No PPI without Endoscopy + Biopsy of - Falk · PDF filePrague Criteria, Gastro 2006; 131:...
Transcript of No PPI without Endoscopy + Biopsy of - Falk · PDF filePrague Criteria, Gastro 2006; 131:...
No PPI without Endoscopy + Biopsy ofSquamo-columnar Junction!!
NERD, ERD and GERD: which diagnostic
tools are available and when are they needed?
Martin RieglerVienna, Austria
Falk Symposium, Portoroz
June 15, 2007
It is all about us!
GERD: the stage!
LES
Esophagus
Stomach
LES
Esophagus
Stomach
GERD: the stage!
Cause Effect
Cause Effect
+ PPI!!!
?
Esophageal Adeno CA - Risk Factors
• Barrett Esophagus, Low Grade Dysplasia!
• GERD
• Obesity
• age > 50 years
• white males
Diagnostic tool:
1). Sensitive for Reflux!2). Indicator for Carcinoma Risk!
Diagnostic tool:
1). Sensitive for Reflux!2). Indicator for Carcinoma Risk!
CLE
Columnar Lined Esophagus - History
Barrett 1950: intrathoracic stomach
Allison & Johnstone1953: Esophagus lined with gastric mucous membrane
Barrett 1957: Columnar lined esophagus
Columnar Lined Esophagus (CLE)
• Induced by Reflux!
• Squamous Becomes Columnar!
• Cancer Risk (0.2%-2.0%/year).
Definition of Columnar Lined Esophagus
• Endoscopy
•Anatomy
• Histopathology
normal
Definition of Columnar Lined Esophagus
• Endoscopy
•Anatomy
• Histopathology
CLE
Definition of Columnar Lined Esophagus
•Endoscopy
• Anatomy
•Histopathology
submucosal glands
CLE
Paull-Chandrasoma Classification of CLE
•Endoscopy
• Anatomy
• Histopathology
Cardiac Mucosa Oxyntocardiac Mucosa
Intestinal Metaplasia
Pathogenesis of Columnar Lined Esophagus
Transient LES Relaxations!
Pathogenesis of Columnar Lined Esophagus
Reflux
Cardiac MucosaSquamous
Parietal Goblet
IM=BarrettOCM
geneticswitch?
Barrett Esophagus:
Intestinal Metaplasia in Cardiac Mucosa!
Years
0 15105
CLE
6
LGD HGD
13
CAIM
From CLE to Carcinoma
IM: annual incidence 0.2-2.0%
Barrett-Epidemiology
Normal Population: 0.5%-1.6%
symptomatic GERD: 5%-25% no GERD Symptoms: 25%
Endoscopy: Yes!
Biopsies?
Biopsy Protocol at the EndoscopicEsophago-gastric Junction!
Text
Level 0 = rise of Endoscopic „Gastric Folds“
Text
Biopsy Protocol at the EndoscopicEsophago-gastric Junction!
Level 0 = rise of Endoscopic „Gastric Folds“
Histopathology
(n=114 GERD Pat.)
• CLE = 100 %
• CLE + intestinal Metaplasia = 22.8%
• IM at „normal Junction“ = 17.2%
• LGD = 5/114 = 4.4% (2 at „normal“Junction)
Correlation: Esophagitis & Hernia
(n=114 GERD Pat.)
• Correlation Esophagitis & IM: p = 0.398
• Correlation Hiatal Hernia & IM: p = 0.405
Text
Where Does the Stomach Start?Oxyntic Mucosa!
?
Biopsy Protocol at the EndoscopicEsophago-gastric Junction!
Text
?Where Does the Stomach Start?
Oxyntic Mucosa!
Biopsy Protocol at the EndoscopicEsophago-gastric Junction!
• 102 GERD Pat (42:60 m:w); 50 (18-80) years
Biopsies: n=1998
-1.0 cm -0.5 cm 0 cm +0.5 cm
Biopsy Protocol at the EndoscopicEsophago-gastric Junction!
Endoscopy vs. Histology at the „Junction“
(n= 102 GERD Pat.)
CLE=CM, OCM, IM (18.6%!!)OM=Oxyntic Mucosa = Normal Gastric Mucosa!Squam=Squamous Epithelium
Level OM CLE IM Squam no Bx
> +1.0 0 2% 2% 3% 93%
+1.0 0 3% 4% 26% 67%
+0.5 0 33% 5% 57% 5%
0 1% 84% 12% 2% 1%
-0.5 18% 67% 9% 0 6%
-1.0 71% 23% 4% 0 2%
The „True“ Junction!
Level 0 histologic „Junction“!
CLE + IM Distribution:
n=19/102 = 18.6%
Esophagus (squamous)
Stomach (oxyntic mucosa)
dilated esophagus + CLE
End Stage Dilated Esophagus
Esophagus (squamous)
Stomach (oxyntic mucosa)
dilated esophagus + CLE
End Stage Dilated Esophagus & IM!
IM
Esophagus (squamous)
Stomach (oxyntic mucosa)
dilated esophagus + CLE
End Stage Dilated Esophagus & Adeno CA!
IM
CA
NERD!
Histology: Squamous - CLE - OM!
OM
CM
Squamous
Micro-CLE = „NERD!“
Endoscopy cannot:
1). assess esophagogastric junction!
2). exclude CLE ± IM!
Endoscopic „landmarks“
Squamocolumnar Junction
End of Tubular Esophagus
+1.0 cm
+0.5 cm
level 0
-0.5 cm
-1.0 cmPrague Criteria,Gastro 2006; 131: 1392.
Squamocolumnar JunctionMaximalCircular
End of Tubular Esophagus=level 0!
Prague Criteria,Gastro 2006; 131: 1392.
EGD REPORT:
Diaphragm
Endoscopy in GERD:
4 Bx Squamocolumnar Junction
no IM IM (15-25%)
EGD + Bxin 3-5 years
Multilevel Bx
IMLGDHGD
EGD + Bxin 3a
„act“
OLD DEFINITIONS:
CLE Symptoms EndoscopicEsophagitis
GERD yes yes yes/no
ERD yes yes yes
NERD yes yes no
CONTROLS no no
NOVEL DEFINITIONS:
CLE=Reflux
Symptoms EndoscopicEsophagitis
GERD yes yes yes/no
ERD yes yes yes
NERD yes yes no
? yes no no
NOVEL DEFINITIONS:
DISEASE
abnormal morphology
cancer risk!
symptoms+impaired life quality
ABNORMALITY
abnormal morphology
no cancer risk!
no symptoms
NOVEL MANAGEMENT:
DISEASEABNORMAL
CLEwithout
IM and Symptoms
CLEwith IM
and/or Symptoms
TREATEGD in 3-5 years
FUNCTION TEST!
ESOPHAGEAL MANOMETRY:
PULL THROUGH: normal LES
ESOPHAGEAL MANOMETRY:
PULL THROUGH: impaired LES
ESOPHAGEAL MANOMETRY:
normal impaired motility
ESOPHAGEAL FUNCTION TEST:
Impedance: acidic reflux!
ESOPHAGEAL FUNCTION TEST:
Impedance: non acidic reflux!
ESOPHAGEAL FUNCTION TEST:
Manometry±Impedance
pH Monitoring±Impedance
WHEN:
Before and After Fundoplication!
pH probe placement!Exclude Motility Disorder!
ESOPHAGEAL FUNCTION TEST:
MANOMETRY+/-IMPEDANCE
MOTILITY TRANSPORT
ACHALASIA, SPASM, NUTCRACKER,
IMPAIRED MOTILITY
BODY LES
ACHALASIA, HYPER-HYPOTENSIVE LES
ESOPHAGEAL FUNCTION TEST:
pH MONITORING + IMPEDANCE
ANY REFLUXpH - INDEPENDENT
ACID REFLUXpH - DEPENDENT
+PPI THERAPY
ESOPHAGEAL FUNCTION TEST:
GERD symptoms:
pH Monitoring
abnormal
GERD confirmed
normal
ImpedancepH monitoring
normal
abnormal
do not operate!
TREAT!
Outlook:
High Resolution Manometry!High Resolution Endoscopy!
„NOVEL“ TOOLS FOR GERD!
• HISTOPATHOLOGY!
• Paull Chandrasoma Classification!
• FUNCTION TESTS, Imaging (NBI, HR-Endoscopy)!
• Interdisciplinary approach (GI, Surgery, Pathology)!
Fundoplication on Barrett‘s
author year regression progression
Gurski RR 200328/77 (36.4%)
8/77 (10.3%)
Zaninotto G
2005 6/35 (17%) 5/35 (14%)
CLE & successful Nissen Fundoplication
Parrilla P. et al., Ann Surg 2003, 237: 291
Selective bilateral Vagotomy, Nissen Fundoplikation & Antrum Resektion + Y-
Roux Gastrojejunostomie (Bile Diversion)
Prä OP (n=78) NASOK Post OP
SSBE (n=31) 40 Mo IM (n=11; 36%)
40 Mo CM (n=20; 64%)=Regression!
75 Mo 4/20 von CM in OCM!
LSBE (n=42) 44 Mo IM (n=16; 38%)
44 Mo CM (n=26; 62%)=Regression!
89 Mo 5/26 CM in OCM!
108 Mo LGD (n=1)
extra LSBE (n=5) 96 Mo IM (n=5; 100%)
CLE-length no change!
Csendes A. Surgery 2006; 139: 46-53.