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Clin Med III Unit I > 2 GERD and Esophageal Disorders > Flashcards

2 GERD and Esophageal Disorders Flashcards

1
Q

Prevalence of GERD in the US may be underestimated due to…

A

Frequency of self-treatment

Majority of patients with GERD do not seek medical attention

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2
Q

You do an EGD on a patient with reflux Sxs. What percentage would you expect to find Barret’s Esophagus or Esophagitis?

A

43%

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3
Q

Some degree of reflux is normal (physiologic) as long as…

A

It does not induce Sx or esophageal mucosal abnormalities

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4
Q

What is the pathophysiology of GERD?

A

Lower esophageal sphincter (LES) transiently relaxes, allowing back flow of stomach contents

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5
Q

The Montreal classification defines GERD as a condition that develops when the reflux of stomach contents causes…

A

Troublesome symptoms or complications

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6
Q

What is the hallmark Sx of GERD?

A

Pyrosis (aka heartburn) - typically post prandial

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7
Q

What are some extraesophageal manifestations of GERD?

A

Bronchospasm
Laryngitis/hoarseness
Chronic cough
Loss of dental enamel

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8
Q

Chest pain in GERD patients mimics _________.

A

Angina - squeezing, substernal, radiates to back, neck, jaw or arms

Must R/O cardiac cause

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9
Q

If a GERD patient presents with dysphagia, you must R/O…

A

Stricture

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10
Q

What things can worsen GERD?

A 
Obesity
Gravity
Pregnancy
Tobacco/EtOH
Meds
Foods
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11
Q

What advice about bed positioning should you give to GERD patients?

A

Elevate the head of the bed

Don’t just use a bunch of pillows - put blocks under the headboard for a gradual upward slope

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12
Q

What medications can increase GERD Sx by decreasing LES pressure?

A

Anticholinergics (Ditropan)

TCAs (Amitriptyline)

CCBs

Nitrates

Narcotics

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13
Q

Which meds may increase GERD Sx by injuring mucosa?

A 
BISPHOSPHONATES****
Iron supplements
NSAIDs/Aspirin
Potassium
Tetracycline
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14
Q

What must you document in the patient chart when prescribing bisphosphonates?

A

Patient ed about remaining upright 30-60 min after taking med to prevent mucosal injury —> GERD

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15
Q

Portion of the stomach enters above the diaphragm into the chest

A

Hiatal hernia

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16
Q

What are the two types of hiatal hernia?

A

Sliding hernia (most common)***

Paraesophageal hernia (may require surgical repair)

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17
Q

Hiatal hernias generally present as…

A

Asymptomatic incidental finding

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18
Q

How does a hiatal hernia appear on CXR?

A

Retrocardiac mass with or without an air-fluid level

Without the air-fluid level, dx is difficult to make based on CXR alone

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19
Q

Best diagnostic study to evaluate mucosal injury

A

EGD** (Esophagogastroduodenoscopy)

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20
Q

Test used to observe transit of a bolus of food

A

Esophageal impedance testing

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21
Q

Test to quantify reflux and allow patients to log Sx

A

Esophageal pH monitoring

High sensitivity for detecting reflux

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22
Q

Test for measuring the function of the LES and peristalsis

A

Esophageal nanometers

Measures pressures and pattern of esophageal muscle contractions

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23
Q

_________ is not typically used for the Dx of GERD b/c it does not identify mucosal injury

A

Barium contrast esophagram

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24
Q

What are the two options for esophageal pH monitoring?

A

Trans nasal catheter

Wireless capsule

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25
Red flags for GERD (all require further workup)
``` Dysphagia Hematemesis/GI bleeding Unexplained weight loss, fever, fatigue Anemia **Inadequate response to therapy** Prior anti-reflux surgery Personal Hx of cancer ```
26
How do you diagnose GERD?
Clinical diagnosis in most cases Dx studies and labs usually not needed with classic hx of GERD without warning signs
27
What lifestyle/dietary modifications should you recommend to a patient with GERD?
Adjustment of bed (elevate head) No food or drink within 3 hours of bedtime Weight loss Selective elimination of dietary triggers Eat smaller meals
28
What meds can be used to treat GERD?
Antacids H2 blockers (Ranitidine) Proton pump inhibitors
29
GERD is considered to be mild/intermittent if...
Less than 1-2 episodes/week No evidence of erosive esophagitis
30
GERD is considered severe if...
Frequent (≥2 episodes/week) Symptoms impair quality of life
31
What is the pharmacological approach to mild/intermittent GERD treatment?
Step UP therapy Lifestyle mods, H2RAs, +/- antacids
32
What is the pharmacological approach to severe GERD treatment?
Step DOWN therapy PPI daily x 8 weeks + lifestyle mods Gradually decrease therapy (unless maintenance PPI therapy necessary)
33
What’s the deal with Antacids and GERD?
Do not PREVENT GERD Neutralize gastric pH —> symptomatic relief Short lived benefit
34
How do H2 blockers work against GERD?
Block action of histamine at H2 receptors of gastric parietal cells Leads to decreased secretion of stomach acid
35
Examples of H2 blockers
Ranitidine (Zantac) Famotidine (Pepcid)
36
How do Proton Pump Inhibitors work?
Reduce the amount of acid produced by glands in the stomach
37
Examples of PPIs
Omeprazole (Prilosec) Lansoprazole (Prevacid) Esomeprazole (Nexium) Pantoprazole (Protonix)
38
When should PPIs be taken?
30 min before 1st meal of the day
39
What are the main concerns related to long term PPI use?
Risk of infection Malabsorption
40
Why do PPIs increase risk of infection?
B/c the acidic environment of the stomach is protective Decreasing acid can increase risk of C. diff and other infections
41
What deficiencies can result from long-term PPI use?
MAGNESIUM, Calcium, B12, Iron Check Mg level periodically Consider yearly B12 (controversial) Consider checking bone density
42
How long should GERD patients without severe erosive esophagitis or Barrett’s esophagus stay on acid suppression meds?
Lowest dose and shortest duration appropriate D/c meds completely in patients without Sx
43
How long should GERD patients with severe esophagitis or Barrett’s esophagus stay on acid suppression meds?
Require maintenance acid suppression with a PPI Recurrent Sx and complications likely if meds d/c
44
What are the indications for surgical management of GERD?
Failed optimal medical management GERD complications (Esophagitis, Barret’s esophagus) Noncompliance
45
What is the surgical treatment for GERD?
Nissan Fundoplication Passage of the gastric fundus behind the esophagus to encircle the distal esophagus Laparoscopic and open options exist
46
How do you decide whether to start a patient on an H2 blocker or a PPI?
If full BID dosed H2 blocker was already used, start with PPI If patient hasn’t tried BID H2 blocker, try that first H2 blockers are effective for many patients
47
The most common cause of esophagitis is...
GERD!
48
How does esophagitis develop?
Gastric acid, pepsin, and bile irritate the squamous epithelium Can lead to irritation, inflammation, erosion, or ulceration
49
What are the five different types of esophagitis?
``` Reflux esophagitis (most common***) Infectious esophagitis Pill esophagitis Eosinophilic esophagitis Radiation esophagitis ```
50
What are the possible complications of esophagitis?
Bleeding, stricture, Barrett’s esophagus
51
What IS Barrett’s Esophagus?
Squamous epithelium in distal esophagus replaced with COLUMNAR epithelium due to recurrent acid injury
52
Barrett’s esophagus predisposes patients to...
Adenocarcinoma of the esophagus
53
Barrett’s esophagus is found in ______% of patients undergoing EGD for GERD Sx
10-15% 2-3:1 M>F Average age at Dx is 55
54
What is the progression of Barrett’s esophagus?
GERD —> Barrett’s Esophagus —> Low Grade Dysplasia —> High Grade Dysplasia —> Adenocarcinoma
55
What is the pharmacological treatment for Barrett’s Esophagus?
Indefinite use of PPI - aggressive anti-reflux meds may prevent cancer QD dosing may be sufficient vs. BID EGD Surveillance to detect evidence of dysplasia
56
What are the different options for surgical treatment of Barrett’s esophagus?
Endoscopic Eradication Therapy (EET) or Endoscopic Ablation (EA) - Thermal or photochemical energy to destroy Barrett mucosa Endoscopic Resection - Removal of segment of Barrett mucosa (therapeutic and provides info on depth of involvement)
57
What are the two types of esophageal cancer?
Squamous cell carcinoma Adenocarcinoma
58
Incidence of squamous cell carcinoma is higher in ....
Urban areas of US African American men
59
Risk factors for Squamous Cell Carcinoma
SMOKING***** EtOH***** Diet low in fruits/veggies Nutritional deficiencies (selenium, zinc) Caustic esophageal injury (ie hot coffee) HPV
60
What increases the risk for adenocarcinoma?
Barrett’s****** Smoking Obesity
61
Adenocarcinoma is 4 times more common in ______ than ______
Caucasians > African Americans Also, M>F 6:1
62
What are you thinking if a patient has progressive dysphagia with solid food?
Possible esophageal cancer May progress to dysphagia with soft foods, then liquids Pay attention to weight loss, odynophagia, malnutrition, anorexia
63
________ is recommended in all patients with dysphagia
Endoscopy Can also do a barium contrast esophagram but EGD is a must
64
Regardless of histology, _______ of esophageal cancer patients present with incurable, unresectable, or metastatic disease
50-80% Endoscopy if warning signs allows for earlier detection Palliative treatment is the goal for the majority of patients
65
What would you think the cause of esophagitis would be in a patient with DM and asthma (using ICS) who was recently on 2 rounds of Abx for PNA?
Infectious esophagitis (possibly candida overgrowth)
66
How would infectious esophagitis due to TB present?
+PPD Night sweats Cough
67
Patient has trouble swallowing pills and occasionally his ibuprofen gets stuck
Pill esophagitis
68
A patient has collagen vascular disease (systemic sclerosis). How might esophagitis occur?
Poor acid clearing —> epithelial damage
69
If a patient with hx of asthma, rhinitis, food allergies, and chronic eczema develops GERD sx...
Consider Eosinophilic esophagitis
70
“Worms, wheezes, weird diseases”
Eosinophilic
71
Chronic immune/antigen-mediated esophageal disease
Eosinophilic esophagitis Eosinophil-predominant inflammation —> dysphagia, food impaction, CP, refractory heartburn, upper abdominal pain
72
How is eosinophilic esophagitis diagnosed?
Clinical Hx + EGD (***stacked circular rings, stricture***)
73
How do you treat eosinophilic esophagitis?
Diet (avoid allergens) Acid suppression (PPI) ICS but SPRAY AND SWALLOW (don’t inhale) +/- esophageal dilation
74
Esophageal motility disorders should be considered in patients with...
Dysphagia, noncardiac CP, and refractory GERD Sx Must perform EGD first to exclude structural abnormality
75
What are the two major disorders of esophageal peristalsis?
Hypercontractile (Jackhammer) esophagus Achalasia
76
If instead of heartburn, a patient has dysphagia with solids AND liquids and CP, consider...
Achalasia
77
What diagnostic studies should be performed on patients with suspected esophageal motility disorders?
Manometry Barium Swallow Possibly esophageal pH and impedance monitoring
78
Manometry shows high pressure contractions in esophagus, normal relaxation of the esophagogastric junction Pain mimics angina, but typically occurs with meals
Hypercontractile (Jackhammer) Esophagus
79
Treatment for jackhammer esophagus
CCB (Diltiazem) or TCA (Imipramine) +/- botulinum toxin injection
80
Manometry shows aperistalsis in the distal two-thirds of the esophagus and incomplete LES relaxation
Achalasia
81
How will achalasia show on barium esophagram?
Esophageal dilation ***BIRDS BEAK*** (caused by persistently contracted LES) Aperistalsis Poor emptying of barium
82
What causes achalasia?
Progressive degeneration of esophageal neurons leading to failure of relaxation of LES and no peristalsis
83
SSx of achalasia
``` Dysphagia Regurgitation Difficulty belching CP Heartburn ``` Gradual onset
84
_____ is required for dx of achalasia
Manometry, showing defect in LES relaxation and aperistalsis in distal 2/3 of esophagus) EGD NECESSARY TOO to r/o malignancy
85
Consider achalasia in patient who is ...
Unresponsive to PPI trial (4 weeks) with dysphagia to solids and liquids and regurgitation
86
How do you treat achalasia?
Disruption of LES muscle fibers • Pneumatic dilation • Heller myotomy Biochemical reduction in LES pressure • Botulinum toxin • Nitrates • CCBs
87
Mucosal laceration in distal esophagus and proximal stomach
Mallory Weiss tear
88
Mallory Weiss tears are usually associated with...
Repetitive vomiting, retching Predisposing factors: • Excessive EtOH consumption • Hiatal hernia (increased abdominal pressure)
89
How is a Mallory Weiss tear diagnosed?
Endoscopy or clinical exam if issue has already resolved
90
How do you treat a Mallory Weiss tear?
Stabilize patient Control bleeding if doesn’t stop on its own Treat with PPI Address predisposing factors if present

Clin Med III Unit I (6 decks)

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