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1. Clin Med III > 1- GERD, Esophageal Cancer/ Disorders > Flashcards

1- GERD, Esophageal Cancer/ Disorders Flashcards

1
Q

What are the 4 most common complications of GERD?

A

Barrett’s esophagus, erosive esophagitis, strictures, esophageal cancer

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2
Q

Among untreated patients with GERD, 30% will have what finding on endoscopy?

A

Esophagitis

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3
Q

What is the pathophysiology of GERD?

A

LES transiently relaxes, allowing backflow of stomach contents

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4
Q

According to the Montreal classification, GERD is a condition that develops when the reflux of the stomach contents cause what?

A

Troublesome sxs or complications

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5
Q

What is the hallmark sx of GERD?

A

Heartburn (pyrosis)

(other sxs: regurgitation, chest pain, dysphagia, water brash/ hypersalivation, globus sensation, odynophagia, nausea)

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6
Q

The following are extraesophageal manifestations of what condition?

Bronchospasm, wheezing, laryngitis/ hoarseness, chronic cough, loss of dental enamel

A

GERD

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7
Q

Chest pain described as squeezing, substernal, radiate to back/ neck/ jaws/ arms is concerning for what and what must you r/o?

A

Concerning for GERD, must r/o cardiac cause

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8
Q

What factors have the potential to worsen GERD? (6)

A

Obesity, gravity, pregnancy, tobacco/ EtOH, foods, meds

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9
Q

Meds that do what have the potential to increase GERD sxs?

A

Decrease LES pressure or injure mucosa

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10
Q

What medication class can lead to mucosal injury therefore worsening GERD sxs?

A

Bisphosphonates

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11
Q

What condition is defined as a portion of the stomach that enters above the diaphragm into the chest?

A

Hiatal hernia

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12
Q

What are the 2 main types of a hiatal hernia?

A

Sliding (most common) and paraesophageal (may require surgery)

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13
Q

How is a hiatal hernia typically found?

A

Most asx and incidental finding

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14
Q

Hiatal hernia has the potential to cause what other condition and will present with heartburn, cough, hoarseness, CP?

A

GERD

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15
Q

A hiatal hernia may be an incidental finding on CXR found as a retrocardiac mass with or without what?

A

An air-fluid level

(w/o air-fluid level, dx difficult to make)

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16
Q

What is the diagnostic study of choice to evaluate mucosal injury?

A

EGD

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17
Q

What is the esophageal impedance test used for?

A

Observation of bolus transit (complete or incomplete)

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18
Q

What diagnostic test has a high sensitivity for detecting and quantifying reflux and allows pts to log sxs?

A

Esophageal pH monitoring

(trans nasal catheter vs wireless capsule option)

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19
Q

What diagnostic test measures the function of the LES and peristalsis/ pressures and pattern of esophageal muscle contractions determining esophageal motility disorder?

A

Esophageal manometry

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20
Q

Why is a barium contrast esophagram not typically used for the dx of GERD?

A

Does not reliably identify mucosal injury

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21
Q

What are the red flags/ alarm features of GERD and require further workup? (9)

A

Dysphagia, odynophagia, GI bleeding, unexplained weight loss, anemia, inadequate response to therapy, new onset dyspepsia in ≥ 60yo, prior anit-reflux surgery, hx of cancer

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22
Q

Are dx studies/ labs usually needed with classic hx of GERD W/O warning signs?

A

No (usually clinical dx)

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23
Q

What are the 3 general tx options for GERD?

A

Lifestyle and dietary modification, meds, anti-reflux surgery

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24
Q

What lifestyle and dietary modifications should be made for the tx of GERD?

A

Elevate head of bed, no food/ drink w/i 3 hours of bedtime, weight loss, selective elimination of dietary triggers

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25
Q

What meds are used in the tx of GERD?

A

Antacids (TUMS), H2 blockers (H2RA)- Ranitidine, PPIs (Prilosec, Prevacid, Nexium)

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26
Q

What is defined as mild/ intermittent sxs of GERD?

A

Less than 1-2 episodes/ week, no evidence of erosive esophagitis

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27
Q

What is the treatment for GERD if mild/ intermittent sxs?

A

Step up therapy (lifestyle mod, H2RAs, +/- antacids)

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28
Q

What is defined as severe sxs of GERD?

A

Frequent (≥ 2 episodes/ week) and sxs impair quality of life

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29
Q

What is the treatment for GERD if severe sxs?

A

Step down therapy (PPI daily x 8 weeks + lifestyle mod), gradually decrease therapy unless maintenance necessary

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30
Q

What drug class works to neutralize gastric pH but does not prevent GERD and has only a short lived benefit?

A

Antacids

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31
Q

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?

A

H2 blockers/ H2 antagonists

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32
Q

What H2 blockers/ H2 antagonists are used in the tx of GERD?

A

Ranitidine, Famotidine

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33
Q

What drug class used in the tx of GERD reduces amount of acid produced by glands in the stomach?

A

PPIs (take 30 min before 1st meal of day)

34
Q

What drug class consists of drugs ending in “prazole” and is used to treat GERD?

A

PPIs

35
Q

What are the 2 greatest concerns related to long term PPI use?

A

Risk of infection and malabsorption

36
Q

Why does a pt on PPIs long term have an increased risk of infection?

A

Acidic environment is protective (decreasing acid can increase risk of C. diff)

37
Q

Malabsorption of what ion is related to long term PPI use and should therefore be checked periodically?

A

Magnesium

38
Q

How long should a GERD pt without severe erosive esophagitis or Barrett’s esophagus be treated with meds?

A

Lowest dose/ shortest duration, d/c meds completely in pts w/o sxs

39
Q

How long should a GERD pt with severe esophagitis or Barrett’s esophagus be treated with meds?

A

Require maintenance acid suppression w/ PPI (recurrent sxs and complications likely if med DC)

40
Q

What are the indications for surgical management of GERD?

A

Failed optimal med management, GERD complications, noncompliance

41
Q

What is the preferred anti-reflux surgery for GERD?

A

Nissen Fundoplication

(passage of gastric fundus behind esophagus to encircle distal esophagus)

42
Q

What is the order of treatment management for GERD?

A

H2 blocker → PPI → PPI BID w/ close f/u or endoscopy

(endoscpoy FIRST if develop any alarm signs)

43
Q

What is the most common cause of esophagitis?

A

GERD

44
Q

What condition is defined as gastric acid, pepsin, and bile irritating the squamous epithelium and leading to irritation, inflammation, erosion, or ulceration?

A

Esophagitis

45
Q

What are the 5 types of esophagitis and which is the most common?

A

Reflux (most common), infectious, medication induced, eosinophilic, radiation

46
Q

Esophagitis has sxs similar to what other condition?

A

GERD (heartburn, regurgitation, cough, CP)

47
Q

What are the complications of esophagitis?

A

Bleeding, stricture, Barrett esophagus

48
Q

What condition is defined as squamous epithelium in distal esophagus replaced with columnar epithelium and is due to recurrent acid injury?

A

Barrett Esophagus

49
Q

Barrett esophagus predisposes patients to what?

A

Adenocarcinoma of esophagus

50
Q

What is the progression of Barrett’s esophagitis? (5 steps)

A

GERD → Barrett’s esophagus → low grade dysplasia → high grade dysplasia → adenocarcinoma

51
Q

What is the tx for Barrett’s esophagitis?

A

Indefinite PPI use (qd dosing, may prevent cancer) and EGD surveillance to detect dysplasia

52
Q

What are the 2 types of endoscopic eradication therapy (EET) used in the tx of Barrett’s esophagus?

A

Endoscopic ablation (EA) and/ or endoscopic resection (ER)

53
Q

What are the 2 main types of esophageal cancer?

A

Adenocarcinoma (RFs: Barrett’s, caucasian)

SCC (RFs: AA, smoking, EtOH)

54
Q

What is “key” to adenocarcinoma?

A

Prevention and early detection

55
Q

If a pt presents with sxs of GERD as well as dysphagia, what should the next step be?

A

Endoscopy (and barium contrast esophagram)

56
Q

Regardless of histology, most pts with esophageal cancer present with disease that is what?

A

Incurable, unresectable, or metastatic

(goal of tx = palliative)

57
Q

What type of esophagitis is chronic and immune/ antigen-mediated?

A

Eosinophilic esophagitis

58
Q

There is a strong connection between esosinophilic esophagitis and what?

A

Allergic diseases

(food allergy, rhinitis, asthma, atopic derm)

59
Q

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?

A

Eosinophilic esophagitis

60
Q

What is the tx for eosinophilic esophagitis?

A

Diet (avoid allergens), acid suppression (PPI), topical corticosteroids, +/- esophgeal dilation

61
Q

What is important pt edu regarding topical corticosteroids/ ICS in the tx of eosinophilic esophagitis?

A

Spray and swallow, DO NOT INHALE

62
Q

What type of disorders should be considered in pts with dysphagia, noncardiac CP and refractory GERD sxs?

A

Esophageal motility disorders

63
Q

What are the major motility disorders of esophageal peristalsis?

A

Hypercontractile (jackhammer) esophagus, distal esophageal spasm (DES), achalasia

64
Q

What dx testing is used to evaluate for an esophageal motility disorder?

A

Manometry, barium swallow, +/- esophageal pH and impedance monitoring

65
Q

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)?

A

Hypercontractile (jackhammer) esophagus and DES

66
Q

What is the goal of tx for hypercontractile (jackhammer) esophagus and DES?

A

Control GERD and relax hypercontractile smooth muscle

(PPI, CCB- Diltiazem, TCA- Imipramine)

67
Q

What non-pharmacologic tx can be used to treat hypercontractile esophagus and DES if NO GERD?

A

Peppermint oil

68
Q

Aperistalsis in distal 2/3rds of esophagus and incomplete LES relaxation on manometry is concerning for what?

A

Achalasia

69
Q

Esophageal dilation, “birds beak”, aperistalsis, and poor emptying on barium esophagram is concerning for what?

A

Achalasia

70
Q

What condition is defined as progressive inflammation and degeneration of esophageal neurons leading to relaxation failure of LES and no peristalsis?

A

Achalasia

71
Q

Pt c/o dysphagia, regurgitation, difficulty belching, CP, and heartburn is concerning for what?

A

Achalasia

72
Q

What is required for dx of achalasia?

A

Manometry

73
Q

What is necessary to r/o malignancy in the dx of achalasia?

A

EGD

74
Q

What should you consider in a pt who is unresponsive to PPI trial with dysphagia to solids/ liquids and regurgitation?

A

Achalasia

75
Q

What is the tx for achalasia?

A

Mechanical disruption of LES muscle fibers or biochemical reduction in LES pressure

76
Q

What are the 2 types of mechanical disruption of LES muscle fibers in the tx of achalasia?

A

Pneumatic dilation and Heller myotomy (incision into muscles of LES)

77
Q

What are the 3 types of biochemical reduction in LES pressure in the tx of achalasia?

A

Botox, nitrates, CCBs

78
Q

What condition is defined as a mucosal laceration is distal esophagus and proximal stomach and is usually associated with repetitive vomiting and retching?

A

Mallory Weiss syndrome

79
Q

What are the predisposing factors to Mallory Weiss syndrome?

A

Heavy alcohol use, hiatal hernia (inc abd pressure)

80
Q

What is used to dx Mallory Weiss syndrome and also r/o other etiologies/ allows for therapeutic intervention?

A

Endoscopy

81
Q

How is Mallory Weiss syndrome treated?

A

Stabilize pt and treat w/ PPI

(also endoscopic bleeding control (prn) and address predisposing factors)

1. Clin Med III (29 decks)

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