gastroesophageal reflux diseases
DESCRIPTION
CHRONIC COUGH. due to. GASTROESOPHAGEAL REFLUX DISEASES. MÜNEVVER ERDİNÇ Department of Chest Diseases Ege University Faculty of Medicine. A cute Cough lasting less than 3 weeks Subacute Cough lasting 3 to 8 weeks. Chronic Cough. Lasting more than 8 weeks. - PowerPoint PPT PresentationTRANSCRIPT
1
MÜNEVVER ERDİNÇDepartment of Chest Diseases
Ege University Faculty of Medicine
2
Acute Cough lasting less than 3 weeks
Subacute Cough lasting 3 to 8 weeks
Chronic CoughLasting more than 8 weeks
Morice AH.Eur Respir J 2004 :24:481-492
Fontana GA.Thorax 2003;58:1092-1095
Irwin RS.NEJM 343(23): 1715-1721,2000
Irwin RS. Chest 1998; 114(suppl1) :133S-181S
3
10
12
1312
16
64
ASTHMAPNDS
GERD
Chest 1999;116:279-284
1. Gastroesophageal reflux disease (21-41%) 2. Cough variant asthma (24-59%) 3. Postnasal drip syndrome (41-58%)
4
38,5%
35,9%
16,7%
8,9%
Chest 1999;116:279-281
Percentage of Cases Presenting 1,2,3, and 4 Causative Factors
1
2
3
4
5
İmmunocompetent patients Not exposed to enviromental irritants Chest radiograph is normal Not taking an ACE inhibitor Nonsmoker
Asthma and/or GERD, PNDS
responsible for 93.6% of the casesof chronic cough
Harding SM .Chest 2003;123:659-660
6
Coughthe most common complaint for
seeking medical care
In the USA Ist (1993)
GERD GERD the most common chronic
disease ın the USA!
R. C. Orlando
7Journal of the best Sabah. January 2004: 7
8
GASTROESOPHAGEAL REFLUX The backflow of stomach contents into the esophagus
(gastric acid, pepsin, bile, pancreatic enzymes)
Heartburn (pyrosis) and regurgitationAt least weekly symptoms
manifested by either by extraesophageal reflux symptoms
and/or esophageal mucosal damage
Irwin SR. Chest 2006:129:80S-94S
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
9
What happens during nonpathologic reflux?
Kahrilas PJ.CCJM 70(5):S4-19,2003
10
ANTIREFLUX BARRIERS
Intraabdominal
+5 mmHg
Expiration Inspiration
LES +25mmHg
Intrathoracic
-5 mmHg
Diaphragma
11
Impaired esophageal clearance
Functional defect in
LES syphincter Hiatal hernia
Delayed gastric emptying İncreased intra-abdominal
pressure
Katzka & DiMarino 1995
GERD ? Decreased
saliva
12
Causative Factors in GERD1.Gastroesophageal barrier function impairment
Hiatal herniaİmpaired diyaphragmatic crus Transient LES relaxations
2.Delayed esophageal clearanceLow amplitude or simultaneous contractionsReduced salivation
3.Exogen factors Alcohol, smoking, drugs, hot drinks , hypertonic foods, aging
4.Gastric factorsAcid hypersecretion ?Delayed gastric emptyingAbnormal antropyloroduodenal motility (Alkalen reflux)
5.Impaired mucosal resistance
13
Gastroesophageal Reflux Diseases İzmir - Olmsted Prevalance
02
46
8101214
1618
20
Heartburn Regurgitation
Wee
kly
sym
ptom
s %
Izmir, Türkiye (630) S.Bor et al. DDW 2000Olmsted, USA (2073) Locke et al. Gastroenterology,1997
20 19.8
10
15.6
6.3
17.8
Pyrozis/ Regurgitation
14
Menderes (Ege ÜTF) Olmsted (Mayo)Symptom GERD (+)
%GERD (-)
%GERD (+)
%GERD (-)
%
Dysphagia 35,7 7,9 * 29,4 13,5 *
NCCP 44,4 18,7 * 37 23,1 *
Odynophagia 10,3 2,4 *
Globus 23,8 8,1 * 14,2 10,6 *
Regurgitation 24,6 13,8 *
Hiccup 9,5 2,4 *
Cough 19,8 10,3 *
Hoarseness 28,6 13,1 *
Asthma 0,8 2,2 11,6 9,3
GERD Related Symptoms
15
Physiologic
GERD SPECTRUM
ComplicationsExtraesophageal
Typical
AtypicalNERDChronic coughHoarsenessAsthmaLaryngitisAspiration pneumoniaDental erosionsSnoringNoncardiac chest pain
StrictureBleedingBarrett Adenocarcinoma
Chest painHiccupDyspepsiaNight sweatsGlobusSleep disturbances
Esophagitis
16
FLR Signs
•Edema and hyperemia of larynxEdema and hyperemia of larynx•Vocal cord erythema, polyps, granulomas, ulcersVocal cord erythema, polyps, granulomas, ulcers•Hyperemia and lymphoid hyperplasiaHyperemia and lymphoid hyperplasia of posterior pharynx of posterior pharynx •Interarytenoid changesInterarytenoid changes•Subglottic stenosisSubglottic stenosis
17
GERD-related cough incidence GERD-related cough incidence 5 - 41% 5 - 41%
ARRD 1981;123:413-417 ARRD 1981;123:413-417 Arch Intern Med 1996;156:997Arch Intern Med 1996;156:997
Chest 1993;104:1511-1517Chest 1993;104:1511-1517 Irwin RS. Chest 2006;129:80S-94SIrwin RS. Chest 2006;129:80S-94S
May be the sole presenting symptomMay be the sole presenting symptom
Thorax 2003:58;1092-1095)Thorax 2003:58;1092-1095)Chest 1997; 111: 1389-1402Chest 1997; 111: 1389-1402Irwin RS. Chest 2006;129:80S-94S
Association between cough and reflux is importantEsophageal-tracheal-bronchial Esophageal-tracheal-bronchial
reflex reflex MicroaspirationMicroaspiration
Nonacid factors?Esophageal dysmotility?
18
.. Mediator Mediator ReleaseRelease.. I Inflammationnflammation.. Edema Edema.. Mucus Mucus .. Smooth Smooth MuscleMuscle
MicroaspirationMicroaspirationREFLUXREFLUX
EsophagealEsophagealVagalVagal
AfferentsAfferents
Bronchial HyperreactivityBronchial Hyperreactivity
Airway VagalAirway VagalAfferentsAfferents
CNSCNS
Stein MR.Am J Med 2003Chest 1997;111: 1389-1402Chest 1997;111: 1389-1402
Airway
Airway VagalAirway VagalEfferentsEfferents
EsophagusEsophagus Central Central Nervous Nervous SystemSystem
Tracheobronchial Tracheobronchial TreeTree
19
Diagnostic Tests
inGERD
HistoryPPI test
Impedans
Endoscopy
Bernstein test
Bilier scintigraphy
Esophagography
Aspiration methods
Bilier scintigraphy
Reflux scintigraphy
Esophageal biopsy
Esophageal manometry
Standardized acid reflux test
High magnificated endoscopy
24-h intraesophageal impedance and pH
Telemetric esophageal pH monitorization
24-h intraesophageal pH monitoring
20
Stomach
Oesophagus
21
DeMeester scoreDeMeester score-Total time below pH 4
- Fractional of total time 4.2% - Fractional time of upright position 6.3% - Fractional time of supine position 1.2%
-Total reflux events 50 - Length of time 9.2 min.
Richter JE, DeMeester TR.Gastroenterology 1990;98:122
ProximalProximal
DistalDistalDeMeester score >14.7
-Total time below pH 4- Fractional of total time 1.1% - Fractional time of upright position 1.7% - Fractional time of supine position 0.6%
-Total reflux events 5- Length of time 3 min.
The most sensitive and specific test for GERD is
24-h esophageal pH monitoring
22
Causes of chronic cough
Primary cause of cough No. of patients (%)*
Eosinophilic bronchitis 12 (33.3%)
Postnasal drip syndrome 8 (22.2%)
Gastroesophageal reflux 8 (22.2%)
Idiopathic chronic cough 8 (22.2%)
Postinfectious cough 2 (5.6%)
Cough-variant asthma 1 (2.8%)
Ayık SÖ, Başoğlu ÖK, Erdinç M. Respir Med Vol. 97 (2003) 695-701
23
Reflux symptoms in chronic cough patients are associated Reflux symptoms in chronic cough patients are associated with pathologic reflux in proximal esophaguswith pathologic reflux in proximal esophagus
Ayık SÖ,Erdinç M,Bor SAyık SÖ,Erdinç M,Bor S
Pathologic reflux in proximal (+)
Pathologic reflux in proximal (-) p
Sex 2 E-10 K 1 E-16K 0.18
Age 44.081±13.95 45.59 ±12.71 0.38
Duration of chronic cough
17.25 ±23.21 40.71 ±61.41 0.11
Reflux at distal probe 5 3 0.083
GERD symptoms 8 3 0.003
24
Esophageal-pulmonary Reflux Lipid-laden macrophages in BAL Adding indicators to feedings Glucose oksidase test Scintigraphic monitoring Exhaled breath condensate (EBC) Esophageal pH monitoring Symptoms Empiric PPI therapy
Effros RM.Am J Med 2003;115:137S-143S
25
90
75
85
70
80
GER (-)Grade 1
Severei GERGrade 3
İntermittent GER Grade 2
FEV
1/FVC
%
GER severity
Schachter LM.Chest 2003;123:1932-38
DLCO decrease in severe GER
30
DLC
O
ml/m
in/m
mH
g
28
18
20
22
24
26
GER severity
GER (-)Grade 1
Severei GERGrade 3
İntermittent GER Grade 2
26
The empiric trial of medical therapyis appropiate when pHmonitoring cannot
be done or is not available
American College of Chest Physicians Chest 1998; 114(suppl1) :133S-181S
The empiric trial of medical therapyshould be considered even in cases
pHmonitoring can be done
Thorax 2003 ;58:901-907Poe RH.Chest 2003;123:679-684Chest 2003 ;123:650-660
27
1. GERD the most common cause of chronic cough2. Empiric PPI therapy is not only practical but is also ‘cost-effective’3. Consensus should be reconsidered4. pHmetry should be done in nonresponsive to empiric therapy
24 hour pHmetry Empiric PPI therapy
Harding SM. Chest 2003 ;123:650-660
28
pHmetry,High sensitive in typical symptoms
however diagnostic value in extraesophageal symptoms
50 - 80%
Symptom / reflux associationis more important in atypical symptoms
Empiric PPI therapy sensitivity 62.5 - 81%-Patients presented with laryngeal symptoms and cough-
29Roka R.Digest.2005:92-96
Respiratory symptoms prevalance
with GERD symptoms
30
3 cm
5 cm
7 cm
9 cm
15 cm
17 cm
pH - 5 cm
6 impedance channels
1 pH electrode
+
Adult Standard
Model ZAN-S61C01E
Multichannel intraluminal impedance-pH catheter
31Kastelik JA. Thorax 2003;58:699-702
Results of oesophageal manometry and 24 hour ambulatory pH monitoring in patients with chronic cough with (n=34)
and without (n=9) symptoms of gastro-oesophageal reflux
Normalinvestigations
AbnormalManometry
alone
Abnormal24-h pHalone
Abnormalmanometry
and 24-h pH
10
20
30
40
50
0
SymptomsNo symptoms
Per
cent
age
of
subj
ects
Oesophageal Oesophageal dysmotility ?dysmotility ?
32Sifrim D.Gut 2005;54:449-54Weakly acidic reflux with chronic cough
33
Irwin RS. Chest 2006;129:80S-94S
In patients with chronic cough who had failedto respond very intensive medical therapy,the improvement or elimination of cough in
all subjects 12 months following surgery
Irwin RS.Chest 2002;121:1132-1140
The term acid reflux disease when appliedto chronic cough due to GERD, can be misnomer
34
PPIs H2RB
Life-styles
Prokinetic agents
Antacids/ alginates
Fundoplication
Hatlebakk & Berstad, Clin Pharmacokinet 1996; 31: 386–406.
GERD
Therapetic Options
Endoscopic
35
1) Acid inhibition / neutralizationAntascides
H2 receptor blockersRanitidinFamotidinNizatidin
Proton pump inhibitorsOmeprazolLansoprazolPantoprazolRabeprazol Esomeprazol
Pharmacological Therapy in GERD
2) Barrier Alginic acid
3) Cytoprotectives Sucralfat Mizoprostol
4) Prokinetics Cisapride Domperidon? Metoclopramid?
36
Risk ratio.012003 1 83.3135
Study % Weight Risk ratio (95% CI)
0.26 (0.15,0.46) Bardhan 1995 5.0 0.33 (0.16,0.69) Klinkenberg-Knol 1987 3.3 0.42 (0.28,0.62) Havelund 1988* 7.1 0.48 (0.33,0.69) Sandmark 1988 7.8 0.59 (0.48,0.73) Bate 1990 11.1 0.60 (0.37,0.98) Dehn 1990* 5.9 0.63 (0.42,0.94) Bianchi Porro 1992 7.1 0.72 (0.54,0.95) Koop 1995 9.5 0.61 (0.38,0.99) IROSG 1991 5.9 0.37 (0.24,0.57) Robinson 1995 6.6 0.26 (0.10,0.67) Vantrappen 1988* 2.2 0.64 (0.52,0.79) Farley 2000 11.0 0.35 (0.21,0.59) Jansen 1999 5.5 0.59 (0.29,1.20) Armbrecht 1997 3.5 0.52 (0.36,0.76) Van Zyl 2000 7.6 0.09 (0.01,0.62) Soga 1999 0.6
0.50 (0.43,0.58) Overall (95% CI)
Moayyedi. Health Care Needs Assessment, 2002
Comparison of H2B with PPI Metaanalysis
PPI H2RA
37
Therapy in Esophageal-pulmonary Therapy in Esophageal-pulmonary refluxreflux
Conservative and lifestyle measuresConservative and lifestyle measures Pharmacological therapyPharmacological therapy: Proton pump inhibitors: Proton pump inhibitors PPI x 2 / 3 monthsPPI x 2 / 3 months Therapy failure Therapy failure 24 hour intraesophageal pHmetry 24 hour intraesophageal pHmetry ( pharyngeal( pharyngeal pHmetry pHmetry ) )
GERD (+)GERD (+) High dose PPI High dose PPI Surgery, Surgery,
+ H + H22 blocker agent blocker agentPulmonary and Crit Care Update 1994;Pulmonary and Crit Care Update 1994;
Vol 9Vol 9 Morice AH. ERJ 2004;24:481-492Morice AH. ERJ 2004;24:481-492
38
J. A.Koufman. ENT-Ear, Nose & Throat Journal, Sep 2002 SuppMorice AH.ERJ 24:481-492,2004
Reflux /Symptom/ Therapy GERD FLR Esophagopulmonary
Nocturnal reflux (supine) ++++ + +Upright reflux (daytime) + ++++ +++Pyrosis and/or regurgitation
++++ + +Cough, dysphonia, globus +/- ++++ ++++Respond to H2 antagonists
85% 65% 70%
Respond to PPI (once a day) +++ + +Respond to PPI (twice a day) ++++ +++ ++++
39
Stomach
Esophagus
PPI PPI
40Poe RH.Chest 2003;123:679-684
Specific therapyfor diagnosis and treatment
Results of therapy in treating cough due to GERD
41
Weeks of antireflux therapy Patients responded
No No (%)
2 16 (41) 4 38 (86) 6 42 (95) 8 43 (99) 12 44 (100)
Poe RH.Chest 2003;123:679-684
Cumulative Response to GERD Therapy
42Ciccaglione AF.Gut 2003;52:464-470
Effect of the GABAEffect of the GABABB agonist baclofen agonist baclofen on symptoms in patients with GERDon symptoms in patients with GERD
43
Approximate Diaphragmatic
crurae
Reduce Hiatal Hernia
Anti-Reflux SurgeryRestore
Intraabdominal esophagus
Perform Fundoplication
44
PreoppH <4: %23.6De Meester:
85
PostoppH <4: %2.4De Meester:
9.9
45
PreoppH <4: %14.5De Meester:
52.9
PostoppH <4: %3.8De Meester:
14.2
46
1. Chronic cough for at least 2 months
2. Immunocompetent patients
3. Chest radiograph is normal
4. Not exposed to enviromental irritants nor a present smoker
5. Not taking an ACE inhibitor
6. Symptomatic asthma has been ruled out 7. Rhinosinus diseases has been ruled out: 8. ‘Silent sinusitis’ has been ruled out
9. Nonasthmatic eosinophilic bronchitis
has been ruled out:
BPT is negativeCough has not improved
with asthma therapy
1st generation H1 antagonists has been used
Eo 3%in induced sputum
Cough has not improved with steroids
Irwin RS. Chest 2006;129:80S-94Sİrwin RS. AJRCCM Vol 165; 1469-1474, 2002
Clinical Profile That Chronic Cough İs Likely Due To ‘Silent GERD’
47
abnormalabnormalnormalnormal
History and Physical
Asthma, PNDSSpirometry (BPT)ENT evaluation
pHmetry ( surgery?)Psychogenic cough(?)
Spesific diagnosis and treatment
Avoid irritantsDiscontinue ACE ihibitors
Smoking cessation
GERD symptoms (-) (+)
Chest radiograph
Ampiric PPI Three months b.i.d.
Sputum cytology,HRCT scanBronchoscopyEsophagographyCardiac evaluation
Cough persists
Chronic CoughChronic Cough
Cough persistsCough persists
Spesific diagnosis and treatment
48
Pharyngeal pHmetryPharyngeal pHmetry
+-Not GERD
Clinical GERD symptoms ?Nonacid, weakly acid reflux?
Increase dose PPI + alginate
İmproved Not improved
Continue pHmetry under treatment
Consider
Simultaneously dual probes
24 hours pHmonitoringand
intraesophageal impedance Irwin RS.AJRCCM 165:1469-74,2002McGarvey LPA.Thorax 59:342-346,2004
49
GastroenterolojiErişkin-Çocuk
Göğüs, Pulmoner reflü
KBB Faringolaringeal
reflü
KardiyolojiNCCP
CerrahiErişkin, Çocuk
PatolojiDiş Hek.
Psikiyatri, Halk sağlığı
www.gerd-turkey.org
EGE REFLUX WORKING GROUP