GERD

Question 1

Postulated causes of increasing incidence of GERD

Answer 1

• H. Pylori Treatment

- Obesity

Question 2

Four causative factors of GERD?

Answer 2

• Gastric Acid and Pepsin
• Duodenal contents
• High Gastric Volume
• High Abdominal Pressure

Question 3

In what syndrome is GERD worse?

Answer 3

Zollinger Ellison Syndrome (hypergastrinemia)

Question 4

Acid and Pepsin are synergistic in the pathophyiologi of gerd

Answer 4

ok…remember, pepsin = protein digestion

Question 5

Duodenal reflux can be problematic in causing GERD. What are the Duodenal contents that we must worry most about?

Answer 5

Bile acids (act as a detergent to dissolve fats)
Amylase- dissolves polysaccharides
Trypsin (proteins)
lipase (lipids)

Question 6

What are the three physiologic protective barriers against acid reflux

Answer 6

1) Diaphragm- forms a pinchcock around the the entrance of the esophagus into the stomach
2) Lower esophageal sphincter
3) Angulation created as the fundus of the stomach meets the esophagus. This is known as the angle of His. Forms a flap valve that prevents reflux.

Question 7

Two components of the diaphragm?

Answer 7

Costal- ventilatory muscle
Crural- ventilatory muscle as well but also has a sphincter like action around the esophagus. The crural diaphragm increases lower esophageal pressure especially during instances when there is an increased pressure gradient between the stomach and the esophagus that favors reflux.

Question 8

Healthy LES pressure

Answer 8

10-30mm Hg

Question 9

Hypotensive LES that can lead to reflux occurs in two instances…they are

Answer 9

• Severe esophagitis (inflammation)
• Pregnancy ( related to hormonal change in estrogen and progesterone)

May also be related to systemic diseases such as scleroderma or surgical procedures such as Heller’s myotomy to fix achalasia

Question 10

Fat, chocolate, peppermint

Answer 10

reduce LES

Question 11

Transient LES relaxation accounts for

Answer 11

most epidsodes of GERD

Question 12

transient LESr lasts about how long? Swallowing produces LESr that lasts how long?

Answer 12

30 seconds (longer than 10 at least)
Just a few seconds (5)

Also note that tLESR leads to inhibition of the crural diaphragm which further decreases the functional pressure barrier to esophageal reflux.

Interesting, everytime you burp it is most likely a tLESR

Question 13

Hiatal hernia occurs when?

Answer 13

When a widened diaphragmatic hiatus and relaxed phrenoesophageal ligament allows the proximal stomach to migrate into the thorax. In this condition, barrier functions are disrupted.

• The LES shortens
• Lose the angle of his

Question 14

Some protective physiology when GERD is occuring:

Answer 14

• Peristalsis clears refluxate back into stomach
• Bicarbonate neutralizes acid
• squamous mucosa resistant to acid injury

Salivation is important

Question 15

GERD is worse when

Answer 15

• Supine
• Delayed Gastric emptying
• Abdominal and Intrgastric pressure

Question 16

GERD cardinal symptoms

Answer 16

• Heartburn: burning behind sternum readiating up to neck, worse after meals and when lying flat
• Regurgitation
• Dysphagia

Other symptoms

• Belchng and hiccups
• water brash: excess salivation due to high acid content
• Reflux laryngitis due to inflammation of vocal cords
• Cough and bronchospasm from aspiration

Question 17

Clinical diagnosis procedure

Answer 17

• Symptom questionnaire: not very specific

- Two week therapeutic trial with anti-reflux lifestyle and high dose PPI

Question 18

Regarding pH, acid reflux is defined as

Answer 18

pH less than 4 lasting more than 5 seconds.

Pathologic if this occurs more than 5% of teh time.

Question 19

What is esophageal manometry

Answer 19

Measures esophageal motility in different sections of the esophagus over time.

Question 20

Wht type of study allows you to evaluate for refluxed contents that are non-acidic?

Answer 20

Impedence

Question 21

IMpedence studies are useful when evaluating duodenal content that has been refluxed because duodenal contents have been neutralized by pancreatic bi-carb and therefore are not acidic

Answer 21

ok

Question 22

How to exploit gravity in treatment?

Answer 22

don’t lie down after a meal
elevate head
sleep on left side

Question 23

What are the two classes of antacids?

Answer 23

Magnesium based agents (maalox or mylanta)

Aluminum based agents (amphogel)

Question 24

Magnesium based antacids can cause what when overused?

Answer 24

diarrhea

Question 25

Aluminum based antacids can cause what when overused?

Answer 25

constipation

Question 26

H2 receptor blockers

Answer 26

block histamine receptors on parietal cells which release acid

Question 27

PPIs block what pump

Answer 27

H/K ATPase. The acid is the H+.
This is the most effective antacid.
Best taken half an hour before meals.
Irreversible binders

Question 28

Prokinetics

Answer 28

agents that effect GI motility. They ARE NOT effective as a single agent as mus tbe combined with acid suppression

Question 29

Fundoplication

Answer 29

anti-reflux surgery which tacks down the stomach below the diaphragm, preventing the fomrmation of a hiatal hernia
- Strengthen the LES by wrapping the stomach around the esophagus

Question 30

GERD complications

Answer 30

• Aspiration
• Vocal cord damage
• Inflammation and scarring- esophagiitis/ peptic strictures
• Intestinal metaplasia: Barrett Esophagus +/- dysplasia
• Cancer: adenocarcinoma
• Neoplastic transformation

Question 31

Barrett Esophagus

Answer 31

Chronic GERD

• Damage to squamous epithelium
• heal through metaplastic process
• replaced by columnar epithelium

Question 32

Significance of Barrett Esophagus?

Answer 32

Predisposition to esophageal adenocarcinoma

Question 33

Z line

Answer 33

demarcation between end of squamous and beginning of columnar