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BRGE
DEFINITIE: Cnd avem n vedere boala de reflux
gastroesofagian( acronim BRGE) ne referim la totalitatea
simptomelor nsoite sau nu de leziuni ale mucoasei esofagiene -
datorate prezenei refluxului gastroesofagian .
RGE reprezinta fenomenul fiziologic de trecere a continutului
gastric in esofag ce devine patologic cand mecanismele antireflux
devin incompetente.
Esofagia de reflux reprezinta leziunea esofagiana indusa de
RGE, leziune ce nu se produce in mod obligatoriu in toate cazurile de
reflux patologic.
6
Dou grupe de pacieni dup modul n care se exprim BRGE:
BRGE pare s fie cea mai frecvent tulburare interesnd tractul digestiv
superior n arile vestice unde se estimeaz c 1 din 10 persoane prezint
simptomele tipice BRGE
Prevalena BRGE endoscopic negativ pare s fie
de 55-81% din toi bolnavii cu BRGE.
BRGE este egal prevalent la ambele sexe dar
esofagita este mai frecvent la barbai ( 2:1- 3:1) ca i
esofagul Barrett ( 10:1).
Toate formele de BRGE par mai frecvente la rasa alb fa de alte rase .
stenoza peptic
ulcerul esofagian
hemoragia
cancerul esofagului distal.
11
Patogenie
Exist un reflux gastroesofagian considerat fiziologic.
Simptomele tipice BRGE apar cnd tolerana
epiteliului la agresiune este depit
Factorul de agresiune asupra mucoasei esofagiene este
reprezentat de fluidul refluat n esofag. Efectul su nociv este
realizat n principal prin
ionul de hidrogen
pepsin
sruri biliare
tripsina
lisolecitina
hiperosmolaritate
Factorii de aparare a mucoasei sunt:
integritatea jonctiunii esogastrice
clearence-ul acid esofagian
rezistenta tisulara.
Pe lnga aceti factori bine definii se pare c alti factori precum dieta, factori
emotionali sau comportamentali joaca un rol n scderea toleranei epiteliului
esofagian la reflux.
a) Integritatea jonciunii esogastrice.. Refluxul
gastroesofagian implic o afectare a funciei jonciunii
esogastrice i n particular a sfincterului esofagian inferior.
ligamentul frenoesofagian
.
Pirozisul, regurgitaia i disfagia sunt cele
mai frecvente simptome ale BRGE dar si
cele mai emblematice
pH 4
Time 2 sec
1
Am J Gastroenterol 2007;102:24-32.
Capsule Attachment Step 2
Se aplica suctiunea la o
presiune negativa de 510
mmHg si apoi se asteapta 30 de
secunde pentru umplerea
camerei vacuum.
Capsule Attachment Step 3
Introducerea acului de atasare
1 2
Capsule Attachment Step 4
3
Capsule Attachment Step 5
Startul inregistrarii
Bravo Capsule Post-placement
ASGE 2013
Diagnostic diferential
Trebuie reinut c un pacient care prezint pirozis are o mare
sans s aib BRGE, cu alte cuvinte acest simptom este relativ
specific pentru aceast afeciune. Totui n faa unui pacient care se prezint
cu simptome sugestive pentru BRGE trebuie luat n considerare i posibilitatea
existenei altor entitti nosologice.
n primul rnd n faa unei dureri toracice trebuie exclus o
boal coronarian care poate evolua spre complicaii grave
cnd nu este recunoscut ( ECG, test de efort, coronarografie
etc). Exist apoi alte afectri ale esofagului cum sunt
esofagitele infecioase sau medicamentoase (mai ales dup
administrarea de Fosamax sau Doxiciclin) care au ns un
aspect endoscopic diferit i asociaz disfagia mai frecvent ca
BRGE. Alte patologii digestive precum dispepsia,
tulburrile motorii esofagiene, gastritele, ulcerul peptic
sau afeciunile biliare pot evolua cu simptome asemntoare
BRGE-
Pirozis-ul functional
Angina esofagiana
Evolutie i complicaii
BRGE este o afeciune cronic cu prognostic
favorabil care determin rareori complicaii vitale dar
a crei evoluie este grevat de posibilitatea
recderilor dup tratament.
Prezentarea la medic se face de obicei la 1-3 ani de
la debutul simptomelor.
Recderile dup tratament sunt consemnate la pn
la 80 % din cazuri, cel mai frecvent n primele 3 luni,
riscul depinznd de severitatea esofagitei iniiale.
GERD: plecand de la pirozis
Esophagitis, NERD, Functional Heartburn?
pH monitoring
excess esophageal + NERD
acid exposure
-
+
Functional heartburn
non-acid reflux
Complicaii ale BRGE sunt:
stenozele peptice ( la circa 8-20% din pacienii cu
esofagit)
ulcerul esofagian ( prevalena 5%)
hemoragia semnificativ este rar( sub 2 %)
perforaia este excepional
dezvoltarea cancerului esofagian
Tratamentul BRGE
Routine global elimination of food that can trigger refl ux (including chocolate, caffeine,
alcohol, acidic and / or spicy foods) is not recommended in the treatment of GERD.
(Conditional recommendation, low level of evidence)
Tratament Medicamentos
1. H2RA doze standard
2. H2RA doze duble
3. IPP doze standard
4. EDS pentru confirmarea diagnosticului i
excluderea complicaiilor
5. IPP n doze duble
In
In Europa
Europa de
de Est
Est prima
prima procedura
proceduraTIF2
TIF2
EsophyX
EsophyX aa fost
fost realizata
realizata in
in mar
mar 2009
2009 Sp
Sp
Floreasca
Floreasca (dr
(drAdrian
Adrian Lobontiu)
Lobontiu)
Procedura
Procedurace ceutilizeaza
utilizeazaEsophyX
EsophyX are areca
caobiectiv
obiectiv
tratarea
tratareapacientilor
pacientilorcu cuBRGE
BRGElalacare careprocedurile
procedurile
medicale
medicalesunt
suntineficiente
ineficientesisicare
caresunt
suntcandidati
candidati
potentiali
potentialilalachirurgia
chirurgiaantireflux.
antireflux.
Practic
PracticEsophyX
EsophyXarearein
invedere
vederepacientii
pacientiicandidati
candidati
pentru
pentruchirurgia
chirurgiaantireflux
antirefluxdar
darcu
cuhernie
herniehiatala
hiatala
de
desub
sub22cm.
cm.
NB!
NB!NuNupoate
poatereface
refacehiatusul
hiatusulesofagian
esofagianal
al
diafragmei
diafragmei
Device Patient Interface
Helical Retractor
Tissue Mold Scope Retainer
Helical Retractor
in Home Position
Chassis
Fastener
Tissue Mold
Ports
Elbow
Elbow
Chassis
Window
Invaginator
Shaft
Pusher Deployment Knob
Retractor Lock
Retractor Control
Vacuum Connection
Retractor
TIF2 Procedure
Pozitiile 1 si 2
2 seturi de
fasteners pe
fiecare parte 1 cm
deasupra Z-Line
Pozitiile 3 si 4
1 set fasteners
pentru fiecare parte 3
cm deasupra Z-Line
Indicatiile
Indicatiile interventiei
interventiei cu
cuEsophyX
EsophyX((Cadiere,
Cadiere,Rajan,
Rajan,Germay,
Germay,
et al. Surg Endosc 2008;22:333-42)
et al. Surg Endosc 2008;22:333-42)
Criterii
Criteriide
deincludere
includere::
Varsta
Varsta18-80
18-80(18-80
(18-80years
yearsofofage)
age)
BRGE
BRGEsimptomatica
simptomaticapeste
peste66luni
luni(Chronic
(Chronicsymptomatic
symptomaticGERD
GERDfor
for>>66
months)
months)
Rezistenta/
Rezistenta/dependenta
dependentalalaIPP/
IPP/(Demonstrated
(DemonstratedPPI
PPIdependence)
dependence)
Reflux
RefluxG-E
G-Edocumentat(Demonstrated
documentat(Demonstratedrefluxreflux-48-h
-48-hpH
pHmetry,
metry,UGI
UGI
radiography)
radiography)
Criterii
Criteriiexcludere
excludere: :
Esofagita
Esofagitagrd
grdDD Los
LosAngeles
AngelesEsophagitis
Esophagitisgrade
gradeDD
BMI
BMI35
35
Hernie
Herniehiatala
hiatalapeste
peste22cm(Irreducible
cm(Irreduciblehiatal
hiatalhernia
hernia>>22cm)
cm)
Stenoza
Stenozaesofagiana(Esophageal
esofagiana(Esophagealstricture)
stricture)
Barretts
Barrettsesophagus,
esophagus,ulcer,
ulcer,dysphagia
dysphagia
Tulburare
Tulburarededemotilitate
motilitateesofagiana
esofagiana(Esophageal
(Esophagealmotility
motilitydisorders)
disorders)
Eficienta
EficientaTIF2
TIF2--EsophyX
EsophyX
80-88% of patients with significantly improved quality of life
and reduced dependency on daily PPIs
References
1 Cadire et al. World J Surg 2008; 32: 1676-1688.
2 Lorenzo et al. J Gastrointest Surg 2008 (submitted).
TIF1 vs. TIF2 at 6 Months
TIF1 Phase 2 TIF2 Feasibility
(N = 81) 1 (N = 10) 2
GERD-HRQL scores normalized 80% 89%
Heartburn eliminated 86% 78%
Regurgitation eliminated 62% 89%
Completely off PPIs 69% 70%
Normalized pH 41% 67%
Esophagitis eliminated 39% 67%
Hiatal hernia eliminated 62% 78%
Valves > 270 degrees 4% 50%
Tight valves 23% 90%
LES resting pressure increase 53% 120%
Arrows indicate the level of improvement between TIF1 vs. TIF2; < 20%, > 20%
References
1
Cadire et al. World J Surg 2008; 32: 1676-1688.
2
Lorenzo et al. J Gastrointest Surg 2008 (submitted).
Complicatii(86
Complicatii(86ptt)
ptt)
--durerea
durereain
ingat
gat
--durerea
durereain
inumar
umar
--durera
dureraretrosternala
retrosternalasevera
severa
--sangerarea
sangerarea
--doua
douaperforatii
perforatiiesofagiene
esofagienelaladisp
dispTIF
TIF11
Guy-Bernard
Guy-BernardCadierre
Cadierreetetcol
colAntireflux
AntirefluxTransoral
TransoralIncissionsless
Incissionsless
undoplication
undoplicationUsing
UsingEsophyX:
EsophyX:12 12Month
MonthResults
Resultsofof prospective
prospective
Multicenter
MulticenterStudy
StudyWorl
WorlJJSurg
Surg2008
200832:1676-1688)
32:1676-1688)
Guy-Bernard Cadie`re Michel Buset Vinciane Muls Amin Rajan
Guy-Bernard Cadie`re Michel Buset Vinciane Muls Amin Rajan
Thomas Rosch Alexander J. Eckardt Joseph Weerts Boris Bastens
Thomas Rosch Alexander J. Eckardt Joseph Weerts Boris Bastens
Guido Costamagna Michele Marchese Hubert Louis Fazia Mana
Guido Costamagna Michele Marchese Hubert Louis Fazia Mana
Filip Sermon Anna K. Gawlicka Michael A. Daniel Jacques Devie`re
Filip Sermon Anna K. Gawlicka Michael A. Daniel Jacques Devie`re
ESTABLISHING THE DIAGNOSIS OF GERD Recommendations ASGE
1. A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and
regurgitation. Empiric medical therapy with a PPI is recommended in this setting. (Strong recommendation,
moderate level of evidence).
2. Patients with non-cardiac chest pain suspected due to GERD should have diagnostic evaluation before
institution of therapy. (Conditional recommendation, moderate level of evidence ) A cardiac cause should be
excluded in patients with chest pain before the commencement of a gastrointestinal evaluation (Strong
recommendation, low level of evidence)
3. Barium radiographs should not be performed to diagnose GERD (Strong recommendation, high level of evidence)
4. Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended
in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat
endoscopy is not indicated in patients without Barrett s esophagus in the absence of new symptoms. ( Strong
recommendation, moderate level of evidence)
5. Routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD. (Strong
recommendation,moderate level of evidence)
6. Esophageal manometry is recommended for preoperative evaluation, but has no role in the diagnosis of
GERD. (Strong recommendation, low level of evidence)
7. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical
therapy in patients with NERD, as part of the evaluation of patients refractory to PPI therapy, and in situations
when the diagnosis of GERD is in question. (Strong recommendation, low level evidence).
Ambulatory reflux monitoring is the only test that can assess reflux symptom association ( Strong recommendation,
low level of evidence).
8. Ambulatory reflux monitoring is not required in the presence of short or long-segment Barretts esophagus
to establish a diagnosis of GERD. (Strong recommendation, moderate level of evidence).
9. Screening for Helicobacter pylori infection is not recommended in GERD. Eradication of H. pylori
infection is not routinely required as part of antirefl ux therapy (Strong recommendation, low level of evidence)