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GERD Inferno: How to Douse it?

Nov 19 | 1:30 PM

Instacon is back with another exciting session. Gastroesophageal reflux disease (GERD) is common throughout the world, resulting in significant health-care costs. In India, the prevalence of GERD varies from 7.6% to 30%, but community-based data on the disease's prevalence is still lacking. Join us as we learn about GERD management with Dr. Anthony Paul Chettupuzha.

[Music] so good evening everyone i am dr samadhnya on behalf of team netflix i welcome you all to the second session of instacorn we have with us dr rejo matthew senior consultant radiologist will be moderating the session today thank you so much over to you sir thank you doctor for that wonderful introduction and summation has given you the right directions to how to maximize the and utilize this netflix channel so once again a warm welcome to instacon a platform that is jointly organized by indian multidisciplinary society of men's health and insta specialty hospitals let me first wish all of you and happy men's day when because today november 19 is international men's day so on behalf of indian multi-disciplinary society of men's health and healthy aging let me once again wish each one of you have joined and happy men's health day and i welcome you all to this very very important session on gerd inferno that is gastroesophageal reflex disease the inferno how to douse it and we have a very eminent gastroenterologist to speak to us on this particular topic and he is a senior consultant and the director of gastroenterology of at insta specialty hospitals and also at the vps lakeshore hospitals in kuching he did his mbbs from trishur medical college md from gurudeya guru gurudev dave university punjab and dm in gastroenterology from calicut university and has been and has taken advanced endoscopy training in the gigi medical center in japan and under the mentorship of the famous dr hinori yamamoto and he is a specialist and most sought after gastroenterology exposed procedures like double balloon endoscope i have the pleasure to introduce dr anthony paul chipura the director of gastroenterology and the senior consultant gastroenterologist at insta speciality hospitals to talk to you on this particular subject gastroesophageal reflex disease gerd either inferno how to douse it this is a common problem that many of us not only men including all all men and women come across in their life and the incidence of gerd is said to be 30 to 40 percent in the general population so to enlighten us on this particular topic and to give us some very important treatment uh methodology treatment modalities and to share with us is experience i have the pleasure to invite dr anthony paul che tipra to give us this time over to you dr anton thank you for that nice word dr richo richard myself associated for last 30 years more than that from medicaid college onwards he was my senior and very good friend and now we are co-directors in our insta speciality hospital you know jet is not a men's problem it's a unisex problem with it involves it it happens to both men men and women equally i put gastroesophageal reflux diseases this acronym is gerd inferno means fire large fire is called inferno you know common symptoms heart burns actually burning and how to treat it you know jerk is a chronic it's not acute problems chronic it's relapsing it comes and goes in which reverse flow of gastric content into the esophagus resulting in the burning symptoms and the reflux symptoms and that affects the quality of life so this is the shortest definition observed epidemiology worldwide prevalence around 13 but india in general population a population based study shows that around 22.2 percent have this problem this is i'm coming to anatomy everyone knows what is low reciprocity sphincter is actually in the junction of esophagus and stomach there are uh we know the sphincter of the esophagus is made of internal sprinklers made of the circular muscles and there is supporting divert this diaphragm this diaphragmatic ligament and diaphragm is also involved in that sphincter action and together is it acts as anti-reflux barrier the low response sprinkler function is a mechanical barrier between stomach and esophagus it generates a high pressure zone in the junction so that content from the stomach will not regret reflux up so the primary mechanism is the transient relaxation of this low responsive sprinter that is a primary mechanism so with that sprinkler relaxation what happens that gastric content will go in the reverse order and you get the disease expanding on the trans physiology as i said shown in the earlier slide the right crust of the diaphragm circles the lower resistance filter and provides additional support both the structure together generate this high pressure zone in the distillation vagus failure of either of these either uh isomorphic sphincter or the right cross will predispose patient to gastrophysical reflex upright decrease in the least pressure to the level of intra-gassing pressure unrelated to swallowing response to majority episode of reflux disease so basically we have that eye pressure zone if any uh mechanism by which this is damaged either a lower sphincter or the diaphragmatic this crust is damaged we can have this disease for the types of gerd basically it is divided into reflux and known uh this is reflexes facilities is it involves erosions and mucosal breaks actually because the acid reflects the mucosa get damaged otherwise non-erosive reflux disease without an erosion or mucosal break we can have this reflux disease in short it's called nerd and nerd is the most common form of jerk the severity of this reflex this fragile ism that is is based on los angeles classification i just come to that this slide shows what is los angeles classification this has four grades a to d a is mild and b is severe form in a we have one or more of mucosal break less than five millimeter and does not extend with the two tops of mucosal folds that's small single mucous will break less than five millimeter if it is more than five millimeter it is called red b if it is more than one mucosal break and less than 75 percent circumference that is grade c is more than seventy five percent of economic circumference that is grade d ready is a severe disease this is based on this this is done using our endoscopy so here i am showing little bit of cartoon regarding the risk factors one is called hiatus hernia hyatt means the gastric uh gastro stomach will pulled up into the space of asphalt and spring to get loose so we have a large cup in the lower part of the esophagus from where acids start regurgitating that's called higher discernment the other one is obesity or overweight high fat diet tobacco smoking alcohol consumption helicobacter pylori infection pregnancy and some genetic factors pregnancy if ladies will know that during pregnancy they have many people they main symptom is the gas or what you call the heart bones of grd because the hormonal effect the valve relaxes and there are many aggravating factors for this and what whatever is good for eating whatever we find is which is good all bad for our dessert like chocolate coffee spicy food oranges tomatoes fatty food fermentable carbohydrate disorders carbonated drinks and few other medications can also cause grd symptoms and notorious among that is biphosphates calcium channel blockers nsaids tetracycline and typical symptom that's most common symptom is hard bone can occur both during day time and night time another is regurgitation and a brush but heartburn with regulation if it is happening we can certain that he is having jerk but it can perspect it can present as a typical symptoms and patient can can go into ent department the pharmacology department then could do cardiology but main problem will be grd and like nausea irritation have belching and early satiety can have come with epigastric pain can have abdominal bloating vomiting chest pain this is one of the commonest cause of known cardiac chest pain and respiratory symptoms can have cough bees chronic rhinos and sinusitis hoarseness of voice pharyngeal pain globus glopus sensation means always they feel there is something in the throat some foreign body is stuck in the throat that's that can be because of function also but many times it could because of jerk and early awakening nocturnal awakening nightmares and breath breathing problem that is another counter and i have seen many times they come with migraine it can crisp with migraine as well but the problem is that it can overlap with many other upper jay conditions like peptic ulcers gastritis gastroparesis dyspepsia and it can coexist the complication as i said esophagitis chronic inseparabilities can lead in to lead to metaplasia of that region and it is called barrett's esophagus and sometimes it can erode into vessel and can bleed can have gastrophysic bleeding and esophageal adenocarcinoma this balance is actually predisposed in factor for carcinoma esophagus adenocarcinoma and if the ulcer is there in the higher the surname we call this cameroons also typical symptom is heartburn and regulation if that is present most likely we can diagnose as dirt in the bedside the presence of heartburn and or regurgitation two or more times a week is certainly observed for diagnose characterizing this is apart from clinical we can use endoscopy we can use ph battery to conver to characterize the disease once you suspect it is joel we can use something called ppa therapy there is no short term therapy actually formal course of ppa therapy or advocate duration if the eight peak is required to assess the treatment response suppose the patient doesn't respond with two weeks that means he's refractory tpa non-responders then we have to think of functional heartburn rather than grd and you have to also consider the alternative diagnosis the creptic culture apogee malignancy functional dyspepsia yeast effluence facilities achalasia or cardiovascular disease many times in last five six years i have at least five six people who came with cpa jet symptoms finally ended up in cardiology departments with stent that's mostly in right coronary then suppose patient is refractory then you have to consider uh alternative treatment i told you first yet first you have to know whether it's actually then you have to do a uh yes stop epa for one week and do ambulatory 24 hour each ph metric ph metering impedance monitoring and that gives that shows whether this content is acidic or alkaline content is coming up during your symptoms and with the mr score we we can say whether it is a symptom is related to gerd or not again for partial pp refractory also we can use the same ph battery with continuous continuation of bpa with combination in a straightforward case in a young patient that is enough to start treatment but patient is having uh alarm symptoms especially alarm symptoms like anorexia weight loss if there is blood in vomiters if there is a blood insta this vomiting hiccups and refractory cup then you have to do endoscopy especially for new onset apart symptoms and and it is helpful in differentiating between the erosive species with non-disposal non-erosive reflux disease where regions for prevalence of z is low there is this endoscopy indication we have to do endoscopy in very soon not wait for any tpa therapy here radiologist or moderator dr vigil can be helpful in doing barium radiograph that is mainly for the evaluation of dysphagia and to characterize the higher the sermia and to look for any complication of dirt like structure drinks or dismountability then other investigation what we do use is esophageal manometry especially if patients are referred for surgery we used to do esophagenometry in 24-hour phd especially this is used when endoscopy negative patient unresponsive tpa therapy to look for motility disorder and i said it's as a pre-operative evaluation and to look for a ph probe especially recommended if you suspect achillesia or scleroderma next goals of treatment mainly to relieve symptoms to improve the life quality he is proven symptom recurrence and it should be a cost-effective treatment for complication these are the goals of management the core principle of management is one is lifestyle other is reduction of acid luminal acid esophageal luminal acid lives i i will come to the lifestyle intervention if patient is getting uh first thing you have to do along with the ppa trial you have to do ask for a lifestyle modification like eat smaller meals means small uh allocates in frequent intervals like every one and one to under hours you take a small helicopter elevate the head of the bed for night symptoms especially we recommend six inch elevation of the bed uh legs of the bed lying on the left side of the body while rusting and the patient has to keep smoking and alcohol and weight loss is a must for obese patients this may help to a large extent and avoid food that aggravates reflux symptoms different people this is different this this aggravating factor is different different food so yeah if the patient is getting some reflux with certain kind of food you have to avoid that then other advice is don't go to bed within uh before three hours of the last dinner or meal last meal suppose you go to sleep at ten o'clock your meal should be at seven o'clock three hours gap should be there otherwise whatever you have food in the stomach you lie down this food will start regurgitating through his facts and you have to have sufficient fluid beforehand during the meals as a medical management the first common this is otc my over-the-counter prescription we get over the counter we get uh and assets like uh what is used to say lucille digest whatever it is they are basically uh neutralize hydraulic hydrochloric acid leading to increase in ph or the gastric conduct like sodium bicarb calcium carbonate magnesium carbonate aluminum hydroxide migration hydroxide magnesium trisilicate these are the immediate uh bedside or home remedies like like a home run you can take ideally you have to take 30 ml at a time rather than one teaspoon 30 ml at a time you to take to get it can get immediate relief and acids can give immediate relief and the earlier at this anti-acid therapy was actually histamine h2 receptor antagonist like usually gastrin secretion after me leads to histamine release stimulation of h2 receptor lead to hydrochloric acid release by this uh proton pump h2 receptors are selective completely antagonists of hd histamine h2 receptors suppressing both basal and stimulated acid secretion produced by instrument release so this action is via h2 receptor action it's not direct and proton pump it is used mainly for short term and medium term use not for prolonged use problem with these drugs are tachyphylaxis that means after some time the efficiency diminishes the commonly used drug cemetery in random information is added symptom is no more available pioneering and thermotyring is a commonly available extruder sub antagonist in india this can be still used even though this is not gone from the market it's still in the use but we gaston knowledge are more into proton pump inhibitors it irreversibly inactivates active form of proton pump by blocking both histamine to gas and coronary source of acid production there are inviting gastric acid secretion directly this effect enables healing of ulcers reflux disease viruses asphegus solinger election syndrome as well as it is a part of antih pylori treatment regime and common molecules most of the doctors will be knowing isoprosol dexa lance president oprah salt random preserve and derived result and the problem starts now suppose patient doesn't respond to pp what to do there's no known responders to pp therapy and in several observational studies shown that overall prevalence of partial and known responders are up to 45 percent both randomized studies or heartburns showed that this refracted 32 percent refractory and troublesome regurgitation in 28 and another problem with ppa is that bioavailability and increased tp metabolism in indians there is a genetic difference in drug metabolism there are rapid metabolizers which have reduced the gastric suppression and lower rate of healing and it is found that in asia around 12 to 20 percent patients are rapid metabolism means if you give bpa therapy there is a chance that it is a rapidly metabolized adequate acid separation doesn't occur so in the management of good the american code of gasoline recommend that therapy other than ppa including pro kinetic and or baclofen should be considered refractory ppa prokinetics uh everyone knows about prokaryotics also the commonly used ones aromatic clock right dome periodontal muscle prior level cell products earlier use pro kinetics pro kinetic engine symbol registration via the effect on lease pressure esophageal peristalsis and acid clearance of promoting gastric emptying so combined with ppa it results in significant improvement in reflex symptoms and it has shown in studies and foreign for my knowledge i know that combination therapies are only available in india in everywhere you have to take two separate tablets bpa with a pro kinetic and this neuromuscular synapses is where mechanism of this prokaryotic act there are several receptors and they'll just come and each drug act in different different receptors i'll come to the communists used for older drugs like dom peridone it is a d2 receptor antagonist that's only moderate pro kinetic kinetic activity crosses the blood-brain barrier and lead to galactoria and sometimes acute prolongation is also reported and there is a recommended caution used for dog peridot is a d2 antagonist h 533 antagonist and phi h store agonist it's important pro connecting nas antimatic activity it crosses the blood brain barrier and causes extrapolating side effects like parkinsonism dyskinesia also reported to cause galactoria levosulfate is a d2 receptor antagonist and phi ht for agonies it's moderate pro kinetic activity it crosses the blood-brain barrier reported because parkinsonism tremors and many cases i've seen with the drug patient especially elderly people it can cause parkinsonism and in women it can cause galactoria it's ideally used for younger people for a shorter duration of time see separate is five stiffer again is moderate to strong programmatic activity because of this cardiac event it is withdrawn from the market the most separate action is almost similar and i'm just coming to a new module actually stalkers i prepared for a pro kinetic interpret one group so that that's why one or two slides more or less different it is a pro kinetic with a dual mode of action it is again d2 has enhanced receptacle it improves gastric emptying reduce uh transient low resistance relaxation increases lea stone safety it is cns safety it is because being a polar molecule doesn't cross the blood grain barrier and acceptable effect is not that much reported and cardiac safety is also good doesn't interfere with cardiac does not report cause due to prolongation so basically interpret is safe this is about the drug one slide actually i couldn't uh know that is suppose drug doesn't act we have endoscopic therapy yes nowadays there are several endoscopic therapies right most of them failure latest one is called this is arma this is anti-reflex ablation this ablation of the uh gastric mucosa near the gastroesophageal junction so the scarring happens and the g junction that junction gets narrowed we are doing that arma in our hospital so i just mentioned about that and ladies and gentlemen take a message from today's talk primary mechanism of astrophysical reflex is transient relaxation of the low-risk virgin sphincter non-erosive reflux this is the most common form of gastrophysic reflex disease heartburn and regurgitation is suffice to diagnose gerd a formal cause of ppe therapeutically duration usually requires the treatment response a typical and refractory cases require ph symmetry manometry and or endoscopy ppi is the backbone of gastric fabrication management ppa refractor gesture is procrastinating alone or in combination safety profile interpret is better thank you gentlemen i'll take few questions from you thank you thank you dr anthony parchetta for that wonderful presentation you have highlighted the most important features of gastroesophageal reflex disease and the treatment strategies for that as a marathoner and i would like you to highlight a few more points on the lifestyle interventions and what are your recommendations for the i think jared is most of the doctors who are seeing it most of them i am sure will be uh having uh at least 50 or 60 percent would be having a journey as a chronic problem for most of them so what was the recommendation for them especially for doctors who are most of the time sitting and having a relatively less physical activity so what is your recommendation to them irrespective whether you do marathon or not you can get dead i am an example i am having a jed and i am taking this ppa but not regularly regularly but this is like once in two days three days whenever i get symptoms i start taking like that after a long after two weeks course i think that is enough for most of the patients you can take on and off ppa that is suffice to reduce your symptoms and as i said obesity is a risk factor for gerd so decreasing the weight definitely have to be in some exercise program and diet program only diet indexes combined will reduce your weight once reduction of weight and you reduce your waste circumference definitely you get a lot of relief of the symptoms so as exercise program you can have both cardio and known cardio cardiac is like running walking everything is coming to cardiac exercise and you can do gym training for weight weight training to increase your muscular activity yeah i think probably in yoga they have a lot of breathing exercises from which they can improve their diaphragmatic activity yoga will help in that case for diaphragmatic exercises then regarding the diet the age-related weakness of that diaphragm can it be reversed it's slowly will increase only thing is you have to be careful you have to practice lot of this lifestyle modifications and surgery is the mainstay in that case patient has to for surgery patient is unwilling to take medicine otherwise if you take ppa you get they get good relief if the patient is unwilling i don't want surgery then you can i don't want medication then you can send for surgery after that ph and manometry so there's a question from dr sanjay um sir is there any role of yoga and deep breathing exercises in preventing the disease i just we just mentioned about that yoga will actually increase the diaphragmatic uh dynamics and it can help in increasing that a low resolution sprinter that high pressure iso will be there so that that reflex will get reduced yeah docker yoga will definitely help along with the diet restriction also if you take a lot of food and start doing yoga will not help you have to be strict with this diet also in reducing the dirt symptoms yeah weight reduction definitely is helpful i feel weight reduction definitely dr anthony there is one more question here after giving metaclopramide if extra pyramidal symptoms occur then how can we manage then stop the medication and and he can give we give he stop medicine we can give maybe dopa for some time one or two days of doppler then patient reverse drill rules it's a reversible condition not a permanent condition so right now you recommend a ppa plus an enterprise kind of thing or what is your current uh start with a ppi loan then patient if suppose uh respond to ppa continue suppose is not improving in ppa then we have to evaluate for whether it is a jade or non-jet other condition you have to exclude other condition and still we find that it's a jet then you have to add pro kinetic pro kinetic as i mentioned there are several pro prokaryotics available i commonly use interpret because of the less cns and cardiac side effects then see for eight weeks and patients still continuing you have to be put on long term uh man medication and instead of giving every day you can make it alternate minimum dosages minimum dosage to keep him symptom free then you have to continue that and patient is unwilling to take long-term medication then you have to opt for endoscopic therapy or surgery you mentioned about the endoscopic therapy where the scarring is uh hope that the of ideal junction how are the long-term results of this process this is this came only in the last one year so we are not sure about the long-term reports last one-year report around 60 50 to 60 percent patient they get good relief with this procedure so this is basically yeah this is uh means long-term patient recurring ppa and unwilling to take medication because of the fear of taking long-term medication if they're not want to take medication basically with argon plasma we'll burn that area in the cardiac area uh fundus cardiac area which burns semicircular burning will be done so that the tissue starts and it contracts in that area so that it it cause pseudo alias will form there so one more question by dr amus sir i heard that pharmaceutine which helps in subside stomach pain little bit what is the role of mercury in here is h2 receptor antagonist uh this is for initial small term use we can use but many times we found that that is not that effective as bpa but in some case of ppa there is nighttime uh lapses is there in that case in night time family training can be good morning you give your ppa with a nighttime family today or ranting can be given one last question before we wind up this session when dr mahesh kumar has asked her does two week of ppi suffice so you mentioned about a two-week trial uh yeah it's actually not right actually we start for a eight week course but if suppose patient is not responding at two weeks that means we know uh he's not going to improve so we will advise for other uh methods to know whether it is actual third or we are dealing with some other disease fine so uh i think we have dr anthony have cleared all the queries that has come across and it is time to wind up this program let me thank you once again for giving this excellent lecture on a very important topic of gastroesophageal reflex disease the real inferno the fire and how to douse it and you have explained it in a beautiful way and once again i wish all the uh all over all those who have joined international men's state uh happy international wednesday on behalf of the indian multidisciplinary society of men's health and healthy aging and insta speciality hospital thank you dr anthony for this wonderful lecture and we wish to have you again in this platform with more interesting topics you're welcome so thank you so uh it's time for dr sam yeah to wind up the session over to you doctor sometime uh thank you so much dr rajuan thank you so much dr anthony uh it was a very wonderful session looking forward for the next session and thank you so much

BEING ATTENDED BY

Dr. Sonali Ullal & 153 others

SPEAKERS

dr. Antony Paul Chettupuzha

Dr. Antony Paul Chettupuzha

Consultant Gastroenterologist

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dr. Antony Paul Chettupuzha

Dr. Antony Paul Chettupuzha

Consultant Gastroenterologist

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