Disclosures Gastrointestinal Motility Disorders & Irritable - PDF document

9/21/2017 Disclosures Gastrointestinal Motility Disorders & Irritable Bowel Syndrome • None Jasmine Zia, MD Acting Assistant Professor Division of Gastroenterology, University of Washington 6 th Asian Health Symposium October 6, 2017 GI Motility Disorders: GI Motility Disorders Highlighting Differences in Asians Organ GI Motility Disorders Organ GI Motility Disorders Any Differences in Asians • Esophagus GERD Esophagus GERD Yes • Achalasia • Achalasia No Esophageal Spasms: DES, Nutcracker, Jackhammer Esophageal Spasms ??? • Ineffective Esophageal Motility Ineffective Esophageal Motility ??? Stomach • Gastroparesis Stomach Gastroparesis ??? • Small Bowel Small Bowel Dysmotility Small Bowel Small Bowel Dysmotility ??? • Colon Slow Transit Constipation Colon Slow Transit Constipation Possibly 1

9/21/2017 Gastroesophageal Reflux Disease Lower Prevalence of GERD in Asians Ethnic Background GERD Prevalence (Weekly) Caucasians 28% Asians 8% Chinese 3% Taiwan 7% Hong Kong 3% Japanese 5% Malaysians 6% Koreans 8% Indians 8% Iranians 8% Turkish 20% J Clin Gastroenterol 2015;50(1):e1‐e7. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824. GERD‐Related Complications in Asians Barrett’s Esophagus in Asians Compared to Caucasians Ethnic Background Barrett’s Esophagus Prevalence 40 Asians 0.06% to 6% 35 Indians 6 to 23.6%% 30 % Prevalence 25 Japanese 19.9% 20 Chinese 1% 15 Taiwan 0.8% 10 Koreans 0.22% 5 0 Esophagitis Barrett's Hiatal Hernia Stricture Esophagus White Asian Dig Dis Sci. 2009;54(5): 964‐71. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824. 2

9/21/2017 Esophageal Adenocarcinoma in Asians Why are Asians less likely to get GERD? • Lower rates of hiatal hernias Ethnic Background Prevalence Death Rate Japanese Increasing 3.7 to 6.9 per 100,000 population from • Lower rates of transient LES relaxations 1960 to 1995 Singapore Increasing 0.03 to 0.13 per 100,000 population from • Smaller gastric parietal cell mass 1968 to 2002 Chinese • Lower gastric acid output Hong Kong Decreasing 11.7% to 6.4% from 1988 to 2003 Taiwan Unchanged Korea Unchanged Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. Dig Dis Sci. 2009;54(5): 964‐71. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824. Why else is GERD less prevalent in Asians? Prevalence of GERD is rising in Asians Ethnic Background Change in Weekly GERD Prevalence • “Heartburn” has no direct translation Asians 5.2% (2005) 8.5% (2010) • Lower awareness of “GERD” in Asian countries Koreans 7.1% (2002) 7.9% (2007) Singapore 5.5% (1994) 10.5% (1999) where peptic ulcer and gastric cancer are highly prevalent Ethnic Background Change in Esophagitis Prevalence Taiwan 5% (1995) 12.6% (2002) • Less likely to seek medical attention for GERD Koreans 1.8% (1995) 9.1% (2005) – 70‐96% of survey participants with GERD do not Malaysians 2.7% (1992) 9.0% (2001) Singapore 3.9% (1992) 9.8% (2001) consult their medical practitioner Philippines 2.9% (1992) 6.3% (2002) Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. J Clin Gastroenterol 2015;50(1):e1‐e7. J Clin Gastroenterol 2015;50(1):e1‐e7. Diseases of the Esophagus, 2011;24(1):18‐24. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824. 3

9/21/2017 GERD symptoms present differently in Why is GERD increasing amongst Asians? Asians than Caucasians • Increased awareness Caucasians Asians • Increasing age • Heartburn • Non‐cardiac chest pain • Acid regurgitation • Dyspepsia/epigastric pain • Rapid urbanization • Feeling of stomach acidity • Adoption of Western lifestyle • Extra‐esophageal – Dietary habits • Typical acid reflux – Resultant obesity symptoms are uncommon • Decline in H pylori (8 – 15%) – H pylori colonization decreases gastric acid output Diseases of the Esophagus, 2011;24(1):18‐24. J Clin Gastroenterol 2015;50(1):e1‐e7. Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. Treatment Approach of GERD for Asians Asians response to PPIs • More profound gastric acid suppression • Start with: • Higher rate of healing of esophagitis – Upper endoscopy • Required lower maintenance dose of PPI – H pylori test and treat • Why??? • More cost effective than empirical PPI test as – Smaller parietal cell mass – Higher prevalence of poor metabolizers due to cP450 the initial diagnostic strategy for patients with 2C19 polymorphism ‐> higher plasma PPI levels reflux symptoms. – Higher prevalence of H pylori: enhances acid suppressing effects of PPI through increased intensity of corpus gastritis, which further suppresses the acid secretory function Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. 4

9/21/2017 H Pylori Eradication and GERD Asians are less likely to respond to PPIs PPI Response Rates Asians Non‐Asians P value Caucasians Asians Week 4 44.3% 60.7% < 0.001 • Higher failure rates of step‐ • Little effect on GERD Week 8 63.6% 72.2% 0.010 down therapy compared to severity (in terms of • Similar to Caucasians: patients with persistent symptom relapse after infection withdrawal of acid – Higher response rates for ERD (71.3%) versus NERD – 43% vs 21%, P = 0.04 suppressive therapy) (48.5%) • Increase in esophageal acid – ERD and less severe GI symptoms predicted exposure symptomatic response to PPIs. • Attributed to higher • Unlike Caucasians: prevalence of CagA+ strain of H pylori and more severe – Lower BMI did not predict response to PPI therapy corpus gastritis BMC Gastroenterology 2014;14:156. Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. Recommendations for H pylori Achalasia • Current consensus: eradicate H pylori before long‐term PPI in Asian patients with GERD. • H pylori eradication prevents progression of atrophic gastritis (premalignant condition). • This is a big deal where the incidence of gastric cancer is high. Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. 5

9/21/2017 Esophageal Manometry: Prevalence of Achalasia in Asians Differences in Normal Values in Asians • Equivalent to Non‐Asians EMAN Value Caucasians Asians Integrated Relaxation Pressure < 15 mmHg < 20.5 mmHg • In a Singapore Study, within Asians: Chinese Indian Malay Dig Dis Sci 1993;38(10):1920‐5 Journal of Gastroenterology and Hepatology 1999;14:791‐795. Journal of Gastroenterology and Hepatology 2013;28:1611‐1615. Constipation Bowel transit times may be faster in Asians Ethnic Background Colon Transit Times (h) Caucasians Americans 56.2 Canadians 93 French 67 Asians Hong Kong 62 Japanese 33.9 Journal of Gastroenterology and Hepatology 2004;19:1270‐1275. Lancet 1977;2(8029):110‐1. 6

9/21/2017 Asian Factors Affecting Colon Transit Times Prevalence of Constipation by Country Factor Effect on Colon Transit Times Lactose intolerance Reduction H pylori Reduction Eur J of Clin Investigation 2006;737‐742. Best Practice & Research Clinical Gastroenterology 2011;25:3‐18. Sex Differences in Constipation in Laxative Use Amongst Asians with Asians versus Non‐Asians Constipation 100 Caucasians Asians 80 % using laxatives 60 > = 40 Women Men 20 0 China Indonesia South Korea Aliment Pharmacol Ther. 2010;31(2):274‐84. Aliment Pharmacol Ther. 2010;31(2):274‐84. 7

9/21/2017 Irritable Bowel Syndrome (IBS) Irritable Bowel Syndrome ROME IV Criteria: Recurrent abdominal pain at least 1 day/week in last 3 months associated with two or more of the following: 1. Related to defecation 2. Onset associated with change in stool frequency 3. Onset associated with a change in form (appearance of stool) *In absence of selected alarm features Rome IV Diagnostic Criteria for FGIDs Prevalence of IBS is similar between Lower Prevalence of IBS in Asians? Caucasians and Asians 2005 2016 Neurogastroenterol Motil 2005;17:317‐324. J Gastroenterol Hepatol. 2017; ahead of print. 8

9/21/2017 Cultural Differences in Symptom Prevalence of IBS in Asians Interpretations Ethnic Background Prevalence of IBS • Constipation, bloating, & fullness are difficult Japanese 19 – 21% to define and differentiate from each other. Chinese 5 – 20% • Bloating is an English term. Malaysians 16% • Post‐prandial fullness, bloating, and relative Pakistan 13% Bangladesh 13% severity of abdominal pain may not be Singapore 9 – 11% interpreted in the same way in different Koreans 10% countries. Indians 4 – 7% Iran 1% J Gastroenterol Hepatol. 2017; ahead of print. Gender Distribution of IBS in Asians Frequency of IBS Symptoms in Asians versus Non‐Asians and Non‐Asians Non‐Asians Asians > = J Gastroenterol Hepatol. 2017; ahead of print. J Gastroenterol Hepatol. 2017; ahead of print. J Gastroenterol Hepatol 2007;22(8):1168‐9. 9