therapy

The two most common The two most common antirefluxantireflux operations are the operations are the NissenNissen and and ToupetToupet fundoplicationsfundoplications..Both procedures are most commonly performed Both procedures are most commonly performed laparoscopicallylaparoscopically..Common indications include failed medical therapy Common indications include failed medical therapy despite adequate acid suppression; intolerance or despite adequate acid suppression; intolerance or noncompliance to PPI therapy in young patients with noncompliance to PPI therapy in young patients with moderate to severe GERD; persistent moderate to severe GERD; persistent extraesophagealextraesophagealsymptoms; and refluxsymptoms; and reflux--induced regurgitation, aspiration, induced regurgitation, aspiration, asthma, or asthma, or bronchiectasisbronchiectasis not responding to PPI therapy.not responding to PPI therapy.

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Surgical therapySurgical therapy

AntirefluxAntireflux surgery is relatively contraindicated in elderly surgery is relatively contraindicated in elderly patients or in patients with significant patients or in patients with significant comorbiditycomorbidityunrelated to GERD. unrelated to GERD. Both procedures are successful in more than 90% of Both procedures are successful in more than 90% of patients, with relief of symptoms and prevention of patients, with relief of symptoms and prevention of recurrent strictures when performed by experienced recurrent strictures when performed by experienced surgeons at highsurgeons at high--volume referral centers.volume referral centers.Postoperative complications include esophageal Postoperative complications include esophageal hemorrhage, esophageal perforation, hemorrhage, esophageal perforation, cruralcrural disruption, disruption, paraesophagealparaesophageal herniationherniation, and gastric , and gastric volvulusvolvulus..The mortality of the The mortality of the NissenNissen fundoplicationfundoplication is is approximately 0.2%.approximately 0.2%.

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Special situationsSpecial situationsExtraesophagealExtraesophageal manifestations of GERD manifestations of GERD

Pulmonary manifestations of GERD may Pulmonary manifestations of GERD may becausedbecaused by by microaspirationmicroaspiration of acid and pepsin into the of acid and pepsin into the tracheobronchialtracheobronchial tree, or a tree, or a bronchoconstrictivebronchoconstrictive vagalvagalreflex triggered by esophageal irritation.reflex triggered by esophageal irritation.Asthma is frequently associated with GERD.Asthma is frequently associated with GERD.The asthma is typically nocturnal because of the The asthma is typically nocturnal because of the promotion of promotion of gastroesophagealgastroesophageal reflux with reflux with recumbencyrecumbency, , and the absence of food to buffer refluxed acid during and the absence of food to buffer refluxed acid during overnight fasting. overnight fasting.

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Special situationsSpecial situationsExtraesophagealExtraesophageal manifestations of GERDmanifestations of GERD

GERDGERD--associated asthmaassociated asthma should be considered in should be considered in patients who present with asthma in adulthood, lack a patients who present with asthma in adulthood, lack a personal and family history of allergy, have heartburn, personal and family history of allergy, have heartburn, and respond poorly to traditional bronchodilator or and respond poorly to traditional bronchodilator or steroid therapy.steroid therapy.Currently treated with PPI therapy. High dose, twiceCurrently treated with PPI therapy. High dose, twice--daily, and longdaily, and long--term therapy is generally recommended. term therapy is generally recommended. Symptoms improved in 69% of patients receiving Symptoms improved in 69% of patients receiving antirefluxantireflux medications.medications.

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Reflux laryngitisReflux laryngitis is caused by is caused by microaspirationmicroaspiration of acid. of acid. The most common symptom is hoarseness. Others The most common symptom is hoarseness. Others include include globusglobus sensation, frequent throat clearing, sensation, frequent throat clearing, halitosis, sore throats, and chronic cough.halitosis, sore throats, and chronic cough.10% to 40% of patients with chronic cough have GERD.10% to 40% of patients with chronic cough have GERD.Only a minority of patients have heartburn, and Only a minority of patients have heartburn, and endoscopicendoscopic evidence of evidence of esophagitisesophagitis. . Esophageal pH monitoring is the best available Esophageal pH monitoring is the best available diagnostic test, but is only moderately sensitive( 54%), diagnostic test, but is only moderately sensitive( 54%), and specific.and specific.

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PPIsPPIs are the generally recommended therapy, with are the generally recommended therapy, with from 63% to 100% of patients experiencing significant from 63% to 100% of patients experiencing significant improvement in laryngeal symptoms and improvement in laryngeal symptoms and laryngoscopiclaryngoscopicfindings with therapy.findings with therapy.GERD is an important cause of GERD is an important cause of nonbacterial dental nonbacterial dental erosionserosions, in a prospective study, 47.5% of 181 , in a prospective study, 47.5% of 181 patients with dental erosions had GERD, whereas only patients with dental erosions had GERD, whereas only 12.5% of 72 healthy subjects had GERD. 12.5% of 72 healthy subjects had GERD.

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Special situationsSpecial situationsGERD and GERD and Helicobacter pylori Helicobacter pylori infectioninfection

An association between the decreasing prevalence of An association between the decreasing prevalence of H H pylori pylori infection, caused by antibacterial therapy, and the infection, caused by antibacterial therapy, and the increasing incidence of GERD and esophageal increasing incidence of GERD and esophageal adenocarcinomaadenocarcinoma in Western countries.in Western countries.A recent metaA recent meta--analysis of 14 caseanalysis of 14 case--controlled studies controlled studies reported that reported that H pyloriH pylori––negative status was significantly negative status was significantly associated with GERD, and of 10 therapeutic clinical associated with GERD, and of 10 therapeutic clinical trials reported that antitrials reported that anti––H pylori H pylori therapy was therapy was significantly associated with GERD.significantly associated with GERD.AntiAnti––H pylori H pylori therapy should not be withheld, when therapy should not be withheld, when otherwise indicated, because of the quantitatively small otherwise indicated, because of the quantitatively small increased risk of esophageal increased risk of esophageal adenocarcinomaadenocarcinoma after after H H pylori pylori eradication.eradication.

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Complications Complications BarrettBarrett’’s esophagus and esophageal s esophagus and esophageal

adenocarcinomaadenocarcinoma

BE is defined as replacement of normal stratified BE is defined as replacement of normal stratified squamoussquamous epithelium by epithelium by metaplasticmetaplastic, specialized, , specialized, intestinal epithelium that contains goblet cells.intestinal epithelium that contains goblet cells.BE is a BE is a premalignantpremalignant lesion. lesion. From 1/3From 1/3--2/3 of esophageal 2/3 of esophageal adenocarcinomaadenocarcinoma contain contain foci of Barrettfoci of Barrett’’s s metaplasiametaplasia..About 10% of pts have esophageal About 10% of pts have esophageal adenocarcinomaadenocarcinoma at at the time of diagnosis of BE.the time of diagnosis of BE.The annual incidence of esophageal The annual incidence of esophageal adenocarcinomaadenocarcinoma in in pts with established BE is about 1 in 200.pts with established BE is about 1 in 200.The risk of developing esophageal The risk of developing esophageal adenocarcinomaadenocarcinoma is is increased about 100increased about 100--fold in patients with BE.fold in patients with BE.

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adenocarcinomaadenocarcinoma

Demographic risk factors include male sex, older age, Demographic risk factors include male sex, older age, white race, lower socioeconomic status. and probably white race, lower socioeconomic status. and probably smoking tobacco.smoking tobacco.Obesity is an important risk factor.Obesity is an important risk factor.Patients with a Patients with a hiatalhiatal hernia are more likely to have hernia are more likely to have severe reflux severe reflux esophagitisesophagitis, BE, and esophageal cancer., BE, and esophageal cancer.At EGD numerous biopsies should be taken to confirm At EGD numerous biopsies should be taken to confirm the diagnosis of BE the diagnosis of BE histologicallyhistologically and to exclude and to exclude dysplasiadysplasia or or adenocarcinomaadenocarcinoma..

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adenocarcinomaadenocarcinomaThe surveillance interval for BE depends on the degree The surveillance interval for BE depends on the degree of of dysplasiadysplasia. BE without . BE without dysplasiadysplasia :every 3 years; with :every 3 years; with mild mild dysplasiadysplasia :every 6 months; with severe :every 6 months; with severe dysplasiadysplasia, , generally require generally require esophagectomyesophagectomy..PPIsPPIs are the mainstay of medical therapy for GERD are the mainstay of medical therapy for GERD complicated by BE.complicated by BE.Although intense PPI therapy usually effectively reverses Although intense PPI therapy usually effectively reverses severe erosive severe erosive esophagitisesophagitis, evidence for its effect on , evidence for its effect on reversing Barrettreversing Barrett’’s s metaplasiametaplasia and on reducing the risk and on reducing the risk of esophageal of esophageal adenocarcinomaadenocarcinoma is indirect and is indirect and inconclusive.inconclusive.

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ComplicationsComplicationsHemorrhagic Hemorrhagic esophagitisesophagitis

About 7% of patients with GERD have clinically About 7% of patients with GERD have clinically significant acute hemorrhage.significant acute hemorrhage.Only about 40% of these patients report a history of Only about 40% of these patients report a history of heartburn.heartburn.Other risk factors for hemorrhagic reflux Other risk factors for hemorrhagic reflux esophagitisesophagitisinclude cirrhosis, include cirrhosis, coagulopathycoagulopathy, and anticoagulant , and anticoagulant therapy.therapy.Focal lesions with stigmata of recent hemorrhage should Focal lesions with stigmata of recent hemorrhage should receive receive endoscopicendoscopic therapy at the time of therapy at the time of endoscopicendoscopicdiagnosis. diagnosis. Hemorrhagic reflux Hemorrhagic reflux esophagitisesophagitis is generally managed is generally managed medically with intense PPI therapy.medically with intense PPI therapy.

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ComplicationsComplicationsPeptic stricturePeptic stricture

Risk factors include old age, a long history of GERD, a Risk factors include old age, a long history of GERD, a hypotensivehypotensive LES, abnormalities in esophageal peristalsis, LES, abnormalities in esophageal peristalsis, and a and a hiatalhiatal hernia.hernia.Characteristically presents with progressive Characteristically presents with progressive dysphagiadysphagia, , typically to solids and often with antecedent typically to solids and often with antecedent pyrosispyrosis..Weight loss associated with an esophageal stricture Weight loss associated with an esophageal stricture suggests possible malignancy.suggests possible malignancy.Barium Barium esophagramsesophagrams reliably detect peptic esophageal reliably detect peptic esophageal strictures.strictures.

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EGD is usually the choice to evaluate a suspected peptic EGD is usually the choice to evaluate a suspected peptic stricture because of high sensitivity; high specificity; and stricture because of high sensitivity; high specificity; and the ability to perform the ability to perform endoscopicendoscopic therapy.therapy.Multiple biopsies are taken at EGD to exclude BE, Multiple biopsies are taken at EGD to exclude BE, esophageal esophageal adenocarcinomaadenocarcinoma, or other lesions., or other lesions.Peptic strictures are usually treated with mechanical Peptic strictures are usually treated with mechanical dilatation, especially strictures that are tight, severely dilatation, especially strictures that are tight, severely symptomatic, or refractory to medical therapy.symptomatic, or refractory to medical therapy.

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Patients with a peptic stricture should receive intense Patients with a peptic stricture should receive intense PPI therapy to reduce the mucosal inflammation from PPI therapy to reduce the mucosal inflammation from acidacid--induced injury.induced injury.Maintenance PPI therapy greatly decreases the need Maintenance PPI therapy greatly decreases the need for repeated stricture dilatations.for repeated stricture dilatations.

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Clinical presentation, diagnosis, and management of … · Clinical presentation, diagnosis, and management of ... uncomplicated pyrosis or epigastric pain caused ... highly correlates