Exam 1 - GERD Flashcards
What are four significant complications of GERD?
- Barrett’s esophagus
- Erosive esophagitis
- Strictures
- Esophageal cancer
What is the general pathphysiology of GERD?
Lower esophageal sphincter (LES) transiently relaxes, allowing back flow of stomach contents causing troublesome symptoms or complications
What is the hallmark symptom of GERD?
Heartburn (pyrosis) typically post-prandial
What are some extraesophageal manifestations of GERD?
- Bronchospasm/Wheezing
- Laryngitis/Hoarseness
- Chronic cough
- Loss of dental enamel
Other than heartburn, what are some other symptoms of GERD?
- Chest pain which may mimic angina (squeezing, substernal, radiates)
- Dysphagia
- Water brash or hypersalivation
- Globus sensation (lump in throat)
- Odynophagia
- Nausea
If a patient presents with dysphagia, what should you rule out in addition to GERD?
Stricture
What etiologies can worsen GERD?
- Obesity
- Gravity
- Pregnancy
- Foods
- Medication
What medications can increased GERD symptoms by decreasing LES pressure?
- Anticholinergics (Ditropan)
- Tricyclic Antidepressants (Amitriptyline)
- CCB
- Nitrates
- Narcotics
What medications can increased GERD symptoms by injuring the esophageal mucosa?
- Bisphosphonates (Fosamax, Actonel)
- Iron supplements
- NSAIDs/Aspirin
- Potassium
- Tetracycline
What is a hiatal hernia?
What are the two types and which is more common?
Portion of the stomach enters above the diaphragm into the chest.
- Sliding hernia (more common)
- Paraesophageal hernia
What are symptoms associated with a hiatal hernia?
Most are asymptomatic and an incidental findings, but they can cause symptoms of GERD
What x-ray finding is consistent with a hiatal hernia?
Retrocardiac mass with or without an air-fluid level
What diagnostic study is best to evaluate for esophageal mucosal injury?
EGD
If you wanted to observe the transit of a food bolus, what diagnostic test would you order?
Esophageal impedance testing
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?
Esophageal pH monitoring
If you wanted to measure the function of the LES and peristalsis, what diagnostic test would you order?
Esophageal manometry
Is a barium contrast esophagram typically used for diagnosis GERD? Why or why not?
Not typically used for diagnosis of GERD as it does not reliably identify mucosal injury.
What are some alarm features/red flags that require further workup and are not typical of GERD?
- 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
How is GERD diagnosed?
Clinical diagnosis with classic hx of GERD and no warning signs
Define mild/intermittent symptoms of GERD.
What is the recommended treatment?
Less than 1-2 episodes per week and no evidence of erosive esophagitis.
Step-up therapy: Lifestyle modification, H2 blockers (Ranitidine/Zantact), +/- Antiacids (TUMS)
Define severe symptoms of GERD.
What is the recommended treatment?
2 or more episodes per week with symptoms impairing quality of life.
Step down therapy: PPI + Lifestyle modifications then gradually decrease therapy
How do antacids work?
What are some examples?
Neutralize gastric pH
Ex: TUMS
How do H2 Blockers work?
What are some examples?
Block action of histamine at H2 receptors of gastric parietal cells, leading to decreased secretion of stomach acid
Ex: Ranitidine (Zantac), Famotidine (Pepcid)
How do PPIs work?
What are some examples?
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)
What are some concerns that are related to long-term PPI use?
- Risk of infection: acidic environment is protective and decreasing it can increase risk of infections
- Malabsorption: Mg, B12, calcium, iron
If patient is taking a PPI, what lab should you be checking periodically?
Magnesium levels as PPIs can inhibit magnesium absorption
What are some indications for surgical management of GERD?
What is the commonly preferred procedure?
- Failed optimal medical management
- GERD complications (esophagitis, Barrett’s)
- Noncompliance
Nissen Fundoplication most commonly preferred
What is the most common cause of esophagitis?
GERD
What is the most common type of esophagitis?
Reflux esophagitis
What are the different types of esophagitis?
- Reflux esophagitis
- Infectious esophagitis
- Medication induced esophagitis
- Eosinophilic esophagitis
- Radiation esophagitis
What is Barrett’s Esophagus due to?
What is a possible complication?
Due to recurrent acid injury
Predisposes patient to adenocarcinoma of the esophagus
What is the treatment for Barrett’s Esophagus?
- Indefinite use of PPI (QD dosing usually sufficient)
- EGD surveillance to detect evidence of dysplasia
- Endoscopic Eradication Therapy
What is the typical progression of Barrett’s Esophagus to Adenocarcinoma?
GERD –> Barrett’s Esophagus –> Low Grade Dysplasia –> High Grade Dysplasia –> Adenocarcinoma
What are the two main types of esophageal cancer?
- Adenocarcinoma
- Squamous Cell Carcinoma
What are some risk factors for Adenocarcinoma of the esophagus?
Barrett’s, smoking, obesity
Which type of esophageal cancer has a higher incidence in Caucasians than African Americans?
Adenocarcinoma
What diagnostic study is recommended in all patients with dysphagia?
Endoscopy
What is the typical treatment for esophageal cancer?
Palliative treatment is goal:
- Chemotherapy
- Radiation
- Surgery
How is eosinophilic esophagitis diagnosed?
Clinical history + EGD (stacked circular rings, stricture, histology)
What is the treatment for eosinophilic esophagitis?
- Diet
- Acid suppression (PPI)
- Topical Corticosteroids
- (+/-) esophageal dilation
In what patients should you consider esophageal motility disorders?
Consider in patients with dysphagia, noncardiac chest pain and refractory GERD symptoms
What are some major motility disorders of esophageal peristalsis?
- Hypercontractile (Jackhammer) Esophagus
- Distal Esophageal Spasm (DES)
- Achalasia
How is Hypercontractile (Jackhammer) esophagus and DES diagnosed?
Manometry - shows high pressure contractions in the esophagus with normal relaxation of the esophagogastric junction
What is the treatment for Hypercontractile (Jackhammer) esophagus and DES?
Control GERD and relax hypercontractile smooth muscle:
- PPI
- CCB (Diltiazem) or TCA (Imipramine)
***if NO GERD, can use peppermint oil before each meal
What is aperistalsis?
No esophageal contraction in the distal two-thirds of the esophagus and incomplete LES relaxation
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?
Achalsia
The “Bird’s Beak” appearance on barium swallow is the classic finding in a patient with what disorder?
Achalasia
What is the general pathogenesis of achalasia?
Progressive inflammation and degeneration of esophageal neurons, leading to relaxation failure of the LES and no peristalsis
What are signs/symptoms of achalasia?
- Dysphagia
- Regurgitation
- Difficulty belching
- Chest pain
- Heartburn
What diagnostic test if required for diagnosis of achalasia?
Manometry
What is necessary to obtain in order to rule out malignancy if suspicious of achalasia?
EGD
What is diagnostic of achalasia on barium swallow study?
Bird’s beak
When should you consider achalasia in patients who present with GERD-like symptoms?
In patients who are unresponsive to 4 week PPI trial with dysphagia to solids and liquids and regurgitation
What is the treatment for achalasia?
- Mechanical disruption of LES muscle fibers (Pneumatic dilation, Heller Myotomy)
- Biochemical reduction in LES pressure (Botulinum toxin, Nitrates, CCB)
What diagnostic studies should be ordered if you suspect achalasia?
- Manometry necessary to diagnosis
- EGD necessary to rule out malignancy
- Barium swallow, looking for Bird’s Beak
What is Mallory Weiss Syndrome due to and what are some symptoms associated with it?
Mucosal laceration in distal esophagus and proximal stomach.
Associated with repetitive vomiting and retching.
What are some predisposing factors for Mallory Weiss Syndrome?
- Heavy alcohol use
- Hiatal hernia
How is Mallory Weiss Syndrome diagnosed?
Endoscopy
What is the treatment for Mallory Weiss Syndrome?
- PPI
- Endoscopic bleeding control if does not stop on its own
- Address other predisposing factors if present
