GERD

Question 1

What are the clinical manifestations of GERD?

Answer 1

Heartburn, regurgitation, waterbrash, dysphagia, new onset asthma, chronic cough, bronchitis, dental erosions, laryngitis, hoarsness, polyps, laryngeal cancer.

Question 2

What are the diagnostic tests for suspected GERD?

Answer 2

Endoscopy , UGI, 24 hour pH test, esophageal manometry, gastric emptying test, impedance monitoring

Question 3

What percentage of patients with longstanding GERD have Barrett’s esophagus?

Answer 3

Ten

Question 4

Which test is the gold standard for diagnosis of GERD?

Answer 4

24 hour pH test

Question 5

When should esophageal manometry be used in the diagnosis and evaluation of GERD?

Answer 5

In patients in whom surgery is being considered

Question 6

When should a gastric emptying test be performed?

Answer 6

When there is a history of DM, nausea/vomiting and postprandial bloating.

Question 7

A 36 year old male with signs and symptoms concerning for GERD has a normal EGD. What test should be performed next?

Answer 7

24 hr pH study.

Question 8

Indications for antireflux laparoscopic surgery

Answer 8

Chronic GERD symptoms despite medical therapy, Chronic GERD and desire to be off medications; complications of GERD (Barrett’s, esophagitis, stricture) not responding to therapy, paresophageal hernia with GERD, pediatrics with GERD-esophagitis,, and high volume reflux despite therapy.

Question 9

How are the majority of patients with GERD treated?

Answer 9

Medically: with medications (PPIs) and with diet and lifestyle modifications

Question 10

In what percent of patients do proton pump inhibitors heal esophagitis?

Answer 10

85%

Question 11

True or false: Histamine receptor blockers are more effective at medically treating GERD than proton pump inhibitors.

Answer 11

False. PPIs have been shown to be more effective.

Question 12

What is the primary operation currently used to treat GERD?

Answer 12

laparoscopic Nissen fundoplication

Question 13

During dissection and mobilization of the esophagus for lap nissen, what orientation of the stomach facilitates division of the gastrophrenic ligament?

Answer 13

Pulling gastric fundus inferiorly and to the right

Question 14

What is the position of the posterior vagus nerve?

Answer 14

Adjacent and to the right of the esophagus.

Question 15

What is the position of the anterior vagus nerve?

Answer 15

Anterior surface of the esophagus

Question 16

What percentage of cases lap Nissen cases result in esophageal perforation?

Answer 16

> 1%

Question 17

What is the incidence of conversion to open procedure for laparoscopic Nissen fundoplication?

Answer 17

5%

Question 18

Compared to open procedure, what are the advantages of the laparoscopic antireflux surgery (LARS) ?

Answer 18

Reduction in postoperative pain, shorter hospital stays, reduction in overall recover time, and improved cosmesis.

Question 19

Surgery improves typical GERD symptoms (heartburn, regurgitation, and dysphagia) in what percentage of patients?

Answer 19

> 90%

Question 20

What percentage of patients develop new onset dysphagia postoperatively?

Answer 20

10%

Question 21

Is new onset dysphagia (which develops after antireflux surgery) permanent?

Answer 21

No, usually this resolves within one year

Question 22

Which complication of Nissen fundoplication is more common in the laparoscopic approach?

Answer 22

Migration of wrap through esophageal hiatus

Question 23

What do current endoluminal therapies for GERD entail?

Answer 23

Application of radio frequency energy or mechanical suturing of the GEJ. These function to either mechanically thicken the LES or to restore the valvular mechanism of the LES.

Question 24

How is radiofrequency energy used to treat GERD?

Answer 24

The Stretta system applies radiofrequency energy to deliver controlled cautery to the GE junction. It causes heat induced thickening of the GE junction musculature, and reduces compliance of the LES, and via reduction in number of transient LES relaxations.

Question 25

What is endoluminal gastroplication?

Answer 25

Mechanically increasing LES pressure by plicating the area of the esophagus at the squamocolumnar junction.

Question 26

What treatment is available for patients with refractory GERD symptoms after gastric bypass?

Answer 26

Endoluminal therapy for treatment of GERD.

Question 27

In patients with a history of refractory GERD who are found to have gastroparesis, what procedure may be performed in addition to antireflux surgery?

Answer 27

Pyloroplasty