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GI > 2- gastro-oesophageal reflux disease > Flashcards

2- gastro-oesophageal reflux disease Flashcards

1
Q

what is gastro-oesophageal reflux disease (GORD)?

A

a spectrum of diseases producing symptoms of heartburn + acid regurgitation due to retrograde (backwards) movement of gastric contents from stomach to oesophagus

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2
Q

what is pathophysiology of GORD?

A
  • gastric acid secretion
  • lower oesophageal sphincter dysfunction = duodenogastric reflux
  • delayed gastric emptying = increased pressure & volume = reflux
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3
Q

what causes decreased anti-reflux barriers in GORD?

A
  • lower oesophageal sphincter (doesn’t work so allows reflux - supposed to stop reflux)
  • oesophageal acid clearance (supposed to clear acid so doesn’t cause problems but doesn’t work in GORD)
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4
Q

what are risk factors for GORD?

A
  • Obesity
  • Smoking
  • Alcohol
  • Genetics
  • h.pylori gastritis (but reduced prevalence as better at finding and treating)
  • Hiatus hernia
  • Pregnancy
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5
Q

what are clinical features of GORD?

A
  • Asymptomatic
  • Heartburn
  • Reflux
  • Water brash (spit+stomach acid making sour taste)
  • Odynophagia (painful swallowing)
  • Burping
  • Hiccups
  • Nausea/vomiting
  • Cough
  • Hoarseness
  • Chest Pain
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6
Q

what are red flag symptoms of GORD?

A
  • Haematemesis/Melaena
  • Dysphagia
  • Weight Loss
  • IDA (iron deficiency anaemia)
  • Persistent vomiting
  • family history/past medical history of upper gastrointestinal Cancer
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7
Q

what is differential diagnosis of GORD?

A
  • Achalasia (constriction of muscles not allowing to swallow food)
  • Eosinophilic Oesophagitis (EoE)
  • Gastroparesis (delayed gastric emptying)
  • Biliary disease
  • Peptic ulcer disease
  • Cardiac Disease
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8
Q

what investigations can be done to diagnose GORD?

A
  • stool antigen test = to check if any ulcers that need treating
  • do endoscope
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9
Q

what is lifestyle management of GORD?

A
  • Reducing exacerbation foods (spicy, fatty, citrus, chocolate, carbonated drinks)
  • Weight loss (to reduce intra abdominal pressure)

To reduce at night:

  • Not eating at night
  • Raise head of bed
  • Smaller portion sizes

Avoid drugs that lower lower oesophageal sphincter tone like nitrates, calcium channel blockers, diazepam, morphine, theophylline

Avoid drugs that promotes oeosphagitis like bisphosphonates, NSAIDs + steroids

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10
Q

what do you do if lifestyle management of GORD doesn’t work?

A

medical management
- antacid/alginate - gaviscon/peptac

1st step = PPI for 4-8 weeks

2nd step = add H2 (histamine) receptor antagonist (not as effective as PPI but some evidence that better at night)

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11
Q

what do you do if medical management doesn’t work for treatment of GORD?

A

surgical management:

= fundoplication = take top of fundus, wrap around oesophagus and pin underneath to make really tight sphincter

  • Patient has to have pH manometry, have to prove that acid going into oesophagus is what is causing symptoms
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12
Q

what are complications of GORD?

A
  • Oesophagitis
  • Schatski ring
  • Barrett’s oesophagus
  • Oesophageal cancer
  • Haemorrhage
  • Ulcers
  • Perforation
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13
Q

what is barrett’s oesophagus?

A

= an oesophagus in which any portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium, which is clearly visible endoscopically (≥1 cm) above the gastro-oesophageal junction and confirmed histopathologically from oesophageal biopsies

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14
Q

what are risk factors for barrett’s oesophagus?

A
  • Chronic GORD
  • Smoking
  • Obesity
  • family history Barrett’s Oesophagus/Oesophageal Carcinoma
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15
Q

what is pathophysiology of barrett’s oesophagus?

A
  • Damage to the oesophageal squamous epithelium due to GORD causes a metaplastic change to intestinal type columnar epithelium
  • Presumably this metaplastic change to columnar epithelium is a protective mechanism as it is thought to be more resistant to GORD than the native squamous epithelium but unfortunately does have increase malignant potential
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16
Q

do all barrett’s oesophagus patients have symptomatic GORD?

A

no, not all have symptomatic GORD - people can still have barrett’s oesophagus without GORD symptoms

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17
Q

what are the mechanisms underlying GORD?

A
  • gastric acid secretion
  • duodenogastric reflux
  • lower oesophageal sphincter hypotension - reduced pressure means increased reflux
  • ineffective motility - decreased clearance
  • decreased salivary EGF - decreased healing
  • decreased sensitivity - decreased treatment
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18
Q

what are the mechanisms underlying metaplasia?

A
  • molecular reprogramming of oesophageal progenitor cells
  • transdifferentiation - conversion of 1 type of differentiated cell into another type
  • migration of gastric progenitor cells - progenitor cells in gastric cardia migrate into oesophagus in response to chronic inflammation = injury (these contribute to development of barrett’s oesophagus by replacing damaged epithelial cells with cells resembling those of gastric mucosa)
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19
Q

what is mechanism of carcinogenesis?

A
  • Growth self sufficiency - through Oncogene/growth factors
  • Antigrowth insensitivity - by inhibition of tumour suppressor genes
  • Apoptosis evasion - by inhibition of Tumour suppressor gene
  • Limitless replicative potential - Telomerase reactivation
  • Sustained angiogenesis - VEGF
  • Tissue invasion & metastasis - disrupt cell adhesion (Cadherins, catenins) and degrade extracellular matrix (Matrix metallaproteases)
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20
Q

what are the 2 areas of columnar metaplasia and what is the most worrying?

A

= gastric and intestinal metaplasia

  • Intestinal is the worrying one that is mostly unstable and likely to go to cancer
21
Q

what type of cancer can barrett’s oesophagus lead to?

A

adenocarcinoma
low grade dysphagia →high grade dysplasia →intramucosal adenocarcinoma

22
Q

what is cytosponge?

A

= way to test for barrett’s oesophagus, or level of dysplasia - patients like it

patients fasts and then swallows 2cm capsule with gelatin coating, - akes 7.5 mins to dissolve and turns into brillopad soft sponge in stomach and pull it out and it scrapes out all mucosal cells – these then sent to cytology
- Evidence that this can be better at identifying metaplasia than endoscope as no user error

23
Q

what level of TNM staging can you treat barrett’s oesophagus?

A

Can curatively treat up to T1A (mucosal involvement)- if invades into submucosa then very low chance can cure and if into other 2/3 then super unlikely to cure

24
Q

what are 2 surgical treatment options for barrett’s oesophagus?

A
  • radiofrequency ablation (heats + destroys abnormal cells)
  • endoscopic mucosal resection (remove abnormal areas of tissue from the lining of the esophagus using an endoscope equipped with specialized tools(
25
Q

what are complications of barrett’s oesophagus treatments ?

A

treatments = like radiofrequency ablation and endoscopic mucosal resection

Chest pain

Dysphagia

Bleeding

Perforation

Stricturing (less in EMR)

26
Q

what is oesophageal dismotility?

A

Abnormal oesophageal peristalsis or sphincter tone leading to symptoms of dysphagia, odonyphagia or gastroesophageal reflux.

27
Q

what is mandatory procedure to be done to diagnose oesophageal dismotility?

A

Normal OGD to rule out structural causes of symptoms like dysphagia, ondonyphagia is mandatory prior to investigating for dysmotility (Cancer, stricture, EoE)

28
Q

what classification is used to classify oesophageal dysmotility?

A

chicago classification

29
Q

what happens in oesophageal manometry?

A

tube passed down nose to stomach – take repeated swallows and take pressure during swallow attempts to test how effectively all muscles + valves of oesophagus are working

30
Q

what is achalasia?

A

= failure of relaxation of lower oesophageal sphincter and absent peristalsis which can mean functional obstruction at lower oesophageal sphincter leading to food stasis and overtime the body dilates oesophagus as compensatory mechanism

31
Q

what are symptoms of achalasia?

A

Dysphagia, regurgitation, weight loss, chest pain.

32
Q

what are investigations of achalasia?

A
  • CXR – air fluid level in dilated oesophagus
  • Barium Swallow – dilated oesophagus, reduced peristalsis, bird beak sign.
  • OGD – Tight LOS, Dilated oesophagus with food debris and no peristalsis.
33
Q

what are complications of achalasia?

A

Increase risk of squamous cell carcinoma Oesophagus

34
Q

what are features of achalasia I?

A
  • Failure of relaxation of lower oesophageal sphincter
  • Absent Peristalsis
  • Simultaneous contractions of low amplitude.
  • Most responsive to treatment
35
Q

what are features of achalasia II?

A
  • Failure of relaxation of lower oesophageal sphincter
  • Absent Peristalsis
  • Pan oesophageal pressurization >20% of swallows
36
Q

what are features of achalasia III?

A
  • Failure of relaxation of lower oesophageal sphincter
  • Absent Peristalsis
  • Premature spastic contractions >20% of swallows.
  • Least responsive to treatment.
37
Q

what are treatments for achalasia?

A
  • Medical (but not great and reserve for elderly who can’t have surgery) - nitrates + calcium channel blockers
  • Endoscopic – botulinum toxin (to relax it – not curative so have to repeat every 6 months and get less sensitive to it over time), balloon dilation , POEM
  • Surgical - heliers myotomy (big intra-abdominal surgical procedure)
38
Q

what are examples of oesophageal dismotility disorders?

A
  • achalasia
  • distal oesophageal spasm
39
Q

what are symptoms of distal oesophageal spasm?

A
  • Dysphagia and retrosternal pain
  • Diagnosis
  • Normal lower oesophageal sphincter relaxation
  • Premature contractions in >20% of swallows.
  • Impaired inhibitory innervation
  • DL <4.5s
40
Q

what is management of distal oesophageal spasm?

A

Nitrates

Calcium channel blockers

41
Q

what is jackhammer oesophagus?

A

= really severe pain due to abnormal contractions of oesophageal muscles

Symptoms = Dysphagia and retrosternal pain

42
Q

what are types of oesophageal dysmotility?

A
  • achalasia
  • distal oesophageal spasm
  • jackhammer oesophagus
  • absent peristalsis
43
Q

what is management of jackhammer oesophagus?

A
  • Botulinum toxin injection (botox - can temporarily paralyze the muscles - temporary so need to be done multiple times)
  • POEM (Peroral Endoscopic Myotomy = minimally invasive endoscopic procedure)
44
Q

what is absent peristalsis?

A

absence or significant impairment of the normal rhythmic, coordinated contractions of the esophageal muscles

45
Q

what are symptoms of absent peristalsis?

A

Dysphagia and Reflux

46
Q

what helps diagnosis of absent peristalsis?

A
  • No contractions
  • Normal LOS relaxation
47
Q

what is management of absent peristalsis?

A
  • Treat reflux
  • Acid suppression
  • Dietary and lifestyle modifications
48
Q

what type should you wean treatments for in GORD?

A

Wean treatments to lowest effective dose of medication

49
Q

what is the gold standard test for dysmotility?

A

High resolution manometry

GI (56 decks)

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