Gastro-oesophageal reflux disease Flashcards
What is Gastro-oesophageal reflux disease (GORD)?
1 - stomach contents moving into oesophagus
2 - oesophagus contents moving into stomach
3 - stricture in oesophagus
4 - fistula in oesophagus
1 - stomach contents moving into oesophagus
- specifically acid which can damage the squamous cells of the oesophagus
- lower oesophageal sphincter becomes weak
- when it keeps happening this moves from reflux and becomes GORD and patients are symptomatic
What is the key distinguishing feature between Gastro‑oesophageal reflux (GOR) and Gastro‑oesophageal reflux disease (GORD)?
1 - duration of symptoms
2 - if patients have reflux with symptoms or complications
3 - epithelial cells have become dysplastic
4 - patient smokes and has reflux
2 - if patients have reflux with symptoms or complications
Symptoms include: discomfort or pain severe enough to merit medical treatment,
GOR‑associated complications: oesophagitis or pulmonary aspiration).
In Gastro‑oesophageal reflux, do patients always present with symptoms?
- No
Patients can be asymptomatic
Gastro-oesophageal reflux is when patient present with reflux, but they are not symptomatic or do not require medical intervention. How common is this in paediatrics?
1 - 2%
2 - 20%
3 - 40%
4 - 80%
3 - 40%
Typically begin <8 weeks old and can occur >5/day, BUT reduces with time and most childreb by 1 years old are fine
Gastro-oesophageal reflux is when patient present with reflux, but they are not symptomatic or do not require medical intervention. If a child presents with simple reflux, what intervention do they need?
1 - PPIs
2 - gaviscon
3 - no treatment needed
4 - trial different feeds
3 - no treatment needed
Need to reassure parents though, and the child needs to be gaining weight well
Gastro-oesophageal reflux disease is when the stomach contents moving back into oesophagus chronically. How common is this in the western world in adults (those presenting with symptoms)?
1 - 2-3%
2 - 20-30%
3 - 40-50%
4 - >79%
2 - 20-30%
- likely to be higher but not everyone is symptomatic
How long is the oesophagus generally?
1 - 2-5cm
2 - 12-15cm
3 - 25-27cm
4 - 35-40cm
3 - 25-27cm
The oesophagus is generally 25-27cm long and can be divided into 3 main parts. Which of the following is NOT one of these parts?
1 - cervical
2 - thoracic
3 - aortic
4 - abdominal
4 - abdominal
The whole digestive tract has multiple layers. Looking at layers of the small intestines, which layer does the oesophagus NOT have?
1 - mucosa
2 - submucosa
3 - muscularis propria (inner circular and outer longitudinal layer)
4 - serosa
5 - adventitia
4 - serosa
- surrounded by adventitia allows binding to surrounding tissues
Which of the following is NOT a common cause GORD?
1 - lower oesphageal sphincter failure, repeat relaxation or inability to close fully
2 - NSAIDs
3 - diaphragmatic sphincter failure (hiatus hernia)
4 - increased intrabdominal pressure
2 - NSAIDs
Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically. What are the 2 most common risk factors for GORD?
1 - smoking
2 - Helicobacter pylori
3 - NSAIDs
4 - alcohol
5 - BMI
6 - hiatus hernia/repair on diaphragm
7 - prematurity
8 - neurodisability (cystic fibrosis)
2 - Helicobacter pylori
3 - NSAIDs
Children, especially premature infants are at an increased risk of GORD. What is the main reason for this?
1 - lying down so much
2 - more acid in stomach than in adults that can damaged lower oesophageal sphincter
3 - lower oesophageal sphincter is immature and does not function as well as in adults
4 - no peristalsis in lower oesophageal
3 - lower oesophageal sphincter is immature and does not function as well as in adults
Lying down can also also contribute
How does Helicobacter pylori cause Gastro-oesophageal reflux disease (GORD) and ulcers?
1 - secretes urease
2 - secretes protease
3 - secretes excessive pepsin
4 - secretes large volumes of CCK
1 - secretes urease
- urease converts urea into CO2 and ammonia
- ammonia neutralises parts of the stomach
Helicobacter pylori cause Gastro-oesophageal reflux disease (GORD) and ulcers by secreting urease which converts urea into CO2 and ammonia neutralising parts of the stomach so it can survive. Where does H.pylori generally affect?
1 - fundus
2 - cardia
3 - antrum
4 - pyloris
3 - antrum
- lowest pH here so easier to survive
In normal digestion, there is always a degree of acid reflux in most people, but what defence mechanism do we have that stops gastric acid moving up the oesophagus?
1 - oesophagus secretes HCO3-
2 - pyloric sphincter contracts
3 - diaphragm contracts
4 - secondary oesophageal peristalsis
4 - secondary oesophageal peristalsis
- moves gastric secretions back into stomach
- saliva secretions also help neutralise the acid pH
Lower oesophageal sphincter also contracts
If gastric acid reflux becomes chronic, all of the following occur EXCEPT which one?
1 - metaplasia occurs (squamous to columnar)
2 - chronic inflammation causes oesophagitis
3 - fibrous scar tissue is deposited causing stricture of the oesophagus
4 - lower oesophageal sphincter ruptures
4 - lower oesophageal sphincter ruptures
- pathophysiology can lead to Schatski ring (narrow at the entry between the oesophagus and stomach)
Which of the following is NOT a symptom of Gastro-oesophageal reflux disease (GORD)?
1 - pyrosis (heartburn) causing discomfort
2 - dysphagia
3 - peptic ulcer
4 - pleural aspiration
5 - regurgitation
3 - peptic ulcer
To be diagnosed as GORD the symptoms must be sufficiently severe enough to warrant medical attention
Are the symptoms of Gastro-oesophageal reflux disease (GORD) worse when standing or lying down?
- lying down
Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically. We may see a number of things, which of the following is least common structural change as a sign of GORD?
1 - polpys
2 - oeosphagitis
3 - oesphageal stricture
4 - barrett’s oesophagus
1 - polpys
Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically. When looking for a cause of, which of the following is most likely that we will be able to visualise?
1 - hiatus hernia
2 - polyps
3 - malignancy
4 - stricture
1 - hiatus hernia
- need to exclude malignancy though
What cell type lines the surface of the oesophagus?
1 - columnar epithelial cells
2 - transitional epithelial cells
3 - cuboidal epithelial cells
4 - squamous epithelial cells
4 - squamous epithelial cells
Gastro-oesophageal reflux disease (GORD) is when the stomach contents moving back into oesophagus chronically and can cause Barrett’s oesophagus. What can we see at a cellular level in Barrett’s oesophagus?
1 - metaplasia
2 - dysplasia
3 - hypertrophy
4 - hyperplasia
1 - metaplasia (one cell type replaced by another)
- originally stratified squamous cells replaced by a single layer of columnar cells
What is imaging modality can be used to diagnose and treat patients patients with gastro-oesophageal reflux disease (GORD)?
1 - barium swallow test
2 - pH and manometry test
3 - oesophagogastroduodenoscopy
4 - chest X-ray
3 - oesophagogastroduodenoscopy
- also known as an upper endoscopy
Biopsy may also be taken to diagnose oesophagitis and rule out other diagnoses
What is a barium swallow test?
1 - contrast used as part of a CT scan
2 - contrast swallowed by patient
3 - contrast inject using an NG tube
2 - contrast swallowed by patient
- able to diagnose hiatus hernia and dysmotility
- not commonly performed anymore
Which diagnostic technique is able to detect pH and the level of reflux that can be seen in gastro-oesophageal reflux disease (GORD)?
1 - barium swallow test
2 - CT contrast
3 - pH and manometry testing
4 - oesophagogastroduodenoscopy
3 - pH and manometry testing
- patient must have proven reflux with symptoms
- can also assess oesophageal function
In paediatrics this will typically be for 24h to quantify the degree of reflux
In a child with gastro-oesophageal reflux, which of the following is NOT typically part of their management?
1 - Parental reassurance,
2 - Feeding assessment
3 - Smaller, more frequent feeds or
4 - Thickening agents to feeds (e.g.Gaviscon). A 1–2-week trial of alginate therapy, which forms a protective gel above stomach contents,
5 - small dose of PPIs
5 - small dose of PPIs
In a child with gastro-oesophageal reflux, which of the following is NOT typically something that would make the doctors worry?
1 - Faltering growth from recurrent vomiting
2 - Reflux oesophagitis: haematemesis, discomfort on feeding or heartburn, iron-deficiency anaemia
3 - Recurrent aspiration- pneumonia, cough, wheeze, apnoea(Preterms)
4 - Frequent otitis media (e.g >3 episodes in 6 months)
5 - Conjunctivitis due to reflux
6 - Dental erosion
7 - Sandifer’s syndrome. Back arching
5 - Conjunctivitis due to reflux
This does not happen in gastro-oesophageal reflux
In a child with gastro-oesophageal reflux disease (GORD), i.e. someone who has symptoms and requires medical management, would they typically be given thicker or thinner fluids to consume?
- thicker fluids
In a child with gastro-oesophageal reflux disease (GORD), i.e. someone who has symptoms and requires medical management, can they be given PPIs?
- yes
Typically a H2 receptor antagonist such as omeprazole
A fundoplication is an operation used to treat gastro-oesophageal reflux disease (GORD). Is this commonly used in children with GORD?
- Can be used, but is not common
Normally used in children with neurological conditions
In a child with gastro-oesophageal reflux disease (GORD), i.e. someone who has symptoms and requires medical management, and they do not respond to common interventions, which of the following should be suspected?
1 - hirschsprung disease
2 - peptic ulcer
3 - non IgE mediated cow’s milk protein allergy
4 - coeliac disease
3 - non IgE mediated cow’s milk protein allergy
Especially in atopic patients
In patients with gastro-oesophageal reflux disease (GORD), they may be treated conservatively and asked to modify their lifestyle first. Which of the following is NOT a lifestyle modification?
1 - weight loss
2 - smoking cessation
3 - alcohol cessation
4 - reduce fatty foods
4 - reduce fatty foods
- weight loss, but not specific to fatty foods
In patients with gastro-oesophageal reflux disease (GORD), they may be treated conservatively. The first approach is lifestyle advice (smoking and alcohol cessation, weight loss). If this fails they may be prescribed what?
1 - analgesics
2 - proton pump inhibitors
3 - anticholinergics
4 - anti-histamine
2 - proton pump inhibitors
- Omeprazole or Lansoprazole
- also important to ensure H.pylori eradication
If conservative management fails, surgery may be required. What surgery is most commonly performed?
1 - oesophagectomy
2 - total oesophagectomy
3 - fundoplication
4 - stenting
3 - fundoplication
- fundus of the stomach is partially or fully wrapped around the oesophagus
Dysphagia is the medical term for difficulty swallowing. Dysphagia can occur at any stage of swallowing, which can be subdivided into 3 phases. Which of the following is not a phase of swallowing?
1 - oral
2 - pharyngeal
3 - larynx
4 - oeosphageal
3 - larynx
Dysphagia is the medical term for difficulty swallowing. What is the most common cause of dysphagia?
1 - following cerebrovascular incident (stroke)
2 - peptic ulcer
3 - carcinoma of oeosphagus
4 -lymphadenopathy
1 - following cerebrovascular incident (stroke)
A peptic ulcer is a common cause oeophagogastric dysphagia. How do peptic ulcers cause dysphagia?
1 - increased HCL can aspirate up oesophagus
2 - stricture formation
3 - atrophy of muscles
2 - stricture formation
- common in hiatus hernias
Oropharyngeal candidiasis is an infection of the throat. What idiopathic cause is this common in?
1 - incorrect antibiotic use
2 - dental treatments
3 - following surgery
4 - exposure on a ward
3 - following surgery
Myasthenia gravis occurs when the immune system makes antibodies that destroy the ACh receptor (AChR), a docking site for the nerve chemical acetylcholine (ACh). What can this cause in the oeosphagus?
1 - dysphagia
2 - hyper-peristalsis
3 - hypo-peristalsis
4 - adenocarcinoma
1 - dysphagia
Patients with spastic disorders can have dysphagia of the oesophagus. One of these is called nutcracker/ jackhammer oesophagus. What happens here that causes dysphagia?
1 - very powerful peristalsis
2 - disjointed peristalsis
3 - lack of peristalsis and failure of LOS to relax
4 - very weak peristalsis
1 - very powerful peristalsis
Which of the following are not common presentations of patients with nutcracker/jackhammer oesophagus?
1 - dysphagia
2 - hemoptysis
3 - chest pain
2 - haemoptysis
- generally diagnosed using manometry
What are diffuse oesophageal spasms, which can cause dysphagia?
1 - very powerful peristalsis
2 - uncordinated peristalsis
3 - lack of peristalsis and failure of LOS to relax
4 - very weak peristalsis
2 - uncordinated peristalsis
- multiple parts of the oesophagus contract at once
Oesophageal spasms, which can cause dysphagia are due to uncordinated peristalsis where multiple parts of the oesophagus contract at once. What is the incidence of this?
1 - 1 / 100,000
2 - 10 / 100,000
3 - 100 / 100,000
4 - 1000 / 100,000
1 - 1 / 100,000
Achalasia can cause dysphagia. What is achalasia?
1 - genetic disorder causing strictures
2 - neurological disorder causing aperistalsis
3 - genetic disorder causing cachexia
4 - genetic disorder causing a laxity of the lower oesophageal sphincter
2 - neurological disorder causing aperistalsis
- essentially peristalsis if poor
- can be difficult to swallow solids and fluids
- myenteric nerve degeneration
Achalasia is a neurological disorder where myenteric nerve degeneration occurs. This results in causing aperistalsis causing difficulty swallowing solids and fluids. In addition to dysphagia, the oesophagus can also dilate and enlarge. What is the cause of this?
1 - gastric acid irritate the oesophagus and cause dilation
2 - oesophagus dilates to accommodate food and drink
3 - lower oesophageal sphincter cannot relax so food and drink build up
4 - all of the above
3 - lower oesophageal sphincter cannot relax so food and drink build up
- looks like a birds beak on imaging
Achalasia is neurological disorder causing poor peristalsis and therefore dysphagia. Primarily affects the lower oesophageal sphincter and smooth muscle of the oesophagus. What is the yearly incidence of achalasia?
1 - 1 / 100,000
2 - 10 / 100,000
3 - 100 / 100,000
4 - 1000 / 100,000
1 - 1 / 100,000
- very rare but increases with age
- lower oesophageal sphincter does not relax during swallowing
Achalasia is neurological disorder causing poor peristalsis and therefore dysphagia. Does it affect men or women more?
- affects both equally
What age group is most commonly affected by achalasia?
1 - 10-20 y/o
2 - 20-40 y/o
3 - 30-50 y/o
4 - >65 y/o
3 - 30-50 y/o
When we are trying to diagnose achalasia, which one of the following is the first line?
1 - ultrasound
2 - MRI
3 - OesophagoGastroDuodenoscopy
4 - barium swallow with X-ray
3- OesophagoGastroDuodenoscopy
- typically use a combination of all of these
Which of the following are NOT common presentations of a patient with achalasia?
1 - dysphagia (liquids and solids)
2 - chest pain
3 - distended abdomen
4 - reflux
5 - regurgitation
6 - weight loss
3 - distended abdomen
A barium swallow with X-ray can be used to diagnose a patient with achalasia. What is the name given to the image that can often be viewed on an X-ray in a patient with a megaoesophagus due to achalasia?
1 - apple core
2 - coffee bean
3 - baby sign
4 - birds beak
4 - birds beak
A high resolution oesophageal manometry is a test that measures pressure in the oesophagus (food pipe) and sphincters (ring like muscles at junction with stomach). What can this often show in a patient with achalasia?
1 - narrowing of lower oesophageal sphincter and lower pressure in oesophagus
2 - widening of lower oesophageal sphincter and lower pressure in oesophagus
3 - narrowing of lower oesophageal sphincter and increased pressure in oesophagus
4 - widening of lower oesophageal sphincter and increased pressure in oesophagus
3 - narrowing of lower oesophageal sphincter and increased pressure in oesophagus
Which of the following is NOT a common treatment for achalasia?
1 - balloon dilation
2 - botox injection
3 - endoscopic myotomy
4 - NSAIDs
4 - NSAIDs
- endoscopic myotomy = removal of muscle layer from proximal oesophagus and lower oesophageal sphincter to help food and fluids flow
Patients with severe achalasia may undergo a procedure called Hellers cardiomyotomy, which involves division of the lower oesophageal sphincter. What is the success rate of relieving dhyspagia?
1 - 0.8%
2 - 8%
3 - 38%
4 - 80%
4 - 80%
- BUT can increase risk of oesophageal perforation and cause contents to leak into mediastinum
What scoring system is typically used to score manometric findings?
1 - CURB score
2 - Chicago classification
3 - Freemantle classification
4 - Modified Glasgow score
2 - Chicago classification
In a patient that is having problems with both solids and fluids when swallowing, is this likely to be due to a functional or mechanical disorder?
- functional = muscles and nerves affecting motility of the esophagus
- mechanical = something within the esophagus blocking it
- functional = muscles and nerves affecting motility of the esophagus
In a patient that is having problems with just solids when swallowing, is this likely to be due to a functional or mechanical disorder?
- functional = muscles and nerves affecting motility of the oesophagus
- mechanical = something within the oesophagus blocking it
- mechanical = something within the oesophagus blocking it
- such as adenocarcinoma or strictures
In a patient that is having dysphagia, it can be intermittent or progressive. Of functional and mechanical, which will most commonly be intermittent and which progressive?
- intermittent = functional as swallowing is sometimes ok
- progressive = mechanical as something is growing or becoming narrower
Look at the question in the image, what is the diagnosis:
- oesphageal cancer
During the post take ward round the consultant asks you for the most common cause worldwide of GI bleeding. Which one of the following is the correct answer?
- Oesophageal varices
- GI tumours
- Peptic ulcer disease
- Dieulafoy lesions
- Mallory Weiss tear
- Peptic ulcer disease
