General oto GERD

Question 1

What are common initial symptoms of GERD?

Answer 1

Heartburn 30 minutes to 2 hours after eating and regurgitation. Symptoms worsen with lying down or bending over. Less common symptoms include chest pain, chronic cough, laryngitis, asthma, and dental caries. Patients may complain of odynophagia and dysphagia in addition to belching.

Question 2

What symptoms are worrisome for a more sinister

diagnosis than isolated GERD?

Answer 2

Dysphagia, odynophagia, choking, weight loss, chest pain,
upper GI bleed, and no or poor response to an empiric trial
of antacids. If these symptoms are present, or if a patient
does not improve on empiric therapy, endoscopy should be
considered.

Question 3

Why is an initial empiric trial of antacid therapy a
reasonable first step in a patient with symptoms
suggestive of GERD?

Answer 3

It is noninvasive, cost-effective, and in most cases diag-

nostic and therapeutic.

Question 4

What technique offers the best evaluation of a patient’s esophageal mucosa?

Answer 4

Endoscopic esophagoscopy

Question 5

What is commonly seen on esophagoscopy in a

patient with reflux esophagitis?

Answer 5

Erosions or ulcerations at the squamocolumnar junction (Z-

line)

Question 6

To determine the severity of acid reflux, demonstrate reflux in a patient with normal endoscopic findings, or to evaluate response to therapy, a 24-hour pH probe test may be performed. What is the primary limitation of this test?

Answer 6

A fourth of patients with erosive esophagitis and a third of
patients with nonerosive esophagitis will have normal
results.

Question 7

When discussing lifestyle modifications for the management of GERD, what foods should be avoided?

Answer 7

Fatty foods, chocolate, coffee, excess alcohol, colas, red
wine, orange juice, large meals, peppermint, basically
anything that increases pH or decreases sphincter tone

Question 8

Beyond dietary considerations, what lifestyle
modifications should be considered to improve
mild GERD?

Answer 8

Elevate the head of bed while sleeping, avoid eating right

before sleep, exercise regularly, and lose weight.

Question 9

Which histamine 2 (H2) blocker is the most effective for treating GERD, and what is the dose-
dependent relationship between symptoms and therapy?

Answer 9

When adjusted for potency, no H2 blocker has been shown
to be stronger or more effective than another. There is not a dose-dependent relationship. If a patient is treated with 6 weeks of standard therapy and does not respond, it is time
to look to additional intervention.

Question 10

In a patient diagnosed with erosive reflux disease,

what medical management is indicated?

Answer 10

PPI therapy

Question 11

Is there any difference in treatment outcome for GERD when comparing once-daily proton pump
inhibitor therapy with more frequent dosing
regimens?

Answer 11

Yes. More frequent dosing schedules (twice a day) have
been shown to result in a significant improvement in gastric
pH and provide a longer duration of effect.

Question 12

After discontinuing a PPI for GERD, in what time frame do most patients who have recurrence begin to experience relapsing symptoms?

Answer 12

Three months

Question 13

What risks are associated with chronic suppressive

PPI therapy for reflux disease?

Answer 13

Potentially decreased bone density, infections, and electrolyte abnormalities

Question 14

In a patient with long-standing esophageal reflux
disease, the endoscopist identified specialized intestinal metaplasia or metaplastic cuboidal epithelium extending proximally to the natural squamocolumnar junction. What disease process is most likely associated with this finding?

Answer 14

Barrett esophagus

Question 15

To classify peptic esophagitis on endoscopy and decrease interobserver variability, several classification systems have been devised. The Los Angeles classification system is most commonly
used. Describe the different grades involved in this
system.

Answer 15

Los Angeles Classification
● Grade A: One or more mucosal break, each ≤ 5 mm long
● Grade B: One or more mucosal break > 5 mm long,
without continuity between the tops of adjacent mucosal
folds
● Grade C: One or more mucosa breaks continuous
between the tops of adjacent mucosal folds; not
circumferential
● Grade D: Circumferential mucosal break
Note: Historically the Savory-Miller grading system was the
most prevalent; however, because of variable definitions, it
is not as commonly used today.

Question 16

During endoscopy for erosive esophagitis, what is
the strongest predictor of Barrett esophagitis on
examination?

Answer 16

The length of the columnar appearing epithelium segment
extending from the GE junction (long segment > 3 cm, short segment < 3 cm). Specialized intestinal metaplasia is required on pathology to confirm the diagnosis.

Question 17

What is the most feared complication of Barrett

esophagus?

Answer 17

Esophageal adenocarcinoma. Annual incidence ranges

between 0.12 and 0.5% in patients with Barrett esophagus.

Question 18

With Barrett esophagus, how often should a patient with (1) no evidence of dysplasia, (2) low-
grade dysplasia, and (3) high-grade dysplasia without eradication therapy be examined endoscopically?

Answer 18

1. Every 3 to 5 years
2. Every 6 to 12 months
3. Every 3 months

Question 19

What three management strategies are available

for patients with Barrett esophagus?

Answer 19

Controversy regarding optimal management is ongoing.
Options include the following:
● Management of GERD
● Surveillance via serial endoscopy
● Attempt to eradicate dysplasia

Question 20

What endoscopic options are available for dysplasia eradication in patients with Barrett esophagus?

Answer 20

● Radiofrequency ablation
● Photodynamic therapy
● Endoscopic mucosal resection (recommended for patients with dysplasia and a visible mucosal irregularity to evaluate for T stage)

Question 21

Provide several reasons why the prognosis for

esophageal cancer is poor.

Answer 21

It often manifests late in the disease, and the esophagus is without an outer serosal layer, which may lead to early
spread.