GERD

Question 1

(1) Some degree of reflux is Some degree of reflux is physiologic. Physiologic reflux
episodes typically occur postprandially, are short-lived, asymptomatic, and rarely occur during sleep.
(2) Pathologic reflux is associated with symptoms or mucosal injury and often occurs nocturnally.
(3) GERD is a condition that develops when the reflux of stomach contents causes troublesome symptoms or complications.
(4) Uncomplicated cases do not require diagnostic studies.
(5) Endoscopy demonstrates abnormalities in one- third of patients.

Answer 1

GERD

Question 2

Pertinent Anatomy of a patient with Gastroesophageal Reflux Disease (GERD)

Answer 2

Esophagus

Question 3

What plays a vital role in the frequency and severity of GERD

Answer 3

Lower Esophageal Sphincter

Question 4

Pain associated with GERD is primary or secondary to the stimulation and activation of mucosal chemoreceptors by acid.

Answer 4

secondary

Question 5

What foods lead to GERD

Answer 5

Spicy, acidic and salty food

Question 6

Symptoms

Answer 6

(1) Heartburn occurs 30-60 minutes after meals and upon bending over or reclining.
(2) Patients often report relief from taking antacids or baking soda.
(3) Patients may complain of regurgitation (the spontaneous reflux of sour or bitter gastric contents into the mouth).
(4) Dysphagia occurs in one-third of patients and may be due to erosive esophagitis, abnormal esophageal peristalsis, or the development of an esophageal stricture.
(5) “Atypical” or “extraesophageal” manifestations of gastroesophageal disease may occur,

Question 7

“Atypical” or “extraesophageal” manifestations of gastroesophageal disease may occur, including:

Answer 7

(a) asthma,
(b) chronic cough,
(c) chronic laryngitis,
(d) sore throat,
(e) non-cardiac chest pain

Question 8

Differential Diagnosis

GERD

Answer 8

(a) esophageal motility disorders,
(b) peptic ulcer,
(c) functional dyspepsia,
(d) angina pectoris.

Question 9

Differential Diagnosis

Reflux erosive esophagitis

Answer 9

(a) pill- induced damage,
(b) eosinophilic esophagitis,
(c) infections (CMV, herpes, Candida).

Question 10

Complications

Answer 10

Barrett Esophagus

Peptic Stricture

Question 11

This is a condition in which the squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells (specialized intestinal metaplasia).
(b) Present in up to 10% of patients with chronic reflux, it arises from chronic reflux
induced injury to the esophageal squamous epithelium
(c) does not provoke specific symptoms, but gastroesophageal reflux does.
(d) Most patients have a long history of reflux symptoms, such as heartburn and
regurgitation.
(e) The most serious complication is esophageal adenocarcinoma. It is believed that most adenocarcinomas of the esophagus and many such tumors of
the gastric cardia arise from dysplastic epithelium

Answer 11

Barrett Esophagus

Question 12

(a) Stricture formation occurs in about 5% of patients with esophagitis.
(b) It is manifested by the gradual development of solid food dysphagia progressive over months to years.
(c) Often there is a reduction in heartburn because the stricture acts as a barrier to reflux.
(d) Most strictures are located at the gastroesophageal junction

Answer 12

Peptic Stricture

Question 13

Lab

Answer 13

None

Question 14

RAD

Answer 14

Endoscopy- used in complicated patients

Question 15

Treatment

(1) Mild, intermittent symptoms:

Answer 15

(a) Lifestyle modifications:
(b) Weight loss should be recommended for overweight patients.
(c) Patients with nocturnal symptoms should be advised to avoid lying down within 3 hours after meals, the period of greatest reflux, and to elevate the head of the bed on 6-inch blocks or a foam wedge to reduce reflux and enhance esophageal clearance.
(d) Antacids

Question 16

antacids

Answer 16

As antacids do not prevent GERD, their role is limited to intermittent (on- demand) use for relief of mild GERD symptoms that occur less than once a week.
Antacids usually contain a combination of magnesium trisilicate, aluminum hydroxide, or calcium carbonate
1) Ranitidine (Zantac) - Histamine H2 Antagonist
a) Dose: 150 mg PO bid
2) Famotidine (Pepcid)
a) Dose: 20-40 mg PO bid

Question 17

Treatment

Troublesome Symptoms:

Answer 17

Proton Pump Inhibitors (PPI)

1) When taken for active heartburn, these agents have a delay in onset of at least 30 minutes. However, once these agents take effect, they provide heartburn relief for up to 8 hours.
2) Examples:
a) Omeprazole (Prilosec) 20 mg PO daily
b) Pantoprazole (Protonix) 20 mg PO daily
c) Esomeprazole (Nexium) 40 mg PO daily
3) Dosed daily, 30 minutes before breakfast, for 4-8 weeks

Question 18

_____Are the treatment of choice.

Answer 18

Proton Pump Inhibitors (PPI)

Question 19

When to Refer

Answer 19

(a) Patients with typical GERD whose symptoms do not resolve with maximum empiric management with three months of twice-daily proton pump inhibitor therapy.
(b) Patients with significant dysphagia or other alarm symptoms for upper endoscopy (e.g. weight loss, bleeding, hoarseness or voice changes, chronic cough of nonpulmonary, allergic or cardiac causes).
(c) Patients with Barrett esophagus or esophageal stricture for endoscopic surveillance.
(d) Patients who have Barrett esophagus with dysplasia or early mucosal cancer

Question 20

Initial Care

Answer 20

(1) Emphasis on eliminating the causative factor should be the basis of treatment.
(2) Lifestyle modification could prove efficient in the treatment of GERD