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GERD Flashcards

1
Q

In a country with a high incidence of this finding, what would you expect the incidence of GERD to be?

A

Low

(Inverse relationship between H. pylori and GERD incidences; H. pylori causes gastric atrophy so reduces acid)

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2
Q

A patient taking an OTC medication for “allergies” presents with substernal chest pain and dry mouth. What is the mechanism for her symptoms?

A

May be taking a first generation antihistamine, which has anticholinergic effects = decreased salivation = decreased esophageal clearance + less neutralizing bicarb

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3
Q

What is the function of the crural diaphragm?

A
  1. Ventilation
  2. Forms pinchcock around lower esophagus to increases LE pressure and prevent reflux
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4
Q

List 3 protective factors of the esophagus against development of GERD.

A
  1. Saliva - induces peristalsis and its HCO3- neutralizes acid (as well as HCO3- from esophageal glands)
  2. Many layers of squamous epithelium resistant to acid damage
  3. Peristalsis clears reflux
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5
Q

Dx?

A

Hiatal hernia

(Gastric folds present above the diaphragm, which is the circular constricted area)

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6
Q

This finding is the most common cause of GERD due to:

A

Hypotensive LES

(Notice all the neutrophils + the squamous epithelium = esophagitis)

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7
Q

What sign would you expect in this patient?

A

Bowel sounds in lung fields

(Rolling hernia/paraesophageal hernia)

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8
Q

Dx?

A

GERD

(Notice epithelium is all still squamous; nuclei in desquamated cells; lymphocytes, PMNs, and eosinophils present)

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9
Q

A patient with an A1c of 12 has had poorly controlled DM for over a decade. He now presents with CP that is worse at night and after meals. What is the mechanism of his symptoms?

A

Diabetic gastroparesis - causes delayed gastric emptying

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10
Q

Dx of acid reflux vs. pathologic reflux using pH monitoring

A

Esophageal pH < 4 for > 5 seconds = acid reflux

pH < 4 for > 1.2 hours (5%) in 24 hours = pathologic reflux

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11
Q

What is the function of the angle of His?

A

Forms a flap valve that anatomically prevents reflux

(Angle between fundus of stomach and esophagus)

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12
Q

A patient presents with cough and vomiting after meals but denies chest pain. First step in management?

A

Impedance study

(This checks for non-acid reflux, i.e. from duodenum, by measuring the conductivity of the refluxed liquid; no chest pain because acid isn’t present to destroy mucosa)

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13
Q

Dx?

A

Esophageal adenocarcinoma

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14
Q

Describe the pathogenesis of this type of hernia.

A

Widening of the diaphragmatic hiatus and relaxation of the phreno-esophageal ligament

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15
Q

What is causing this endoscopic finding?

What symptom may the patient present with?

A

GERD leading to a bleeding ulcer

Hematemesis

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16
Q

A patient presenting with substernal chest pain worse at night is found to have Tzank cells on biopsy of his esophagus during endoscopy. What is the mechanism of his symptoms?

A

Esophagitis (due to HSV) leads to hypotensive LES, which leads to GERD

17
Q

How do strictures occur in GERD patients? What other complication can they cause?

A

Acid knocks out the mucosa and its stem cells; healing of ulcers occurs by fibrosis = strictures

Strictures can cause esophageal dysmotility

18
Q

Why might a patient with CREST syndrome develop GERD?

A

Esophageal dysmotility (the “E” in CREST) results in inability to clear esophageal contents

(Esophageal dysmotility may also result from GERD)

19
Q

A patient presents with chest pain that comes and goes and is in the middle of his chest. He has also developed a cough that seems to only happen at night. He has lost some weight as eating makes the pain worse. What is the first step in management of this patient?

A

Two week trial with anti-reflux lifestyle modifications (elevate head of bed, etc) + PPI

20
Q

What is this patient’s risk of developing esophageal adenocarcinoma?

A

~0.5%

(Barrett’s esophagus - notice non-ciliated columnar epithelium with goblet cells next to normal squamous epithelium)

21
Q

Dx?

A

High-grade dysplasia, Barrett’s

(Irregular glands, nuclear atypia)

22
Q

How does tLESr compare with normal LES relaxation during a meal?

A

Normal LES relaxation

induced by swallowing; couple of seconds long; followed by primary peristalsis in esophageal body

tLESr

independent of swallowing; >10 seconds long; followed by repetitive contractions in esophageal body; accompanied by inhibition of crural diaphragm

23
Q

A pregnant patient presents with chest pain and a cough at night. What is the mechanism of her symptoms?

A

Hypotensive LES due to estrogen and progesterone

24
Q

What are the 3 results of this surgery? 3 complications?

A

Fundoplication

Results:

  1. Tack down stomach below diaphragm to prevent hiatal hernias
  2. Strengthen LES
  3. Restore flap valve formed by angle of His

Complications:

  1. Dysphagia - usually improves with time
  2. Gas bloat syndrome - can’t burp so lots of farting
  3. Vagus nerve injury - delayed gastric emptying
25
Q

A patient presents with substernal chest pain. A two week trial of omeprazole provides no relief. pH monitoring shows pH < 4 never exceeds 5 seconds. What is the next step in management of this patient and what diagnosis do you suspect?

A

Manometry

Nutcracker syndrome

(Forceful esophageal contraction with normal pH because no reflux is occuring)

26
Q

Dx?

A

Hiatal hernia + Barrett’s

(Z line + gastric folds above diaphragm)

27
Q

Why does sleeping on the left side alleviate reflux?

A

Allows gastric contents to pool in fundus behind the flap valve created by the angle of His

28
Q

Dx?

A

Low-grade dysplasia, Barrett’s

(Notice some loss of cellular polarity with nuclei not basal; crowded cells; fewer goblet cells; gland irregularity)

29
Q

A patient with a history of GERD presents with recurrent episodes of a bad taste in her mouth. What is happening?

A

Water brash - regurgitation of sour/salty saliva into mouth to neutralize acid

30
Q

A patient presents with substernal chest pain that he says is worse after he eats and especially when he tries to go to bed at night. His PMH is significant only for a surgery he had because he “couldn’t swallow anything at all.” What is the mechanism for his current symptoms?

A

Ablation surgery (Heller myotomy) for achalasia creates relaxation of the LES

31
Q

Which test would not be helpful in the diagnosis of Barrett’s esophagus?

A

Radiography

32
Q

What symptom would have prompted the endoscopy yielding this finding?

A

Odynophagia

(Suggests esophagitis and is an indication for endoscopy)

33
Q

What is the major motility problem causing GERD?

A

Failure of primary peristalsis; usually >80% of primary peristaltic waves sweep through entire esophagus; in GERD, <60% of primary peristaltic waves sweep through entire esophagus

(Diagnosed via manometry)

34
Q

A patient with a BMI of 35 presents with substernal chest pain and a “burning feeling” in her throat. What is the mechanism of her symptoms?

A

Increased abdominal pressure causing reflux

35
Q

Dx?

A

Barrett’s

(Z line = where columnar [pink] epithelium meets squamous [white] epithelium is above the gastroesophageal junction)

36
Q

Who should be screened for Barrett’s?

A

>50 yo white males with hx of chronic GERD, hiatal hernia, and/or obesity

37
Q

What are the arrows pointing to?

A

Eosinophils present in esophagus with GERD

38
Q

Dx?

A

Esophageal ACA

(Glands invading into mucosa and submucosa)

39
Q

List 2 stains that could be used for esophageal adenocarcinoma

A

Her2/neu and beta-cantenin

GI (10 decks)

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