GERD Flashcards
What are the causes of GERD?
Inappropriate transient relaxation of LES the most common cause. Risk increases with age
Low basal LES tone: Often seen in patients with Scleroderma & other Motility disorders
Contributing factors
- High intra-abdominal pressures e.g. Obesity. Pregnancy, large meal
- Hiatal hernia (worsens reflux but is not a cause of GERD)
- Smoking, NSAIDs, H. pylori (Alcohol use is NOT a RF)
- Fixed GOO / Functional delayed gastric emptying - eg lying down after heavy meal
- Irritable bowel syndrome
- Anxiety/depression
What are the clinical features of GERD?
Ask for esophagus = Heartburn, Regurg, Waterbrash, Dysphagia, Globus, Odynophagia
Heartburn (pyrosis)
- Retrosternal burning sensation
- Epigastric Pain
- Often post-prandial
- Worse on lying down
- Relieved by antacid
Regurgitation: Effortless return of gastric contents from the stomach into the mouth
a/w other symptoms
- Water brash, globus sensation, dysphagia (late), odynophagia (rare)
- chest pain, chronic cough, hoarseness, dental erosions
What are the complications of GERD?
Bleeding
Esophagitis 🡪 Dysphagia, Odynophagia
Oesophageal strictures – scarring can lead to dysphagia 🡪 Dysphagia
Barrett’s oesophagus
Oesophageal malignancy 🡪 Adenocarcinoma
What are the ddx of GERD?
- CAD (make sure to exclude)
- PUD / Functional dyspepsia
- Gallstone disease
- Gastroparesis e.g. long standing DM
- Oesophagitis
- Oesophageal motility disorders e.g. achalasia
What are the investigations to be performed for GERD?
Questionnaires – GERD-Q
Empirical PPI trial of therapy for 8 weeks
- Clinical features w/ symptomatic relief after trial of PPI is diagnostic of GERD
- 3-4 months PPI trial for cough / laryngitis / asthma WITH CONCURRENT heartburn / regurg
OGD if indicated
24-hour pH monitoring / pH impedance study
What are the indications (red flags) for OGD?
- > 55yo w new-onset dyspepsia
- Persistent/progressive GERD despite empiric trial of PPI
- Dysphagia
- Odynophagia
- Unexplained weight loss >5%
- Anorexia
- Evidence of any GI bleed / iron deficiency anemia
- Persistent vomiting
What is the indications for 24-hour pH monitoring / pH impedance study ?
To exclude an oesophageal motility disorder e.g. achalasia – eg: in pt w/ refractory symptoms and normal endoscopic findings
Prior to anti-reflux surgery to definitively rule out motility disorder
What is the indications for Oesophageal Manometry?
Performed to exclude an oesophageal motility disorder e.g. achalasia
Prior to anti-reflux surgery to definitively rule out motility disorder
Evaluate peristaltic function before anti-reflex surgery. Surgical fundoplication less likely to be successful if there is abnormal peristalsis
What is the lifestyle management of GERD?
Diet alterations (symptomatic relief)
- Avoid caffeine, alcohol, chocolate, fatty food, spicy food, citrus foods
- Smaller more frequent meals
Weight loss (if obese)
Sleep alterations (avoid recumbency 2-3 hours after meals)
Smoking cessation
What is the pharmacological management of GERD?
Antacids e.g. magnesium trisilicate, Al hydroxide, Ca carbonate
H2 receptor antagonist e.g. Cimetidine, Famotidine
Prokinetics increase LES tone, antrum contractions, bowl peristalsis
- Metoclopramide
- Domperidone
Proton Pump Inhibitors (PPIs) e.g. omeprazole, esomeprazole, lansoprazole
P-CAB (potassium competitive acid blocker) e.g. Vonoprazan (x300 more potent than PPI)
Visceral analgesics e.g. TCA, trazodone, SSRI, SNRI – used in lower doses
What are the risks of long term therapy of PPIs?
Hypochlorhydria
- Calcium malabsorption (use Calcium citrate for supplementation) 🡪 Osteoporosis
- C. diff colitis
- Pneumonia (CAP)
- Acute interstitial nephritis (not dose-dependent)
- B12 deficiency, hypomagnesemia (from reduced intestinal absorption)
What are the indications of surgery of GERD?
Failure of relief with maximal medical therapy or noncompliance with medical therapy
Manometric evidence of a defective LES and exclusion of reflex mimics
Severe symptoms or progressive disease
Complications of reflux esophagitis (e.g. Barrett’s, respiratory compromise)
What are the complications of Nissen fundo
- mortality rate (<1%)
- bleeding, infection, esophageal perforation
- “gas bloat syndrome”: patient experiences difficulty burping gas that is swallowed
- dumping syndrome (rapid gastric emptying)- food enters SI largely undigested
- dysphagia: excessively tight wrap
- recurrence of reflex
- perforation of the esophagus (most feared complication, may result in mediastinitis if not promptly detected and repaired intraoperatively)
- “slipped nissen” occurs when the wrap slide down, the GE junction retracts into the chest and the stomach is partitioned usually due to a foreshortened esophagus unrecognised in the first operation.
What is the definition of Barrett’s oesophagus?
Metaplasia of normal squamous oesophageal epithelium to abnormal columnar epithelium containing-type intestinal mucosa
What is the risk factors for Barrett’s oesophagus?
Risk factors include male, >50 years, smoker, obese, hiatus hernia, long history of reflux
