Care Initiative Gerd Chicago Meeting Slides PDF
Transcript of Care Initiative Gerd Chicago Meeting Slides PDF
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CARE Initiative on
ot ty sor ersin Primary Care:
ERD
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FACP, FAACHEmeritus Chief, Division of Gastroenterology
on e ore e ca en er anAlbert Einstein College of MedicineProfessor of Medicine and Sur erAlbert Einstein College of Medicine
New York, New York
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Faculty
John Allen, MD, MBA, AGAFMedical Director for QualityMinnesota GastroenterologyChair, AGAI Clinical Practice and Quality Management CommitteeClinical Councillor, AGA Governing Board
Peter J. Kahrilas, MD, AGAFGilbert H. Marquardt Professor of Medicine
Lead author of AGA guidelines
Stuart S echler MD AGAFChief, Division of Gastroenterology, Dallas VA Medical CenterProfessor of Medicine, Berta M. and Cecil O. Patterson Chair inGastroenterolo
33University of Texas Southwestern Medical Center at Dallas
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Accreditation and Funding
This activity has been planned and implemented in
accordance with the Essential Areas and Policies ofthe Accreditation Council for Continuing MedicalEducation (ACCME) through joint sponsorship of
,Associates LLC, Medikly, and PeerView AcademicNetwork. Albert Einstein College of Medicine isaccredited by the ACCME to provide continuing
medical education for physicians.
This activity is funded through an educational grantfrom Takeda Pharmaceuticals North America, Inc.
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S onsorshi
Co-sponsored by: Albert Einstein College of,Association, DIME, and PeerPoint MedicalEducation Institute, LLC
Jointly sponsored by: Albert Einstein College ofMedicine, Montefiore Medical Center, Gullapalli& Associates, LLC, Medikly, and PeerView
Academic Network
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Conflict of Interest Statement
The Conflict of Interest Disclosure Policy of Albert Einstein
College of Medicine requires that faculty participating in anyCME activity disclose to the audience any relationship(s) witha pharmaceutical, product, or device company. Anypresenter whose disclosed relationships prove to create a
conflict of interest with regard to their contribution to theactivity will not be permitted to present.
faculty participating in any CME activity disclose to the
audience when discussing any unlabeled or investigationaluse of an commercial roduct or device not et a roved foruse in the United States. The Albert Einstein College ofMedicine CCME staff has no conflicts of interest withcommercial interests related directl or indirectl to this
66educational activity.
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Facult DisclosuresJohn Allen, MD, MBA, AGAF
Sources of Funding for Research:NoneConsulting Agreements:Medtronic, Inc.
Speakers Bureau/Honorarium Agreements:None
Financial Interests/Stock Ownership:None
Discussion of Off-Label, Investigational, or Experimental Drug Use:None
Lawrence J. Brandt, MD, MACG, AGAF, FASGE, FACP, FAACH
Sources of Funding for Research:None
Consulting Agreements:NoneS eakers Bureau/Honorarium A reements:None
Financial Interests/Stock Ownership:None
Discussion of Off-Label, Investigational, or Experimental Drug Use:None
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Facult Disclosures contPeter J. Kahrilas, MD, AGAF
Sources of Funding for Research:National Institutes of HealthConsulting Agreements:AstraZeneca Pharmaceuticals LP; RevalesioCorporation; XenoPort, Inc.
Speakers Bureau/Honorarium Agreements:None
Financial Interests/Stock Ownership:NoneDiscussion of Off-Label, Investigational, or Experimental Drug Use:None
Stuart Spechler, MD, AGAF
Sources of Funding for Research:AstraZeneca Pharmaceuticals LP;Takeda Pharmaceuticals; BARRX Medical, Inc.
Consulting Agreements:Procter & Gamble
Speakers Bureau/Honorarium Agreements:None
Financial Interests/Stock Ownership:None
88Discussion of Off-Label, Investigational, or Experimental Drug Use:None
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Plannin CommitteeRosalee Blumer, MA
DIME EditorConsulting Agreements:NoneSpeakers Bureau/Honorarium Agreements:None
Discussion of Off-Label, Investigational, or Experimental Drug Use:None
CCME of Albert Einstein College of Medicine
Sources of Funding for Research:NoneConsultin A reements:Procter & GambleSpeakers Bureau/Honorarium Agreements:NoneFinancial Interests/Stock Ownership:Bioheart, Inc.; Chelsea Therapeutics, Inc.;Pharmacopeia, Inc.
Discussion of Off-Label, Investigational, or Experimental Drug Use:None
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Plannin Committee contBonny McClain, MS, DC
Gullapalli & Associates EditorConsulting Agreements:NoneSpeakers Bureau/Honorarium Agreements:None
Discussion of Off-Label, Investigational, or Experimental Drug Use:None
. ,The AGA Institute
Sources of Funding for Research:NoneConsultin A reements:Procter & GambleSpeakers Bureau/Honorarium Agreements:NoneFinancial Interests/Stock Ownership:NoneDiscussion of Off-Label, Investigational, or Experimental Drug Use:None
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The staff of CCME of Albert Einstein College of Medicine,The American Gastroenterological Association,
Gullapalli & Associates, and DIME have no conflictsof interests to report with commercial interests related
rec y or n rec y o s e uca ona ac v y.
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Continuing Education Credit
Albert Einstein College of Medicine designates this
educational activity for a maximum of 4.0 AMA PRACategory 1 Credits. Physicians should only claimcredit commensurate with the extent of their participationin the activit .
Participants must complete and return the evaluationform at the conclusion of this activit to receive credit.
Certificates will be available online. Please visit. .receive your certificate.
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Primary Care Management of
OverviewMultidisciplinary, multi-interventional educational
program that provides relevant and concise,
validate, and address the gaps and barriersrelated to gastroesophageal reflux disease(GERD) care in the primary care setting
Multi le educational activitiesEducational outreach program; 3 regional
workshops; Performance Improvement activity;
1313e-monograp ; anwebsitewww.medikly.com/gerd
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On completion of this activity, participants should beable to:
Identif risk factors for GERD
Demonstrate multidisciplinary management of
referral and surgical options
management of patients at risk for or diagnosedwith GERD
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GERD Case Study 1: Carol
American Gastroenterological Association Institute (AGAI)2008 Guideline Recommendations
GERD Case Study 2: JimQuestion and Answer Session
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Audience Response System (ARS)
When instructed, press the number
button s that corres ond with our selectedanswer (you do not need to press Enter)
Individual res onses will be dis la ed in the
screen at the top of the keypad
If ou want to chan e our answer ressthe C keyto clear; you may enter a new
answer as long as voting is open Audience results will be displayed on your
main screen immediately after voting is
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GERD
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The Need for Performance Improvement
Performance Improvement (PI) is designed to measure
and demonstrate ractice rocess chan es that arelinked by evidence to improved patient outcomes
Selected activities will inte rate a continuous rocess b
which a provider or a practice environment participatesin the following:
ses e a es gu e nes or mprove pa en care
Improves providerpatient communication
Assesses baseline knowledge regarding the GERD guidelines
Learns about specific performance measures
Retrospectively assesses their clinical practice
useful interval and re-evaluates performance
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CARE Initiative on GI Motility Disorders in
a en -re a e arr ers
From the atients ers ective there are
challenges and barriers to meeting GERDdiagnosis and treatment needs:Lack of awareness about GERD
The psychological impact of GERDPolypharmacy
Poor adherence
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CARE Initiative on GI Motility Disorders
Provider-related barriers in the primary care of GERD Although many providers are involved in the management of
GERD, they experience barriers to optimal care for their
GERD patients, including: Burden of care assigned to PCPs
primary care
Patients psychological resistance to long-term treatment with
Difficulties in referral to gastroenterologists
Financial challenges
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How Can I Im rove Patient Outcomes?
To begin evaluating and potentially improvingpatient care:
1. Go to www.medikly.com/gerd
2. Fill out a brief baseline self-assessment survey3. Gather appropriate patient-level data (based on identified
per ormance measures re rospec ve y or prospec ve yon 10 GERD patients
.
HIPAA = Health Insurance Portability and Accountability Act
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Live support will be available throughout the initiative
All communication will be confidential
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a quantitative report of the data you submitted
an article that will be submitted to a peer-reviewed
journal that focuses on improving patient carenat ona y
You will receive up to 20.0 AMA PRA Category 1
Credits for successful completion of the program*RegistrantsmustcompletetheentireprogramtoreceivethemaximumavailableCME/CNEcredit
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How interested would you be to participate in a
you to do the following for your practice?:
Assess your practice performance against nationally recognized measures.
Compare your practice performance to your peers on a local, regional and.
Compare your performance to other healthcare providers and specialists.(Receive up to 20 CME/CE credits)
Veryinterested
Interested,tell me more
Not at allinterested
1 2 3 4 5 6 7
0 / 100Cross-Tab Label
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Do you have additional questions?
Please speak to personnel on site
or call a PeerPointPerformance Im rovement
site coordinator:
800.777.5790
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Please turn off
cellphones and pagers whileparticipating in todays activity.
Please refrain from photography.
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Your Presenters for Today
Peter J. Kahrilas, MD, AGAF
.Northwestern University Feinberg School of MedicineLead author of AGA guidelines
Stuart Spechler, MD, AGAFChief Division of Gastroenterolo Dallas VA Medical CenterProfessor of Medicine, Berta M. and Cecil O. Patterson Chair
in Gastroenterology
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What is your specialty?1. Internal medicine
2. Family practice
3. General practitioner4. Physician assistant
5. Physical medicine
6. Gastroenterolo ist
7. Other
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Which of the following best describes your
1. Private (individual)
. r va e par ners p or group3. Hospital-based
4. HMO
5. VA6. Other
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ase u y : aro
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Case Study: Carol
Carol, a 37-year-old African American
,of heartburn and occasional regurgitationof food or fluids into her mouth
Ht 52, W 148 lbs, BMI 27 Cor: Re ular rh thm and normal rate
Labs: Normal, including hemoglobin 13/dL hemocrit 42%
Current meds: inhaler
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x s ng con ons: as ma, a a ern a
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On a scale of 1 to 5, with 1 being notconfident at all, and 5 being extremelyconfident, how would you rate your
con ence n rea ng aro1. Not at all confident
2. Somewhat confident
4. Very confident
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Wh n ini i ll r in i n wi h m mof heartburn and regurgitation, which approach
i ll k ?
1. Recommend lifestyle modifications
-. , ,antagonists [H2RAs] and move up to proton pump
inhibitors (PPIs) if symptoms persist3. Step-down approach, ie, start with PPI therapy
4. None of the above
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Clinical Practice Key Points
practice environment
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American Gastroenterological Associationnst tute
2008 Guideline Recommendations For patients with esophageal GERD syndromes, treatment
with antisecretor dru s is recommended for healin
esophagitis, symptomatic relief, and maintenance ofesophageal healing. In this setting, PPIs are moreeffective than H2RAs, which, in turn, are more effectivethan placebo
Grade A: strongly recommended based on goodevidence
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Kahrilas P et al. Gastroenterology. 2008; 135:1392-1413.
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Association Institute (AGAI)
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AGAI 2008 Guidelines
3636Kahrilas P, Shaheen N, Vaezi M. American Gastroenterological Association Institute Technical Review on theManagement of Gastroesophageal Reflux Disease. Gastroenterology. 2008;135:1392-1413.
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Standards of Care for Assessing Evidenceu e nes or
. .guidelines, ie, the US does not put a priority on whichguidelines to use
This process is being refined and may be part ofhealthcare reform, but we are not there yet
AGAI guidelines use US Preventive Services
Task Force (USPSTF) grades to assign strength ofev ence
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USPSTF Grades Usedin AGAI Guidelines
Grade A: strongly recommended based on good evidence that itimproves important health outcomes
important outcomesGrade C: balance of benefits and harm is too close to justify a
Grade D: recommend against; fair evidence that it is ineffective
or that harms outweigh benefits
Grade Insufficient: no recommendation; insufficient evidence torecommend for or against
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Kahrilas P, Shaheen N, Vaezi M. Gastroenterology. 2008;135:1392-1413.
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The Difficulty of Defining GERD
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Symptoms of Gastroesophageale ux sease
ass c symp omsHeartburn
egurg a on
Common symptomsChest pain (noncardiac)
Dysphagia
Source: US National Library of Medicine,National Institutes of Health
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GERD: The Montreal DefinitionGERD is a condition that develops when the reflux of stomach content
causes troublesome symptoms and/or complications
Esophageal syndromes Extra-esophageal syndromes
SymptomaticSyndromes Typical reflux
ProposedAssociation Sinusitis
Syndromes WithEsophageal Injury Reflux esophagitis
EstablishedAssociation Reflux cough
Reflux chestpain syndrome
Pulmonaryfibrosis
Pharyngitis
Recurrent otitis
Reflux stricture
Barrettsesophagus
Adenocarcinoma
Refluxlaryngitis
Reflux asthma
Reflux dentalmediaerosions
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Adapted from Vakil N et al. Am J Gastroenterol. 2006;101:1900-1920.
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What is the Distinction BetweenGERD and Episodic Heartburn?
In the absence of esophageal injury,heartburn of sufficient intensit to be
perceived as troublesome by the patient(after assurance of its benign nature)meets t e ontrea e n t on o a
symptomatic esophageal GERD syndrome
4242Kahrilas P et al. Gastroenterology. 2008; 135:1392-1413.Vakil N et al. Am J Gastroenterol. 2006;101:1900-1920.
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PCP Review of the Pathophsysiology of GERD
External factors
Diet
Tissue resistance Stratified squamous epithelium
Smoking Obesity
Esophageal clearance
Gastric emptying
Body position (gravity)
Antireflux barriers Crural diaphragm Hiatal hernia
Gastric refluxate Acid Pepsin
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u
What is/are your goal(s) whentreating a patient such as Carolwho has typical symptoms of
1. Relieve the symptoms
2. Prevent relapse and complications
3. Heal the eso ha us
4. All of the above
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Goals of Treatment: AGAI Guidelines
Relieve s m toms Prevent relapse and complications
erosive esophagitis
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diagnosing Carol?
. nce- a y r a
2. Endoscopy
3. Manometry
4. H monitorin5. Refer to gastroenterologist
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Diagnosis of Uncomplicated GERD:u e nes
PPI therapy is appropriate foratients with uncom licated
heartburn such as Carols,
need exists for endoscopy or
require immediate referral toa specialist)
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Diagnosis of Uncomplicated GERD:AGAI Guidelines (cont)
Although Carol hascoexistin conditions her
case qualifies asuncomplicated GERDbecause she has no
warning signs
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Which of the following would be a warningsign(s) that would warrant endoscopyand/or immediate referral to a specialist?
1. Weight loss2. GI bleedin
3. Loss of appetite
.
5. Dysphagia
49496. All of the above
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Carols Risk Factors for GERD
ARS Question
? Which of the following is/arerisk factor s for GERD?
1. Overweight
2. st ma
3. Hiatal hernia4. None of the above
5. 1 2 and 3
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Participants perspectives on individual practice
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AR i n: ?Extraesophageal Syndromes
,classified as an extraesophageal syndrome, aswell as laryngitis. If Carol did present with adult-onset asthma or laryngitis concomitant with anycommon or uncommon symptoms of GERD,
1. Yes
. o
3. Depends on physical examination
52524. Not sure
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Treatment of Extraesophageal RefluxSyndromes: AGAI Guideline
Recommendations
Acute or maintenance thera with once- or twice-dailPPIs (or H2RAs) for patients with a suspectedextraesophageal GERD syndrome (laryngitis, asthma)with a concomitant esophageal GERD syndrome
Grade B: recommended with fair evidence that itimproves important outcomes
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Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
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Treatment of Extraesophageal Refluxyn romes: u e ne
Recommendations (cont)
Once- or twice-daily PPIs (or H2RAs) for acuterea men o pa en s w po en a ex raesop agea
GERD syndromes (laryngitis, asthma) in the absenceof a concomitant esophageal GERD syndrome
Grade D: recommend against; fair evidence that itis ineffective or that harm outweighs benefits
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Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
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Treatment of Extraesophageal Refluxyn romes: u e ne
Recommendations (cont)
Once- or twice-daily PPIs for patients with suspectedre ux coug syn rome
Grade Insufficient: no recommendation; insufficientevidence to recommend for or against
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Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
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ues on
Carols GERD symptoms?
.
2. OTC antihistamines
3. Change in diet
4. All of the above5. None of the above
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Nonpharmacologic Approaches
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Weight loss is advised for patients who are overweight
have esophageal GERD syndromes Grade B: recommended with fair evidence that it
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Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
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BMI Associated With Symptoms of GERD in Normal
Association Between BMI and GERD Symptoms in Women
3
.
2.92 2.353.62
2.93 (2.243.85)
P
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GERD in both normal weight andoverwei ht women
Even moderate weight gain among
exacerbate symptoms of reflux
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Jacobson BC et al. N Engl J Med. 2006;354:2340-2348.
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precipitate refluxCoffee alcohol chocolate
fatty foods
precipitate heartburn
Red sauce tomatoes citruscarbonated drinks, spicy foods
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esophageal exposureAvoid late-ni ht meals and bedtime snacks
Raise the head of the bedSto smokin
Weight loss
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Except for weight loss, evidence for lifestylemo cat ons nc u ng smo ng s genera yweak
owever, mo ca ons a ore o eac pa en s
individual circumstances may sometimes beeffective
Elevating the head of the bed for selected patients whoare troubled with heartburn or regurgitation when
Other lifestyle modifications including, but not limited to,avoiding late meals, specific foods, or specific activities
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Contributing Conditions:
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What is the Role of Hiatal Hernia in GERD?
Promotes reflux of stomach contents (via its direct
and thus is associated with GERD
,
potential consequences of GERD: heartburn,esophagitis, Barretts esophagitis, and esophagealcancer
However, the role attributed to hiatal hernia isvariable and difficult to quantify
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Axial Hiatus Hernia is Commonly Associated, spec a y en evere
Type I hiatal hernia.In this example, the
evident at rest, aftercompletion of esophageal
6666Kahrilas, PJ, Pandolfino JE. Hiatus hernia. In: Castell DO, Richter JE, eds. The Esophagus. 4th ed.Philadel hia: Li incott Williams & Wilkins, 2004:389-407.
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Two-Sphincter Model of the
LES relaxation Squamocolumnar junction
CD relaxation
CD incompetence?
Right
a a ern a
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Muscular Anatom of the EGJ
Slin
Spiral m.
Longitudinal m.
fibers
Claspfibers
6868PJ Kahrilas 2004.
The Flap Valve Concept of EGJ Disruption
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The Flap Valve Concept of EGJ DisruptionGrade IGrade I Grade IIGrade II Grade IIIGrade III Grade IVGrade IV
Normal ridge oftissue closely
Ridge is slightlyless well defined
Ridge is effacedand the hiatus is
Hiatus is wide open atall times and displaced
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Adapted from Hill LD et al. Gastrointest Endosc1996;44:541-547.
scopean opens w
respiration
pa u ous axially
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Radiographic Appearance of a Small SlidingHiatal Hernia Durin Swallowin
TubularEsophagus
EsophagealVestibule
Phrenic Ampulla
Sliding HiatalHernia
A ring
B ring
DiaphragmaticRugal Folds
Traversing Hiatus
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impression
Kahrilas PJ and Pandolfino JE. GI Motility Online. 2006;doi:10.1038/gimo48.
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Type I (Sliding) and Type II (Paraesophageal)Hiatus Hernia
EsophagusEsophagus
SquamocolumnarSquamocolumnarjunctionjunction
EsophagusEsophagus
HerniatedHerniatedstomachstomach
PhrenoPhreno--esophagealesophagealmembranemembrane
HerniatedHerniatedgastric fundusgastric fundus
HerniatedHerniatedparietalparietaleritoneumeritoneum
DiaphragmDiaphragm DiaphragmDiaphragmSquamocolumnarSquamocolumnar
junction (normal position)junction (normal position)
7171Modified from Jaffee BM, Surgery of the esophagus. In Orlando RC Ed. Atlas of EsophagealDiseases, Second Edition. 223242.
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Pharmacologic Treatments
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u According to AGAI guidelines, which one
of the following agents is never appropriatein the treatment of GERD?
1. OTC PPIs
2. Metoclo ramide
3. H2RAs
.
5. None of the above, they are all appropriate
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Available Treatments for GERD Promotility agents
Bethanechol
e oc opram e ac ox warn ng; see o ow ng s e orrecommendation)
Histamine2 receptor antagonists (H2RAs) me ne
Famotidine Nizatidine
Proton pump inhibitors (PPIs) Dexlansoprazole
someprazo e
Lansoprazole
Omeprazole
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Rabeprazole
Source: www.fda.gov. Accessed on August 20, 2009.
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Metoclopramide:AGAI Guideline Recommendation
Metoclopramide as monotherapy or adjunctive therapyin patients with esophageal or suspected
Grade D: recommend against; fair evidence that it isineffective or harms outweigh benefits
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Participants perspectives on individual practice
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PPIs and H2RAs:
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AGAI 2008Guideline Recommendation
Antisecretory drugs for the treatment of patients withesophageal GERD syndromes (healing esophagitis
In these uses, PPIs are more effective than H2RAs,which are more effective than placebo
Grade A: strongly recommended based on goodevidence
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ARS Question
c o e o ow ng agen s as emost rapid speed of healing?
1. H2RAs.
3. PPIs
. nset o act on s a out t e same or eac
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Speed of Healing GERD: PPIs vs H2RAsSpeed of healing GERD expressed as the mean percentage ofhealing per week for each drug class at evaluation time points
Placebo
PPI
35
30Healed/week
225
20
(%)
10
5
02 4 6 8 12
Weeks
8181
, 2 ,
but the speed of healing falls off as fewer patients are left to be healedAdapted from Chiba N et al. Gastroenterology. 1997;112:1798-1810.
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ARS Question
ccor ng o e gu e nes, w cof the following agents heal(s) more
1. PPIs
2. H2RAs
3. Promotility agents
4. A and B are equal
8282
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Healing-time Curve: PPIs vs H2RAs vs Placebo100
80PPI
(3)(26)
(2)
60
H2RAlhealed
(4)(27)
(25)
(22)
40
20Placebo%
Tota
(2)
(23) (25)
(8)
(5)
(9)
0
2 4 6 8 12
By week 4, PPIs heal more atients than H RAs and continue to do so
Time in weeks
8383
even after 12 weeks of treatment (number of studies is shown in
parentheses)Adapted from Chiba N et al. Gastroenterology. 1997;112:1798-1810.
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Percentage of Symptom-Free Patientsfor PPIs and H2RAs
Heartburn-PPI
40
30(%)
20
12 34 68
10
Time in Weeks
With longer therapy, PPIs continue to relieve heartburn faster thanH RAs but the s eed of s m tom relief falls off as fewer atients
8484
Adapted from Chiba N et al. Gastroenterology. 1997;112:1798-1810.
remain symptom-free
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Proton Pump Inhibitors-GERD Omeprazole Esomeprazole Lansoprazole Rabeprazole DexlansoprazolePantoprazole
Symptomaticrelief 20 mg daily
X 4 weeks
20 mg daily
X 4 weeks
15 mg daily
X 8 weeks
20 mg daily
X 48
20 mg daily
X 48 weeks
40 mg daily
X 48
Healing of
wee swee s
ulcerativeesophagitis
X 48 weeks
daily X 48weeks
X 816weeks
X 48weeks
daily X 48weeks
X 816weeks
Maintenanceof healing orerosive or
20 mg daily 20 mg daily 15 mg daily 20 mg daily 30 mg daily40 mg daily
8585
Source: www.fda.gov. Accessed on August 22, 2009.
esophagitis
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H2RAs- pprove n cat ons or t e reatment o
Cimetidine Famotidine Nizatidine Ranitidine
Treatment of
GERD
800 mg at night,
or in divideddoses, for up to12 weeks
20 mg bid for up
to 6 weeks
150 mg bid for
up to 12 weeks150 mg bid
Maintenanceof healing or
erosive or
800 mg at night,or in divided
doses for u to
20 or 40 mg bidfor up to 12
150 mg bid forup to 12 weeks
150 mg up to 4xper day
ulcerativeesophagitis
12 weeks
8686
Source: www.fda.gov. Accessed on September 2, 2009.
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Nocturnal Breakthrough Symptoms
8787
C S d 1 C l
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Case Stud 1: Carol
After 4 weeks of once-daily
PPI therapy, Carol returnsto your office
Her symptoms haveimproved somewhat,especially during the day;however, she wakes upa ou n g s a wee wheartburn and regurgitation
8888
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u How would you proceed with your
management of Carols symptoms?
1. Endosco
2. pH monitoring. -
4. Increase PPI to twice a day
5. Refer for surgical consultation
6. None of the above
8989
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Participants perspectives on individual practice
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AGAI guidelines recommend endoscopy to evaluatepatients with a suspected esophageal GERD syndrome
-daily PPI therapy
Grade B: recommended with fair evidence that itmproves mpor an ou comes
9191
Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
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level
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Nocturnal Breakthrou h S m toms: AGAI2008 Guideline Recommendation
There is no evidence of improved long-term efficacy byadding a nocturnal dose of an H2RAs to twice-daily PPI
Grade Insufficient: no recommendation; insufficientevidence to recommend for or against
9393
Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
ARS Question ?
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ARS Question ? Carols symptoms are successfully
managed after 3 weeks on twice-daily
PPI therapy. How would you approachmaintenance therapy?
. on nue ong- erm erapy a e same
dosage2. Continue lon -term thera and titrate down
to the lowest effective dose on the basis ofsymptom control
. discontinue until symptoms reappear
4. All of the above
94945. None of the above
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u t sc p nary anagement
Appropriate Referrals
9595
Case Stud : Jim
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Case Stud : Jim 63 years old
stent, arthritis, GERD
, ,
Meds: clopidogrel, low-dose,
Smoker, drinks a 6-pack of beer
Presenting symptoms: on twice-dail PPI but re orts ersistent
9696heartburn
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Because Jims presenting symptom is
,proceed?
.
2. Perform diagnostic tests to rule out cardiac-
3. Prescribe an antacid trial to see if it relieves
4. Refer him to a cardiologist
97
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Which of the following
closely monitored if Jim isrescribed PPI thera ?
1. Clopidogrel. e a oc ers
3. Low-dose aspirin
4. All of the above
9898
Clinical Practice Key Points
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Clinical Practice Key Points
Participants perspectives on individual practice
Are PPIs Contraindicated in Patients
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Are PPIs Contraindicated in Patientsa ng op ogre
Retrospective cohort study of 8205 patients with
acute coronary syndrome (ACS) taking clopidogrelafter discharge from 127 Veterans Affairs hospitals
, ,
Conclusion: Concomitant use of clopidogrel and PPI
a higher risk of adverse outcomes than use ofclopidogrel without PPI, suggesting that use of PPI
may e assoc a e w a enua on o ene s oclopidogrel after ACS
100100
Ho PM et al. JAMA. 2009;301:937-944.
Cumulative Hazard for Death or ACS
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Cumulative Hazard for Death or ACS0.6
0
eathsor
ACS
.40
rtion
of
ecurrent
Prop
0.2
0
None
Clop
0.0
0Clop+PPI
DaysSinceDischargeAdapted from Ho PM et al. JAMA. 2009;301:937-944.
PPIs Clo ido rel and Cardiovascular
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PPIs, Clo ido rel, and CardiovascularEvents: Expert Consensus Statement
In 2008, the American College of CardiologyFoundation, the American College of
,Association recommended that all patients who arereceiving NSAIDs, aspirin, dual antiplatelet therapy,or concom an an coagu an erapy an w o areat risk for gastrointestinal injury should receive
ro h lactic treatment with a PPI to reduce the riskof ulcer complications and GI bleeding
Bhatt D et al. J Am Coll Cardiol. 2008;52:1502-1517.
Conflicting Results
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Conflicting Results Several recent publications have reported
outcomes of patients concurrently takingclo ido rel and a PPI vs clo ido rel alone
Also, it is unclear if an interaction between
clinically meaningful adverse outcomes
Rude MK, Chey WD. Gastroenterology. 2009;137:1168-1171.
: im n ?
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: im n ? How would you proceed with
Jims treatment?1. Consider surgery
2. Recommend endoscopy
3. Order impedance pH monitoring
4. Switch to a different PPI
5. First ensure that he is taking his
twice-daily PPI therapy at theappropriate time
104104
AGAI 2008
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AGAI 2008u e ne ecommen a on
patients with a suspected esophageal GERD syndromewho have not responded to an empirical trial of twice-
Biopsies should target any area of suspectedmetaplasia, dysplasia, or malignancy
Grade B: recommended with fair evidence that itimproves important outcomes
105105
Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
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Jim reports that he is taking his PPI
medication one-half hour before
breakfast and one-half hour beforedinner
How would you proceed?
1. Endoscopy with or without biopsy
2. Upper GI series
3. Esophageal manometry
4. Ambulatory pH monitoring
5. Impedance-pH monitoring
106106
6. Other
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Which of the following
characteristics put Jim athigh risk for Barrettsesop agus
1. Over 50 years of age
2. White man
.4. All of the above
107107
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Participants perspectives on individual practice
Barretts Eso ha us: Risk Factors
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Barrett s Eso ha us: Risk FactorsGroup at Highest Risk
Age >50 years
ObeseGERD symptoms Early age of onset
Longer duration ( >510 years)
109109
Adapted from Katz PO et al. Curbside Consultation: 49 Clinical Questions. Thorofare, NJ: SLACK Inc., 2008.
m s agnos s
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m s agnos s
Jim is sent for anendoscopy
Results show Barrettseso ha us with hi h-grade dysplasia
110110
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What are the treatment options for patients
'1. Do nothing
2. Surveillance
3. Antireflux sur er
4. Mucosal ablation
. epen s on ex s ence an eve o ysp as a
6. I do not know
111111
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Participants perspectives on individual practice
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What are the next steps
1. Referral to agas roen ero og s e
isnt seeing one already.
3. Antireflux surgery
4. Mucosal ablation
5. De ends on existence
113113
and level of dysplasia
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Barretts Eso ha us
114114
Barretts Esophagus
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p g
115115
Shaheen NJ. Gastroenterology. 2000;119:333..
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Barretts Esophagus andAdenocarcinoma
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Adenocarcinoma
Patients with Barrett's esophagus have anincreased risk of developing esophageala enocarc noma
The incidence of esophagealadenocarcinoma is 0.3%0.5% per patientyear
However, lifetime incidence in anindividual atient ma be 10%11%
117117Reid BL et al. Annu Rev Med. 1987;38:477-492.Eisen GM. Gastrointest Endosc. 2003;58:760-769.
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Pr v l n f B rr E h
in the General Population of Sweden
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in the General Population of Sweden
1000 persons had endoscopy
.
9 (56%) had symptoms of GERD
119119
Ronkainen J. Gastroenterology. 2005;129:1825.
Metaplasia: Response to Chronic InflammationOne adult cell type replaces another
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One adult cell type replaces another
Stratified SquamousEpithelium
Specialized IntestinalMeta lasia
120120
(Normal Esophagus) (Barretts Esophagus)
Histological Features of Dysplasia
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Nuclei showenlargement,
pleomorphism,hyperchromatism,stratification,
Villiform surfacesand tubules showcrowding
121121
No Dysplasia Dysplasia
Estimates of Annual Cancer Incidence for
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. Shaheen. Gastroenterology. 2000;119:333.
Low-Grade Dysplasia: 0.6% Sharma. Clin Gastroenterol Hepatol. 2006;4:566.
- Spechler. Am J Gastroenterol. 2005;100:927. Rastogi. Gastrointest Endosc. 2008;67:399.
122122
Endoscopic Screening and Surveillancefor Barretts Esophagus: Pros
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p g
arre s w cancer s ncreas ng nfrequency
Computer models suggest benefit
No study shows physical harm
123123
for Barretts Esophagus: Cons
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for Barrett s Esophagus: Cons
Endoscopy is expensive
No proof that these procedures improvesurvival
No roof likel in the near future
124124
ARS Question ? As previously noted, Jim has beendi d i h B h d
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?diagnosed with Barretts esophagus and
- . , ,dysplasia is found on 2 endoscopies within1 year, which would be the appropriate nextstep
1. Surveillance endoscopy every year
2. Surveillance endoscopy every 6 months
every 3 years
4. No future surveillance endosco
125125
Wang KK et al. ACG Practice Parameters Committee. Am J Gastroenterol. 2008;103:788.
needed
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If Jim had low-grade dysplasia, how
1. When dysplasia is first noted,
within 6 months
. expert pathologist
. dysplasia is seen on 2consecutive endoscopies
1261264. All of the above
Wang KK et al. ACG Practice Parameters Committee. Am J Gastroenterol. 2008;103:788.
ARS Question ? Which of the following would bei t t ( ) i th
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?an appropriate step(s) in the
-dysplasia?
. an expert pathologist
. months
surveillance (Q 3 months),EMR, endoscopic ablation,
127127
esop agec omy
4. All of the above
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Participants perspectives on individual practice
Appropriate Management of High-Grade
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Have diagnosis confirmed by an expert pathologist
Repeat endoscopy within 3 months;4- uadrant bio sies at 1-cm intervalsmucosal irregularity should have EMR
ons er op ons o n ens ve surve ance mon s ;EMR; endoscopic ablation; esophagectomy
Individualize treatment
129129
Wang KK. ACG Practice Parameters Committee. Am J Gastroenterol. 2008;103:788.
Jim experiences hoarseness which may
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Jim experiences hoarseness, which may
GERD. Which of the following is nota
GERD?
.
2. Neck pain
3. Chronic cough
4. Halitosis
130130
Extraeso ha eal S m toms of GERD
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Hoarseness
Chronic cough
Laryngitis
Sinusitis
Dental erosions
Halitosis
131131
Maintenance Thera
f
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Typical esophageal reflux syndrome
(with or without esophagitis)
(asthma, laryngitis, cough)
decreased or discontinued?
132132
Under what condition(s) should antisecretory
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Under what condition(s) should antisecretory
1. Patient reports likely adverse effect (headache,
2. Patient has been taking PPIs for a prolonged-
3. It is unclear why the patient is taking PPIs
4. The patient was started on twice-daily PPI beforeonce-daily dosage was tried
133133
5. All of the above
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Once PPIs have proven to be clinically effective for thetreatment of patients with esophagitis, therapy should be
-effective dose on the basis of symptom control
Grade A: strongly recommended based on good evidence
134134
Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.
Clinical Conse uencesof Long-term Acid Inhibition
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Screening for potential adverse effects
Calcium supplementation?H. pyloriscreening?
135135
Clinical Conse uencesof Long-term Acid Inhibition (cont)
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Dependency?
with PPIs for 8 weeks may induce rebound
acid-related symptoms upon discontinuanceo e
136136
Reimer C et al. Gastroenterology. 2009;137:80-87.
ARS Question ?Role of Endoscopy in the Long-termM t f GERD
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Mana ement of GERD
When should endoscopy be used as a tool forevaluating treatment failure or risk management?
1. Every 5 years
2. When a patient reports occasional breakthrough,
3. When the patient reports the new sensation of foodsticking in his esophagus
4. Every 10 years
5. When the patient was begun on empiric PPI therapy and
137137
has 80% resolution of heartburn after 2 weeks of therapy
Case Study: JimAntireflux Surgery
ARS Question ?
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ARS Question ? Under what conditions should
antireflux surgery be recommended
1. Never2. If Jim has worsening symptoms
3. After 2 years of PPI therapy,
because it is safer4. If Jim cannot tolerate acid
138138
suppress ve t erapy, even t s
effective
Clinical Practice Key Points
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Participants perspectives on individual practice
Surgery vs Acid-Suppressive Therapy:u e nes
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patient with esophageal GERD syndrome cannottolerate acid-suppressive therapy, even if pharmacology
When treatment with antireflux surgery or PPIs isthought to be similarly effective in a patient withesophageal GERD syndrome, PPI therapy is consideredsafer and is therefore preferred as initial treatment
Grade A: stron l recommended based on ood
evidence
140140
Kahrilas P et al. Gastroenterology. 2008; 135:1392-1413.
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Question and Answeress on
141141