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Clinical Med III > Exam 1 - GERD > Flashcards

Exam 1 - GERD Flashcards

1
Q

What are four significant complications of GERD?

A
  • Barrett’s esophagus
  • Erosive esophagitis
  • Strictures
  • Esophageal cancer
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2
Q

What is the general pathphysiology of GERD?

A

Lower esophageal sphincter (LES) transiently relaxes, allowing back flow of stomach contents causing troublesome symptoms or complications

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3
Q

What is the hallmark symptom of GERD?

A

Heartburn (pyrosis) typically post-prandial

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4
Q

What are some extraesophageal manifestations of GERD?

A
  • Bronchospasm/Wheezing
  • Laryngitis/Hoarseness
  • Chronic cough
  • Loss of dental enamel
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5
Q

Other than heartburn, what are some other symptoms of GERD?

A
  • Chest pain which may mimic angina (squeezing, substernal, radiates)
  • Dysphagia
  • Water brash or hypersalivation
  • Globus sensation (lump in throat)
  • Odynophagia
  • Nausea
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6
Q

If a patient presents with dysphagia, what should you rule out in addition to GERD?

A

Stricture

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7
Q

What etiologies can worsen GERD?

A
  • Obesity
  • Gravity
  • Pregnancy
  • Foods
  • Medication
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8
Q

What medications can increased GERD symptoms by decreasing LES pressure?

A
  • Anticholinergics (Ditropan)
  • Tricyclic Antidepressants (Amitriptyline)
  • CCB
  • Nitrates
  • Narcotics
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9
Q

What medications can increased GERD symptoms by injuring the esophageal mucosa?

A
  • Bisphosphonates (Fosamax, Actonel)
  • Iron supplements
  • NSAIDs/Aspirin
  • Potassium
  • Tetracycline
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10
Q

What is a hiatal hernia?

What are the two types and which is more common?

A

Portion of the stomach enters above the diaphragm into the chest.

  • Sliding hernia (more common)
  • Paraesophageal hernia
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11
Q

What are symptoms associated with a hiatal hernia?

A

Most are asymptomatic and an incidental findings, but they can cause symptoms of GERD

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12
Q

What x-ray finding is consistent with a hiatal hernia?

A

Retrocardiac mass with or without an air-fluid level

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13
Q

What diagnostic study is best to evaluate for esophageal mucosal injury?

A

EGD

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14
Q

If you wanted to observe the transit of a food bolus, what diagnostic test would you order?

A

Esophageal impedance testing

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15
Q

If you wanted a test with high sensitivity for detecting and quantifying reflux, and allowed patients to log symptoms, what diagnostic test would you order?

A

Esophageal pH monitoring

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16
Q

If you wanted to measure the function of the LES and peristalsis, what diagnostic test would you order?

A

Esophageal manometry

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17
Q

Is a barium contrast esophagram typically used for diagnosis GERD? Why or why not?

A

Not typically used for diagnosis of GERD as it does not reliably identify mucosal injury.

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18
Q

What are some alarm features/red flags that require further workup and are not typical of GERD?

A
  • Dysphagia
  • Odynophagia
  • Evidence of GI bleeding
  • Unexplained weight loss
  • Anemia
  • Inadequate response to therapy
  • New onset dyspepsia in pt 60 or older
  • Prior anti-reflux surgery
  • Personal hx of cancer
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19
Q

How is GERD diagnosed?

A

Clinical diagnosis with classic hx of GERD and no warning signs

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20
Q

Define mild/intermittent symptoms of GERD.

What is the recommended treatment?

A

Less than 1-2 episodes per week and no evidence of erosive esophagitis.

Step-up therapy: Lifestyle modification, H2 blockers (Ranitidine/Zantact), +/- Antiacids (TUMS)

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21
Q

Define severe symptoms of GERD.

What is the recommended treatment?

A

2 or more episodes per week with symptoms impairing quality of life.

Step down therapy: PPI + Lifestyle modifications then gradually decrease therapy

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22
Q

How do antacids work?

What are some examples?

A

Neutralize gastric pH

Ex: TUMS

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23
Q

How do H2 Blockers work?

What are some examples?

A

Block action of histamine at H2 receptors of gastric parietal cells, leading to decreased secretion of stomach acid

Ex: Ranitidine (Zantac), Famotidine (Pepcid)

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24
Q

How do PPIs work?

What are some examples?

A

Reduce the amount of acid produced by glands in the stomach; taken 30 minutes before 1st meal of the day

Ex: Omeprazole (Prilosec), Lansoprazole (Prevacid), Esomeprazole (Nexium), Pantoprazole (Protonix)

25
Q

What are some concerns that are related to long-term PPI use?

A
  • Risk of infection: acidic environment is protective and decreasing it can increase risk of infections
  • Malabsorption: Mg, B12, calcium, iron
26
Q

If patient is taking a PPI, what lab should you be checking periodically?

A

Magnesium levels as PPIs can inhibit magnesium absorption

27
Q

What are some indications for surgical management of GERD?

What is the commonly preferred procedure?

A
  • Failed optimal medical management
  • GERD complications (esophagitis, Barrett’s)
  • Noncompliance

Nissen Fundoplication most commonly preferred

28
Q

What is the most common cause of esophagitis?

A

GERD

29
Q

What is the most common type of esophagitis?

A

Reflux esophagitis

30
Q

What are the different types of esophagitis?

A
  • Reflux esophagitis
  • Infectious esophagitis
  • Medication induced esophagitis
  • Eosinophilic esophagitis
  • Radiation esophagitis
31
Q

What is Barrett’s Esophagus due to?

What is a possible complication?

A

Due to recurrent acid injury

Predisposes patient to adenocarcinoma of the esophagus

32
Q

What is the treatment for Barrett’s Esophagus?

A
  • Indefinite use of PPI (QD dosing usually sufficient)
  • EGD surveillance to detect evidence of dysplasia
  • Endoscopic Eradication Therapy
33
Q

What is the typical progression of Barrett’s Esophagus to Adenocarcinoma?

A

GERD –> Barrett’s Esophagus –> Low Grade Dysplasia –> High Grade Dysplasia –> Adenocarcinoma

34
Q

What are the two main types of esophageal cancer?

A
  • Adenocarcinoma

- Squamous Cell Carcinoma

35
Q

What are some risk factors for Adenocarcinoma of the esophagus?

A

Barrett’s, smoking, obesity

36
Q

Which type of esophageal cancer has a higher incidence in Caucasians than African Americans?

A

Adenocarcinoma

37
Q

What diagnostic study is recommended in all patients with dysphagia?

A

Endoscopy

38
Q

What is the typical treatment for esophageal cancer?

A

Palliative treatment is goal:

  • Chemotherapy
  • Radiation
  • Surgery
39
Q

How is eosinophilic esophagitis diagnosed?

A

Clinical history + EGD (stacked circular rings, stricture, histology)

40
Q

What is the treatment for eosinophilic esophagitis?

A
  • Diet
  • Acid suppression (PPI)
  • Topical Corticosteroids
  • (+/-) esophageal dilation
41
Q

In what patients should you consider esophageal motility disorders?

A

Consider in patients with dysphagia, noncardiac chest pain and refractory GERD symptoms

42
Q

What are some major motility disorders of esophageal peristalsis?

A
  • Hypercontractile (Jackhammer) Esophagus
  • Distal Esophageal Spasm (DES)
  • Achalasia
43
Q

How is Hypercontractile (Jackhammer) esophagus and DES diagnosed?

A

Manometry - shows high pressure contractions in the esophagus with normal relaxation of the esophagogastric junction

44
Q

What is the treatment for Hypercontractile (Jackhammer) esophagus and DES?

A

Control GERD and relax hypercontractile smooth muscle:

  • PPI
  • CCB (Diltiazem) or TCA (Imipramine)

***if NO GERD, can use peppermint oil before each meal

45
Q

What is aperistalsis?

A

No esophageal contraction in the distal two-thirds of the esophagus and incomplete LES relaxation

46
Q

On barium esophagram, the following are noted:

  • Esophgeal dilation
  • Birds Beak caused by persistently contracted LES
  • Aperistalsis
  • Poor emptying of barium

What is the likely diagnosis?

A

Achalsia

47
Q

The “Bird’s Beak” appearance on barium swallow is the classic finding in a patient with what disorder?

A

Achalasia

48
Q

What is the general pathogenesis of achalasia?

A

Progressive inflammation and degeneration of esophageal neurons, leading to relaxation failure of the LES and no peristalsis

49
Q

What are signs/symptoms of achalasia?

A
  • Dysphagia
  • Regurgitation
  • Difficulty belching
  • Chest pain
  • Heartburn
50
Q

What diagnostic test if required for diagnosis of achalasia?

A

Manometry

51
Q

What is necessary to obtain in order to rule out malignancy if suspicious of achalasia?

A

EGD

52
Q

What is diagnostic of achalasia on barium swallow study?

A

Bird’s beak

53
Q

When should you consider achalasia in patients who present with GERD-like symptoms?

A

In patients who are unresponsive to 4 week PPI trial with dysphagia to solids and liquids and regurgitation

54
Q

What is the treatment for achalasia?

A
  • Mechanical disruption of LES muscle fibers (Pneumatic dilation, Heller Myotomy)
  • Biochemical reduction in LES pressure (Botulinum toxin, Nitrates, CCB)
55
Q

What diagnostic studies should be ordered if you suspect achalasia?

A
  • Manometry necessary to diagnosis
  • EGD necessary to rule out malignancy
  • Barium swallow, looking for Bird’s Beak
56
Q

What is Mallory Weiss Syndrome due to and what are some symptoms associated with it?

A

Mucosal laceration in distal esophagus and proximal stomach.

Associated with repetitive vomiting and retching.

57
Q

What are some predisposing factors for Mallory Weiss Syndrome?

A
  • Heavy alcohol use

- Hiatal hernia

58
Q

How is Mallory Weiss Syndrome diagnosed?

A

Endoscopy

59
Q

What is the treatment for Mallory Weiss Syndrome?

A
  • PPI
  • Endoscopic bleeding control if does not stop on its own
  • Address other predisposing factors if present

Clinical Med III (12 decks)

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