1- GERD, Esophageal Cancer/ Disorders Flashcards
What are the 4 most common complications of GERD?
Barrett’s esophagus, erosive esophagitis, strictures, esophageal cancer
Among untreated patients with GERD, 30% will have what finding on endoscopy?
Esophagitis
What is the pathophysiology of GERD?
LES transiently relaxes, allowing backflow of stomach contents
According to the Montreal classification, GERD is a condition that develops when the reflux of the stomach contents cause what?
Troublesome sxs or complications
What is the hallmark sx of GERD?
Heartburn (pyrosis)
(other sxs: regurgitation, chest pain, dysphagia, water brash/ hypersalivation, globus sensation, odynophagia, nausea)
The following are extraesophageal manifestations of what condition?
Bronchospasm, wheezing, laryngitis/ hoarseness, chronic cough, loss of dental enamel
GERD
Chest pain described as squeezing, substernal, radiate to back/ neck/ jaws/ arms is concerning for what and what must you r/o?
Concerning for GERD, must r/o cardiac cause
What factors have the potential to worsen GERD? (6)
Obesity, gravity, pregnancy, tobacco/ EtOH, foods, meds
Meds that do what have the potential to increase GERD sxs?
Decrease LES pressure or injure mucosa
What medication class can lead to mucosal injury therefore worsening GERD sxs?
Bisphosphonates
What condition is defined as a portion of the stomach that enters above the diaphragm into the chest?
Hiatal hernia
What are the 2 main types of a hiatal hernia?
Sliding (most common) and paraesophageal (may require surgery)
How is a hiatal hernia typically found?
Most asx and incidental finding
Hiatal hernia has the potential to cause what other condition and will present with heartburn, cough, hoarseness, CP?
GERD
A hiatal hernia may be an incidental finding on CXR found as a retrocardiac mass with or without what?
An air-fluid level
(w/o air-fluid level, dx difficult to make)
What is the diagnostic study of choice to evaluate mucosal injury?
EGD
What is the esophageal impedance test used for?
Observation of bolus transit (complete or incomplete)
What diagnostic test has a high sensitivity for detecting and quantifying reflux and allows pts to log sxs?
Esophageal pH monitoring
(trans nasal catheter vs wireless capsule option)
What diagnostic test measures the function of the LES and peristalsis/ pressures and pattern of esophageal muscle contractions determining esophageal motility disorder?
Esophageal manometry
Why is a barium contrast esophagram not typically used for the dx of GERD?
Does not reliably identify mucosal injury
What are the red flags/ alarm features of GERD and require further workup? (9)
Dysphagia, odynophagia, GI bleeding, unexplained weight loss, anemia, inadequate response to therapy, new onset dyspepsia in ≥ 60yo, prior anit-reflux surgery, hx of cancer
Are dx studies/ labs usually needed with classic hx of GERD W/O warning signs?
No (usually clinical dx)
What are the 3 general tx options for GERD?
Lifestyle and dietary modification, meds, anti-reflux surgery
What lifestyle and dietary modifications should be made for the tx of GERD?
Elevate head of bed, no food/ drink w/i 3 hours of bedtime, weight loss, selective elimination of dietary triggers
What meds are used in the tx of GERD?
Antacids (TUMS), H2 blockers (H2RA)- Ranitidine, PPIs (Prilosec, Prevacid, Nexium)
What is defined as mild/ intermittent sxs of GERD?
Less than 1-2 episodes/ week, no evidence of erosive esophagitis
What is the treatment for GERD if mild/ intermittent sxs?
Step up therapy (lifestyle mod, H2RAs, +/- antacids)
What is defined as severe sxs of GERD?
Frequent (≥ 2 episodes/ week) and sxs impair quality of life
What is the treatment for GERD if severe sxs?
Step down therapy (PPI daily x 8 weeks + lifestyle mod), gradually decrease therapy unless maintenance necessary
What drug class works to neutralize gastric pH but does not prevent GERD and has only a short lived benefit?
Antacids
What drug class used in the tx of GERD blocks action of histamine at H2 receptors of gastric parietal cells and leads to decreased secretion of stomach acid?
H2 blockers/ H2 antagonists
What H2 blockers/ H2 antagonists are used in the tx of GERD?
Ranitidine, Famotidine
What drug class used in the tx of GERD reduces amount of acid produced by glands in the stomach?
PPIs (take 30 min before 1st meal of day)
What drug class consists of drugs ending in “prazole” and is used to treat GERD?
PPIs
What are the 2 greatest concerns related to long term PPI use?
Risk of infection and malabsorption
Why does a pt on PPIs long term have an increased risk of infection?
Acidic environment is protective (decreasing acid can increase risk of C. diff)
Malabsorption of what ion is related to long term PPI use and should therefore be checked periodically?
Magnesium
How long should a GERD pt without severe erosive esophagitis or Barrett’s esophagus be treated with meds?
Lowest dose/ shortest duration, d/c meds completely in pts w/o sxs
How long should a GERD pt with severe esophagitis or Barrett’s esophagus be treated with meds?
Require maintenance acid suppression w/ PPI (recurrent sxs and complications likely if med DC)
What are the indications for surgical management of GERD?
Failed optimal med management, GERD complications, noncompliance
What is the preferred anti-reflux surgery for GERD?
Nissen Fundoplication
(passage of gastric fundus behind esophagus to encircle distal esophagus)
What is the order of treatment management for GERD?
H2 blocker → PPI → PPI BID w/ close f/u or endoscopy
(endoscpoy FIRST if develop any alarm signs)
What is the most common cause of esophagitis?
GERD
What condition is defined as gastric acid, pepsin, and bile irritating the squamous epithelium and leading to irritation, inflammation, erosion, or ulceration?
Esophagitis
What are the 5 types of esophagitis and which is the most common?
Reflux (most common), infectious, medication induced, eosinophilic, radiation
Esophagitis has sxs similar to what other condition?
GERD (heartburn, regurgitation, cough, CP)
What are the complications of esophagitis?
Bleeding, stricture, Barrett esophagus
What condition is defined as squamous epithelium in distal esophagus replaced with columnar epithelium and is due to recurrent acid injury?
Barrett Esophagus
Barrett esophagus predisposes patients to what?
Adenocarcinoma of esophagus
What is the progression of Barrett’s esophagitis? (5 steps)
GERD → Barrett’s esophagus → low grade dysplasia → high grade dysplasia → adenocarcinoma
What is the tx for Barrett’s esophagitis?
Indefinite PPI use (qd dosing, may prevent cancer) and EGD surveillance to detect dysplasia
What are the 2 types of endoscopic eradication therapy (EET) used in the tx of Barrett’s esophagus?
Endoscopic ablation (EA) and/ or endoscopic resection (ER)
What are the 2 main types of esophageal cancer?
Adenocarcinoma (RFs: Barrett’s, caucasian)
SCC (RFs: AA, smoking, EtOH)
What is “key” to adenocarcinoma?
Prevention and early detection
If a pt presents with sxs of GERD as well as dysphagia, what should the next step be?
Endoscopy (and barium contrast esophagram)
Regardless of histology, most pts with esophageal cancer present with disease that is what?
Incurable, unresectable, or metastatic
(goal of tx = palliative)
What type of esophagitis is chronic and immune/ antigen-mediated?
Eosinophilic esophagitis
There is a strong connection between esosinophilic esophagitis and what?
Allergic diseases
(food allergy, rhinitis, asthma, atopic derm)
Clinical hx/ sxs of dysphagia, food impaction, CP, refractory GERD, upper abd pain, and EGD showing stacked circular rings and stricture is concerning for what?
Eosinophilic esophagitis
What is the tx for eosinophilic esophagitis?
Diet (avoid allergens), acid suppression (PPI), topical corticosteroids, +/- esophgeal dilation
What is important pt edu regarding topical corticosteroids/ ICS in the tx of eosinophilic esophagitis?
Spray and swallow, DO NOT INHALE
What type of disorders should be considered in pts with dysphagia, noncardiac CP and refractory GERD sxs?
Esophageal motility disorders
What are the major motility disorders of esophageal peristalsis?
Hypercontractile (jackhammer) esophagus, distal esophageal spasm (DES), achalasia
What dx testing is used to evaluate for an esophageal motility disorder?
Manometry, barium swallow, +/- esophageal pH and impedance monitoring
What esophageal motility disorders present on manometry as high pressure contractions in esophagus with normal relaxation of esophagogastric junction and mimc angina (but typically occur w meals)?
Hypercontractile (jackhammer) esophagus and DES
What is the goal of tx for hypercontractile (jackhammer) esophagus and DES?
Control GERD and relax hypercontractile smooth muscle
(PPI, CCB- Diltiazem, TCA- Imipramine)
What non-pharmacologic tx can be used to treat hypercontractile esophagus and DES if NO GERD?
Peppermint oil
Aperistalsis in distal 2/3rds of esophagus and incomplete LES relaxation on manometry is concerning for what?
Achalasia
Esophageal dilation, “birds beak”, aperistalsis, and poor emptying on barium esophagram is concerning for what?
Achalasia
What condition is defined as progressive inflammation and degeneration of esophageal neurons leading to relaxation failure of LES and no peristalsis?
Achalasia
Pt c/o dysphagia, regurgitation, difficulty belching, CP, and heartburn is concerning for what?
Achalasia
What is required for dx of achalasia?
Manometry
What is necessary to r/o malignancy in the dx of achalasia?
EGD
What should you consider in a pt who is unresponsive to PPI trial with dysphagia to solids/ liquids and regurgitation?
Achalasia
What is the tx for achalasia?
Mechanical disruption of LES muscle fibers or biochemical reduction in LES pressure
What are the 2 types of mechanical disruption of LES muscle fibers in the tx of achalasia?
Pneumatic dilation and Heller myotomy (incision into muscles of LES)
What are the 3 types of biochemical reduction in LES pressure in the tx of achalasia?
Botox, nitrates, CCBs
What condition is defined as a mucosal laceration is distal esophagus and proximal stomach and is usually associated with repetitive vomiting and retching?
Mallory Weiss syndrome
What are the predisposing factors to Mallory Weiss syndrome?
Heavy alcohol use, hiatal hernia (inc abd pressure)
What is used to dx Mallory Weiss syndrome and also r/o other etiologies/ allows for therapeutic intervention?
Endoscopy
How is Mallory Weiss syndrome treated?
Stabilize pt and treat w/ PPI
(also endoscopic bleeding control (prn) and address predisposing factors)
