Clinical GERD Flashcards
Definition of GERD
Symptoms or complications resulting from reflux of gastric contents into the esophagus and possibly into the oral cavity or lungs
What cells release histamine in the gastric tract?
Enterochromaffin cells
Difference between GER and GERD
GER = normal gastric esophageal reflex
- occurs primarily in the day
- allows for burping
- asymptomatic
- no tissue damage
GERD = gastric esophageal reflex disorder
- occurs primarily at night
- is symptomatic
- causes tissue damage and metaplasia overtime
What is the percentage of Americans that have GERD?
20%
- majority of patients DONT seek medical attention thou
3 main contributing factors to GERD
1) backflow of stomach contents
- majority factor
2) flow into stomach impaired
- esophageal strictures or achalasia
3) flow out of the stomach impeded
- Delayed emptying (diabetes, meds, nerve damage)
- gastric or duodenal adenocarcinoma
What is the primary etiology behind GERD?
Incompetent gastro-esophageal junction function
- it is NOT excessive acid production (this is secondary)*
What are the most common risk factors for GERD
Obesity/weight gain
- causes increased intraabdominal pressure
Foods (caffeine,alcohol, peppermint, tobacco, chocolate)
- all work to decreases LES tone secondarily
Eating large meals, eating fatty meals, eating within 2-3 hrs before bedtime (gravity aids reflex)
Being pregnant
- increases intrabdominal pressure and more progesterone is released
Wearing tight fitting clothes
- increases intrabdominal pressure
Hiatal hernia presence
Medications: TCA’s/CCBs/Antihistmines
What are the physiological changes with a hiatal hernia?
1) LES pressure lowers
2) Gastric pouch forms
3) diaphragm doesn’t pinch the esophageal area
Symptoms of hiatal hernia
Heart burn (pyrosis)
Chest pain
Dyspnea
Wheezing
Feels like food or acid is in back of throat
“Water brash”(hypersalivation due to acid backwash)
Globus sensation = “feels like food is stuck in back of throat”
should not see odynophagia or dysphagia
What meds commonly cause delayed gastric emptying?
CCBs
TCAs
Nitrates
progesterone
Red flag symptoms for GERD
Unexplained wt loss
Dysphagia
Odynophagia
Non-cardiac chest pain
Anemia
GIU bleeding
Greater than age 50
if any present, need endoscopy to rule out strictures, ulcers of esophagus, Barrett’s esophagus and malignancy
What are atypical symptoms of GERD
Cough
Hoarseness
Wheezing
Dyspepsia
Bloating
Epigastric pain
need labs to rule out infections, CXRs to rule out masses
Treatment = lifestyle changes and refer to GI/ENT physician
Treatment of normal GERD symptoms
Always start with lifestyle treatment and either PPIs or H2 blockers for 6-8 weeks
If it doesnt work, increase PPI dose to BID instead of daily
What is erosive esophagitis? (ERD)
Seen in the minority of patients with GERD.
- only 30% and will show erosive tissue and bleeding possibly
- *majority (70%) will show Non-erosive reflex disease (NERD)**
- NERD has poor response to PPIs and often needs other intervention
What are lifestyle changes for GERD
Decrease fatty foods
Eat smaller meals
Prevent eating within 2-3 hrs before bed
Limit caffeine/acid foods/alcohol/tobacco/chocolate
Weight loss
Limit heavy lifting before 2-3 hrs of eating
Use a bed wedge
Long term use of PPIs risks
**Increased CKD risk (28x) increase
Increased susceptibility to C. Diff/salmonella and jejuini
Increased risk of pneumonia
Increased risk of bone fractures and osteoporosis
- causes hypochlohydria
Shows rebound gastric hyperacidity after stopping abruptly
Increased risk of malabsorption
What is the majorly risk of using H2 blockers long term?
Tachyphylaxis (decreases efficacy dramatically)
- usually 4-6 weeks after daily use
NOT good long-term option
Surgical options for GERD
1) open laparoscopic Nissan
- frees up to top part of the fundus, and wraps it around the esophagus to make it a pseudo-sphincter
- GOLD STANDARD
2) LINX
- implements esophageal ring
3) TIF (transoral incisionless fundoplication)
- high risk of reoccurrence (failure)
4) Bariatric surgery (bypass)
- really only used in morbidly obese patients
What is laryngopharynx reflux (LPR)?
Is nicknamed “silent reflux”
Is a condition where the stomach acid flow up to the laryngopharynx (above the esophagus)
- usually in the gaseous form
- pepsin is believed to be more involved than in GERD (pepsin might actually live in the oropharynx on cells for a couple days and reactivate)
Symptoms:
- chronic hoarness (most common)
- wheezing
- chronic non-productive coughing
- globus sensation
- dysphagia
- chronic “clearing of throat”
Msot LPR patinets are NOT obese
- most however are ASTHMATICS
can coexist with GERD as well
Difference between esophagus and oropharynx ability to resist reflux
Esophagus = can handle roughly 50 episodes without tissue damage
Oropharynx = develops after only 3 episodes
What is the gold standard test for LPR
PEPTEST
- tests for pepsin levels in oropharynx
- uses salivary
Treatment of LPR
lifestyle changes
Elevate sleeping position
Consider H2 blockers or PPIs if <8weeks
