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Enfermedad por Reflujo Gastro-esofágico
Definición Es el resultado de una exposición anormal de la mucosa esofágica al contenido gastro duodenal, que conduce a la presentación de síntomas y frecuentemente, aunque no siempre, inflamación de la mucosa esofágica.
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• 6$,-.+ *(1+;I/34+ – L="1+&(0 #%$4-$"1$0O *-$'$ +4-%%3% '-%("1$ ;( "+4Q$
Enfermedad por Reflujo Gastro-esofágico • Es el 75% de la patología del esófago • Pirosis (sensación urente retroesternal): – 10% de la población lo presenta diariamente – 15 al 40% de la población lo tienen al mes – 1/3 de los que consultan tienen evidencia endoscópica esofagitis
El iceberg de la ERGE Esofagitis severa Esofagitis moderada
Hospitalizados Ambulatorios
Detectados por encuesta
Esofagitis leve
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G$4("30&+0 ("E%%$,-.+ Peristalsis
Intra-abdominal esophagus
Diaphragm Lower esophageal sphincter (LES) Gastric mucosal folds Unimpeded gastric emptying
?303+*(1+;+/=( Factores lesivos. Agente
Mecanismo
Implicación en la ERGE
Directo
Ácido Agentes lesivos principales, participan en el 90% de la ERGE.
Directo
Pepsina
•Proteólisis
Directo
Bilis
•Acción detergente Indirecto •Aumenta la retrodifusión
Tripsina
Directo •Proteólisis
H+
Limitada capacidad lesiva en ausencia de ácido.
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%$!;;30+"8
Fisiopatología Modificadores del EEI. Aumentan la presión
Disminuyen la presión Colescistoquinina
Hormonas
Gastrina Motilina
Estrógenos/progesterona Glucagón Somastotatina Secretina
Péptidos
Bombesina
Péptido inhibidor gástrico
L-encefalina
PIV
Sustancia P
Neuropéptido Y
Alfa-adrenérgicos Antiácidos
Fármacos
Metoclopramida Domperidone Prostaglandinas F2
Beta-adrenérgicos Antagonistas del calcio Barbitúricos Diazepam Dopamina Teofilina Grasa
Alimentos
Proteínas
Chocolate Alcohol
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Espectro clínico Reflujo fisiológico
Reflujo sintomático
Esofagitis erosiva
PH-metría anormal
Esófago hipersensible
ERNE
SINTOMAS Esofágicos
Extra esofágicos
- Pirosis
- Dolor torácico
- Regurgitación
- Disfagia - Tos – asma - laringitis
Esofagitis complicada - Ulcera - Hemorragia - Estenosis - Barrett - Adenocarcinoma
Cuadro clínico. Signos y síntomas atípicos.
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Aspiración del contenido gástrico
Katz. Rev Gastroenterol Disord . 2005;5(3):126-134.
Asma mediado por reflejo neural
Katz. Rev Gastroenterol Disord . 2005;5(3):126-134.
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Laryngeal granulomas
C(6)$%&-$6 %&*,+-.($-6 *% 0%3#4, 56)$&7%,896);&7%,
Infraglottic edema: Highly sensitive but not specific for LPR
Diffuse laryngeal edema in a patient with >80 episodes of LPR on pH testing
D)%E65%&-$6 *% ($),+$+ %& (6-$%&<%+ -,& 6+=6 Pacientes con asma
100
) % ( s 80 i s o r i p 60 n o c s 40 e t n e i c 20 a P
72
77
0 O’Connell (N=189) O’Connell et al. Gastroenterology. 1990;98:A97. Field et al. Chest . 1996;109:316-322.
Field (N=109)
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F%*$-$.& *% (G *% HI J)+ • <-("EM4(43I" '$ %$,-.+ $"
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Normal
ERGE
<2*0-;( h%(A+ *(%( &$'343I" '$ *Z Ventajas
• Mayor comodidad • Dieta y actividad normal • Tiempos de reporte mas prolongado (48 hrs.)
Relación entre el pH y el grado de daño esofágico 30
% de tiempo de pH intraesofágica < de 4
20
10
0 Normal
No Esofagitis
Erosiones
Grietas
Dano
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Tratamiento
Respuesta
Modificaciones de estilo de vida/antiácidos
20 %
Agonistas de receptores H2
50 %
IBP dosis única
80 %
Dosis múltiples de IBP
> 80%
ANTIACIDOS, ALGINATO, SUCRALFATO NO HAY EVIDENCIA DE ESTUDIOS CON ADECUADA METODOLOGIA QUE JUSTIFIQUEN EL USO DE ANTIACIDOS, ALGINATO Y SUCRALFATO EN ERGE.
EVIDENCIA TIPO B 2
Control de pH intragástrico >4 con PPI o un H2BS Omeprazole, 20 mg una vez al día Ranitidina, 300 mg noche Ranitidina, 150 mg BID Famotidina, 40 mg noche Cimetidina, 400 mg cuatro veces/ día 0
4
8
12
16
Tiempo pH >4 (horas)
20
24
Esomeprazole oral provee control más efectivo del ácido comparado con todos los otros PPIs orales
( DIA 5 ) Esomeprazole 40 mg una/día
***
n=34 *** p=0.001 versus rabeprazole p!0.0001 versus lansoprazole, omeprazole y pantoprazole
Rabeprazole, 20 mg una/día Omeprazole, 20 mg una/día Lansoprazole, 30 mg una/día Pantoprazole, 40 mg una/día 0
5 10 15 Tiempo pH intragástrico >4 (horas)
20
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• • • • • •
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TRATAMIENTO DEL HELICOBACTER PYLORI EXISTE EVIDENCIA QUE MUESTRA QUE LA INFECCION POR Hp NO TIENE EFECTO EN EL ERGE Y SU ERRADICACION NO EMPEORA LOS SINTOMAS DE ERGE. Fallone.AJG,2000 Moayyedi. Gas 2001
EVIDENCIA TIPO 1
Tratamiento endoscópico. Modalidades.
• Inyección de polímeros. • Plicación esofágica intraluminal. • Cauterización por radiofrecuencia.
Intentan regresar la competencia al EEI.
TERAPIA ENDOSCÓPICA • NO Hay evidencia de estudios aleatorizados,
controlados que confirmen la efectividad del tratamiento endoscópico para ERGE.
EVIDENCIA TIPO 1
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Sistema de clasificación LA para la valoración de la esofagitis por reflujo Grado A
Grado B
Una (o más) erosiones de la mucosa, no > de 5 mm, que no se extiendan entre las superficies de unión de las 2 mucosas.
Una (o más) erosiones, > de 5 mms, que no se extiendan entre las superficies de unión de las dos mucosas.
Grado C Una (o más) erosiones que se continúan entre la unión EC, pero que compromete menos del 75% de la circunferencia.
Grado D Una ( o más) erosiones que compromete al menos el 75% de la circunferencia esofágica
Lundell et al 1999
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Esófago de Barrett Metaplasia intestinal del esófago reconocida endoscópicamente y probada mediante histología
Norman Barrett
Evolucion del esófago de Barrett
Squamous esophagus
Daño por reflujo acido o biliar Chronic inflammation
Barrett's metaplasia
Genética, género, raza y otros factores ?
Low-grade dysplasia
High-grade dysplasia
Morales CP et al.
Adenocarcinoma
Aneuploidia
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Tratamiento del esófago de Barrett •Control de los síntomas de ERGE
IBP
•Cicatrización de la esofagitis
IBP
•Prevención de esofagitis recurrente
IBP
•Control del reflujo biliar
Funduplicatura
•Prevención de estenosis
IBP/Funduplicatura
•Eliminación del Barrett
Ablación/resección + IBP
•Quimioprevención de displasia y adenocarcinoma
IBP + ASA/COX-2
Modalidades de ablación para esófago de Barrett •
Térmicas – Laser, asa caliente, Halo360 o 90 etc.
•
Fotoquímicas – PDT
•
Mecánicas – Resección endoscópica de mucosa – Biopsias jumbo – Crioterapia, ultrasonido
Z(;+
Post HALO360
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Adenocarcinoma de esófago Melanoma Ca de próstata Ca de mama Ca de pulmón Ca. colorectal
6 5 4 3 2 1 0 1975
1980
1985
1990
1995
2000
*National Cancer Institute’s Surveillance, Epidemiology, and End Results database J Natl Cancer Inst 2005;97:
142-146
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