UCSF, Department of Medicine, CME GASTROENTEROLOGY Fernando Velayos - PDF document

UCSF, Department of Medicine, CME GASTROENTEROLOGY Fernando Velayos MD MPH Associate Professor of Medicine Division of Gastroenterology University of California San Francisco UCSF, Department of Medicine, CME 1 Case #1-1  42 year old Caucasian man with heartburn  Intermittent retrosternal ‘ burning ’ >12 years  Increasing use of antacids & OTC H2RAs, with only transient relief of symptoms  1-2 packs cigarettes QD, 1-2 glasses wine QHS  Denies chest pain, but notes regurgitation of ‘ sour ’ material occasionally at night  Sleeps on 2 pillows in attempt to decrease this, without much success. Case #1-2  Denies dysphagia, odynophagia or weight loss  Admits to recurrent sore throats with ‘ laryngitis ’ , and occasional dyspnea on exertion  Put on a daily PPI, scheduled for EGD in 4 weeks  EGD: 4 cm of salmon colored mucosa in the distal esophagus (bx ’ d), otherwise unremarkable  Biopsies: intestinal metaplasia (intestinal type epithelium with goblet cells) with no dysplasia  Sxs improved somewhat, but incompletely, on PPI UCSF, Department of Medicine, CME 3 1

UCSF, Department of Medicine, CME Case #1-3 UCSF, Department of Medicine, CME 4 Case #1-4 Which of the following is the most appropriate next step? Repeat EGD for surveillance in 5 years 1. Test for H. pylori infection and treat if present 2. Photodynamic therapy (PDT) or RF ablation of 3. the Barrett’s mucosa Refer to surgeon for anti-reflux surgery. 4. Double the dose of his PPI to BID and repeat 5. endoscopy for surveillance in one year. UCSF, Department of Medicine, CME 5 Case #1-4 Which of the following is the most appropriate next step? (CORRECT ANSWER) Repeat EGD for surveillance in 5 years 1. Test for H. pylori infection and treat if present 2. Photodynamic therapy (PDT) or RF ablation of 3. the Barrett’s mucosa Refer to surgeon for anti-reflux surgery. 4. Double the dose of his PPI to BID and repeat 5. endoscopy for surveillance in one year. UCSF, Department of Medicine, CME 6 2

UCSF, Department of Medicine, CME Case #1-5 ANSWER  Endoscopy (with bx): best test to dx Barrett ’ s  Definition: intestinal metaplasia distal esophagus  EGD indicated as a ‘ once in a lifetime ’ procedure in pts with chronic GERD symptoms (duration undefined), particularly in Caucasian men who have the highest rate of Barrett ’ s and AdenoCA  Medical or surgical anti-reflux therapies do not cause regression of Barrett ’ s; endpoint of Rx is same as non-Barrett ’ s GERD: to ameliorate Sxs UCSF, Department of Medicine, CME 7 Case #1-6 ANSWER  Anti-reflux surgery should not be done solely due to presence of Barrett ’ s, but for failures of optimal medical therapy or patient preference  Progression of Barrett ’ s to AdenoCA (app 0.5%/year) has promoted endoscopic surveillance programs  EGD yearly X2, then Q2-3 years if no dysplasia  Low grade dysplasia: surveillance every 6-12 mos  High grade dysplasia: confirm by a 2nd ‘ expert ’ pathologist, ablation or esophagectomy due to concomitant adenoCA in 30-40% UCSF, Department of Medicine, CME 8 Case #1-7 ANSWER  PDT, argon plasma & (most recently, likely dominant) radiofrequency (RF) ablative Rxs are emerging for HGD (maybe LGD, and still controversial in non-dysplastic disease).  While eradication of Hp does decrease PUD recurrence and maybe gastric CA, it does not decrease the risk of esophageal AdenoCA, in fact might be protective, with a possible inverse association, ie Hp may be protective for reflux / Barrett ’ s / esophageal AdenoCA (but not causative) UCSF, Department of Medicine, CME 9 3

UCSF, Department of Medicine, CME Case #1-8 Esophagus Pearls  GERD is the most common cause of unexplained (non-cardiac) chest pain, and is highly treatable; empiric trial of acid suppression reasonable.  Panic disorder is present in 25-40% of patients with non-cardiac chest pain syndromes, also treatable.  GERD symptoms may mimic cardiac symptoms; history cannot reliably distinguish between these two etiologies of chest pain.  Globus sensation is also commonly due to GERD; empiric treatment also reasonable. UCSF, Department of Medicine, CME 10 Case #1-9 Esophagus Pearls  Factors which impair salivary flow (eg Sjogrens, XRT), esophageal motility (eg PSS), or gastric emptying (eg DM) may aggravate GERD.  Be aware of extraesophageal or ‘ atypical ’ GERD: chronic cough, hoarseness, laryngitis, asthma.  Atypical GERD often requires high-dose PPI treatment for prolonged periods of time  Chocolates, alcohol, nicotine, CCBs, nitrates, antidepressants, progesterone, benzodiazepines reduce LES pressure and can exacerbate GERD. UCSF, Department of Medicine, CME 11 Case #1-10 Esophagus Pearls  Dysphagia: etiology usually evident by Sxs  Intermittent solid: Schatzki Ring ( “ steakhouse syndrome ” ).  Progressive solid: stricture (slow) or neoplasm (rapid).  Solid and liquid: motility disturbance.  Esophagram helpful as ‘road-map’ to plan EGD Rx  Patients with achalasia have esophageal contractions which are never peristaltic and incomplete LESRs.  Oropharyngeal (or ‘ transfer ’ ) dysphagia is usually due to neuromuscular disorders, and is associated w/ coughing, nasal regurgitation, choking. UCSF, Department of Medicine, CME 12 4

UCSF, Department of Medicine, CME Case #1-11 Esophagus Pearls  Eosinophilic Esophagitis increasingly diagnosed  Intermittent solid food dysphagia or food impaction  M>F  “ringed” or corrugated esophagus  Tx with swallowed inhaled steroids, PPIs UCSF, Department of Medicine, CME 13 Case #1-12 Esophagus Pearls  Medications can cause “ pill ” esophagitis: tetracycline, quinidine, iron, ascorbic acid, fosamax, potassium, and are a common iatrogenic cause of chest pain.  Empiric fluconazole is the best initial therapy in AIDS pts with dysphagia and thrush, reserve endoscopy for those not responding.  Causes of esophageal ulcers in AIDS patients: CMV, HSV, idiopathic. UCSF, Department of Medicine, CME 14 Case #2-1  62 y/o woman w/ 4 months of abdominal pain  Epigastric, worse post-prandially, and somewhat, but incompletely relieved by OTC H2RAs  Occasional nausea but has not vomited  5 pound weight loss (5%IBW), which she attributes to decreased food intake  ASA 81mg/d and PRN motrin for OA  PEx: epigastric TTP, otherwise unremarkable. UCSF, Department of Medicine, CME 15 5

UCSF, Department of Medicine, CME Case #2-2Which of the following is the best approach at this time? Empiric H pylori treatment 1. Hp testing and treatment if positive 2. Empiric proton pump inhibitor Rx 3. Upper endoscopy 4. Switch ibuprofen to a COX-2 NSAID 5. UCSF, Department of Medicine, CME 16 Case #2-2 Which of the following is the best approach at this time? (CORRECT ANSWER) Empiric H pylori treatment 1. Hp testing and treatment if positive 2. Empiric proton pump inhibitor Rx 3. Upper endoscopy 4. Switch ibuprofen to a COX-2 NSAID 5. UCSF, Department of Medicine, CME 17 UCSF, Department of Medicine, CME 18 6

UCSF, Department of Medicine, CME Case #2-3 ANSWER  Test-and-treat strategies for Hp have shown some benefit in uninvestigated dyspepsia, presumably due to effect in the subset (10-20%) with active PUD  Large RCTs have failed to show a benefit in non-ulcer dyspepsia (NUD), ie after ulcer disease has been ruled out UCSF, Department of Medicine, CME 19 Case #2-4 ANSWER  With widely available, accurate, and relatively inexpensive tests available, there is no role for empiric Hp therapy  Hp testing in an untreated patient: UBT or stool antigen testing or serology (poor PPV)  If endoscopy is indicated, Hp testing can be easily and accurately done at that time  After Rx, Ab titers do not predictably decline, thus repeat serology useless; use UBT or stool Ag UCSF, Department of Medicine, CME 20 Case #2-5 ANSWER  Empiric acid-suppression has some efficacy in dyspepsia, and is reasonable in young patients with no alarm symptoms (bleeding, dysphagia, or weight loss), esp in low risk Hp populations  New dyspepsia in patients over age 50 (as well as this patient’s weight loss) should be evaluated with an endoscopy to r/o more ominous pathologies, particularly CA  While COX-2 selective NSAIDs do have  GI toxicity, this patient needs endoscopy. UCSF, Department of Medicine, CME 21 7