GERD

Question 1

The presence of characteristic MUCOSAL INJURY seen at ENDOSCOPY and/or abnormal esophageal ACID exposure demonstrated on a REFLUX MONITORING STUDY is known as?

Answer 1

GERD

Question 2

What are the TWO TYPICAL symptoms of GERD?

Answer 2

HEARTBURN and REGURGITATION

Question 3

What is the actual CAUSITIVE agent of INJURY in REFLUX ESOPHAGITIS?

Answer 3

INFLAMMATORY CELLS not the acid itself

Question 4

Chest pain (ESOPHAGEAL); Globus, Sore throat, Burning tongue, Dental erosions, Sinusitis (oropharynx); Laryngitis, Chronic cough, Asthma (airway) are what type of SYMPTOMS?

Answer 4

ATYPICAL GERD symptoms
esophageal vs EXTRAESOPHAGEAL

Question 5

Erythema and Edema in the POSTERIOR Laryngeal region?

Answer 5

Laryngopharyngeal Reflux (LPR)

Question 6

Can a DIAGNOSIS of LARYNGOESOPAHGEAL REFLUX be made on the basis of laryngoscopy findings alone?

Answer 6

NO

Question 7

When presented with EXTRAESOPHAGEAL symptoms (Globus, Sore throat, Burning tongue, Dental erosions, Sinusitis, Laryngitis, Chronic cough, Asthma what should NOT be the first DIAGNOSIS?

Answer 7

GERD (explore non-GERD causes)
UNDERGO REFLUX TESTING BEFORE PPI therapy

Question 8

In patients who have EXTRAesophageal (atypical) GERD symptoms, what SHOULD be done BEFORE trial of PPI therapy?

Answer 8

Explore OTHER CAUSES of manifestations (cough, globus, etc.)

Question 9

In patients who have MIXED EXTRAesophageal (atypical) GERD symptoms, and TYPICAL symptoms (HEARTBURN, REGURGITATION) what SHOULD be done for therapy?

Answer 9

BID PPI for 8-12 weeks

Question 10

WHEN are ENDOSCOPIC or SURGICAL procedures to FIX REFLUX recommended in a patient with ATYPICAL symptoms of GERD?

Answer 10

Only when OBJECTIVE evidence (see mucosal changes on EGD) exists for reflux

Question 11

How long is a swallow-induced LESrelaxation and can REFLUX occur during these?

Answer 11

< 10 seconds
NO! (accompanied by a peristaltic wave)

Question 12

What is the most COMMON mechanism for PHYSIOLOGIC REFLUX?

Answer 12

TLESR (Transient LES Relexation) or the “belch reflex” which occurs during gastric distention to allow trapped air to get our and are >10 seconds long

Question 13

How can you REDUCE the physiologic TLESR episodes?

Answer 13

BACLOFEN (acts on the TLESR inhibitor GABAb receptor)

Question 14

Do you ROUTINELY TEST for H.pylori in a patient with GERD?

Answer 14

NO

Question 15

If H.pylori is found in a patient, do you treat?

Answer 15

ALWAYS

Question 16

How are H.pylori and GERD, Barrett’s Esophagus and esophageal Adenocarcinoma related?

Answer 16

H.pylori is found MUCH LESS in patients with Barret’s or Adenocarcinoma or GERD because it causes GASTRITIS and thus a REDUCTION in REFLUX

Question 17

What CONDITION is associated with GERD and BARRETT’s ESOPHAGUS?

Answer 17

OBESITY

Question 18

What is done for patients with CLASSIC (typical) GERD symptoms (heartburn, regurgitation) WITHOUT ALARM symptoms (bleeding, weight loss, dysphagia)?

Answer 18

8 WEEK trial of PPIs taken ONCE DAILY before meal

Question 19

WHEN do you do ENDOSCOPY for patient with CLASSIC (typical) GERD symptoms (heartburn, regurgitation) and WITHOUT alarm symptoms (bleeding, weight loss, dysphagia)?

Answer 19

AFTER 8 WEEK trial if INADEQUATE to control symptoms OR if symptoms return 2-4 weeks after PPI is STOPPED

Question 20

Can GERD or EoE be DIAGNOSED on EGD if PPIs have NOT been stopped?

Answer 20

NO!!

Question 21

Troublesome REFLUX-RELATED symptoms in the ABSENCE of endoscopically visible MUCOSAL BREAKS?

Answer 21

NERD (Non-Erosive Reflux Disease)

Question 22

What medication CLASS can RAPIDLY provide relief for heartburn BUT cannot be used to HEAL REFLUX ESOPHAGITIS?

Answer 22

H2 Blockers (cimetidine, famotidine, nizatidine) - develop tolerance with REGULAR use

Question 22

How LONG MUST you STOP PPIs for before performing an EGD to be able to DIAGNOSE GED/NERD/EoE?

Answer 22

2-4 WEEKS

Question 23

First-Line therapy for LA Grade C & D Esophagitis?

Answer 23

PPIs (metabolized by CYP2C19)

Question 24

Which of the **PPIs** is the **MOST POTENT**?

Answer 24

**RABEPRAZOLE** (followed by ESOMEPRAZOLE)

Question 25

Which of the **PPIs** is the **WEAKEST**?

Answer 25

**PANTOPRAZOLE**

Question 26

What is the **FIRST STEP** in management of **REFRACTORY GERD**?

Answer 26

Optimization of **PPI** therapy

Question 27

**WHEN** are **PPIs MOST EFFECTIVE**?

Answer 27

When taken **30-60** minutes **BEFORE MEALS** (because they'll be in the blood stream just as the PARIETAL cells start secreting acid which is what PPIs need to work)

Question 28

Is the use of **PPIs** associated with **ANY** adeverse events (cardiovascular, cancer, renal, anticoagulation interference, etc.?)

Answer 28

**NO!!** (only mild entericinfections)

Question 29

Patients with **OBJECTIVE** evidence of **SEVERE** reflux esophagitis, **LARGE** hiatal hernias, or **PERSISTENT GERD** symptoms would benefit from this?

Answer 29

**FUNDOPLICATION** (surgery)

Question 30

What is the **GERD** recurrence rate after **SURGERY** (fundoplication) that requires return to **PPI** therapy?

Answer 30

**10-30%** in **5** years

Question 31

In patients with **REGURGITATION GERD** symptoms who **FAIL PPI** therapy and who want an **ALTERNATIVE** to fundoplication, what do you recommend?

Answer 31

**MAGNETIC** Sphincter Augmentation (MSA)

Question 32

In patients who have **TROUBLESOME HEARTBURN** or **REGURGITATION GERD** symptoms, who do **NOT** have **SEVERE** reflux esophagitis (LA Grades C&D), **HIATAL HERNIAS < 2 cm** and who want an **ALTERNATIVE** to surgery, what do you recommend?

Answer 32

**TIF**

Question 33

What is the **SURGICAL** procedure of **CHOICE** for **GERD** in **OBESE** patients?

Answer 33

**Roux-en-Y** gastric bypass

Question 34

How does **SLEEVE GASTRECTOMY** affect **GERD**?

Answer 34

Can **CAUSE** it or **WORSEN GERD**

Question 35

What is meant by a **STEP-UP** approach for treating **GERD** in the **65%** of women who have this during **PREGNANCY**?

Answer 35

**LIFE STYLE** modifications --> **SUCRALFATE** --> **H2** (famotidine) --> **PPIs** (EXCEPT omeprazole)

Question 36

Is there a **BENEFIT** of treating **GERD** with **SUCRALFATE** outside of **PREGNANCY**?

Answer 36

**NO**

Question 37

Which **TWO PPIs** should be **AVOIDED** when during **PREGNANCY**?

Answer 37

**OMEPRAZOLE** and **ESOMEPRAZOLE** (during breastfeeding)

Question 38

What is **REFLUX HYPERSENSITIVITY**?

Answer 38

**PERSISTENT REFLUX** events that evoke symptoms of **HEARTBURN** when there is no longer **ACID** refluxing - esophageal **REFUX** monitoring

Question 39

When a patient has persistent **GERD-SYMPTOMS** and extraesophageal causes (cardiac, biliary), non-reflux disorders (achalasia, EoE), reflux hypersensitivity and **ACID** has been neutralized by **PPIs**, what is the condition called?

Answer 39

**FUNCTIONAL** heartburn

Question 40

What is **C4M6** Barrett's Esophagus?

Answer 40

**LONG-SEGMENT** Barrett's Esophagus (C=circumferential extent and M=extent in cm)

Question 41

In a patient in whom **GERD** is **SUSPECTED** but **NO OBJECTIVE** evidence on **EGD**, whats the **NEXT** diagnostic step?

Answer 41

**pH MONITORING OFF PPIs** to be able to establish the diagnosis of GERD

Question 42

On **pH MONITORING**, what constitutes **PATHOLOGIC REFLUX**?

Answer 42

**ACID EXPOSURE >6%** of the time (< 4% is NORMAL)

Question 43

In a patient with an **ESTABLISHED** diagnosis of **GERD** whose symptoms have **NOT ADEQUATELY** responded to **BID PPI** therapy, what is the **DIAGNOSTIC** recommendation?

Answer 43

**ph IMPEDANCE** (catheter only) study **ON PPI** therapy - to detect **ACIDIC** and **NON-ACIDIC** reflux episodes (bile, etc.)

Question 44

Should you perform **REFLUX MONITORING OFF PPIs** solely as a **DIAGNOSTIC** test for **GERD** if there is **OBJECTIVE (EGD)** evidence of **LA** Grade **C or D esophagitis** or presence of **LONG-SEGMENT BARRETT**'s Esophagus?

Answer 44

**NO!!** (because severe esopahgitis an long-segment Barrett's ARE considered OBJECTIVE EVIDENCE of GERD)

Question 45

What test allows you to make **DIAGNOSIS** of **REFLUX** **HYPERSENSITIVTY**?

Answer 45

**COMBINED ph-IMPEDANCE** study (pH montoring ONLY measures when reflux pH is < 4 whereas impedence monitoring identifies ALL reflux)

Question 46

In a **REFLUX** monitoring test, a SYMPTOM INDEX (**SI**) **>50%** or Symptom Association Probability (**SAP**) **>95%** indicate what?

Answer 46

**SIGNIFICANT ASSOCIATION** between **RFLUX** episodes and **SYMPTOMS**

Question 47

The condition in which there is **NORMAL** esophageal acid exposure but **POSITIVE** Symptom Index (**SI >50%**) **or** Symptom Association Probability (**SAP >95%**) for **heartburn** and **reflux** episodes is called?

Answer 47

**REFLUX HYPERSINSITIVITY**

Question 48

Biopsies of the **EGJ** show Specialized Intestinal Metaplasia?

Answer 48

**Barrett's Esophagus**

Question 49

**High-Grade Dysplasia** in **Barrett's Esophagus** increases the risk of **ADENOCARCINOMA** by what percentage per year?

Answer 49

**5-8%** per YEAR

Question 50

Whenever **DYSPLASIA** of **ANY GRADE** is detected on Barrett's biopsies, what **MUST BE DONE NEXT**?

Answer 50

**CONFIRMED** by a **SECOND PATHOLOGIST** with **EXPERTICE** in **GI PATHOLOGY**

Question 51

What **QUALIFIES** as **SCREENING EGD** for **Barrett**'s Esophagus?

Answer 51

**CHRONIC GERD** symptoms **AND ≥3 RISK FACTORS** (age >50, Obese, Smoker, Family History, White, Male)

Question 52

Once **BARRETT**'s is **DIAGNOSED**, what is **RECOMMENDED** for **SURVEILLACE EGD** for **DYSPLASIA**?

Answer 52

**BOTH WHITE LIGHT** and **CHROMO** endoscopy **AND** a **STRUCTURED BIOPSY** protocol

Question 53

What **QUALIFIES** as a **STRUCTURED BIOPSY PROTOCOL** surveillance for a patient with **BARRETT**'s esophagus (Seattle Protocol)?

Answer 53

**4 QUADRANT** biopsies every **2 cm** for **NO DYSPLASIA** **4 QUADRANT** biopsies every **1 cm** for **POSITIVE DYSPLASIA**

Question 54

In **NON-DYSPLASTIC** Barrett's Esophagus, what is the **SURVEILLANCE** interval for **SHORT-SEGMENT** (< 3 cm) vs **LONG-SEGMENT** (≥3 cm) Barrett's Esophagus?

Answer 54

**SHORT-SEGMENT**: every **3** YEARS **LONG-SEGMENT**: every **5** YEARS

Question 55

**Medication**-wise, what should a **Barrett**'s patient be on?

Answer 55

**ONCE-A-DAY PPI**

Question 56

Should anti-reflux **SURGERY** be performed for cancer **PREVENTION** in a patient with Barrett's?

Answer 56

**NO!!**

Question 57

What is **RECOMMENDED** for a patient with confirmed **Barrett**'s esophagus with **HIGH-GRADE** dysplasia?

Answer 57

**ERADICATION** THERAPY

Question 58

What are the **THREE** grades of **T1a** lesions that can ALL be removed endoscopically and are limited to the **MUCOSA**?

Answer 58

**m1**, **m2**(< 2% LN mets), **m3** (4-7% LN mets)

Question 59

What are the **THREE** grades of **T1b** lesions that CANNOT be removed endoscopically (except sm1) and are limited to the **SUBMUCOSA**?

Answer 59

**sm1**(13% LN mets), **sm2**(26% LN mets), **sm3** (67% LN mets)

Question 60

What is the **ONLY EXCEPTION** where a **T1b** lesion **CAN** be resected endoscopically?

Answer 60

As an **ALTERNATIVE** to **ESOPHAGECTOMY** **T1b sm1** (**good-moderate** differentiation), **NO** lymphovascular invasion (no poorly differentiated tumors)

Question 61

What is the **BEST METHOD** for **T-STAGING** a tumor in the **GIT**?

Answer 61

**EMR** or **ESD** (staging & therapeutic), NOT EUS

Question 62

Preferred **TREATMENT** of Barrett's Esophagus with **DYSPLASIA**?

Answer 62

**FIRST:** **EMR/ESD** of **ANY VISIBLE** abnormality. **SECOND:** **RFA** (prevents progression to neoplasia and cancer)

Question 63

What is meant by **ENDOSCOPIC ERADICATION THERAPY** of **BARRETT's ESOPHAGUS** with **DYSPLASIA** (regardless of what grade)?

Answer 63

**EMR/ESD + RFA**

Question 64

**AFTER** endoscopic **ERADICATION** therapy for **Barrett's Esophagus** and **COMPLETE** elimination of intestinal metaplasia, how long do you perform **SURVEILLANCE** on these patients?

Answer 64

**LIFE-LONG** (due to frequent **RECURRENCE**)

Question 65

After **COMPLETE ELIMINATION** of Barrett's (intestinal metaplasia) for patients with **HIGH-GRADE** dysplasia or **INTRAMUCOSAL CARCINOMA** prior to having the complete ablation done, is **HOW FREQUENT** do you perform **SURVEILLANCE EGD**? What if the just had **LOW-GRADE** dysplasia prior to eradiction?

Answer 65

**3** months; **6** months; **12** months; **ANNUALLY** For low-grade dysplasia eradication: **1** year; **3** years; every **2** YEARS thereafter

Question 66

When Barrett's Esophagus **RECURS** after complete eradication, **WHERE** does the recurrence occur?

Answer 66

**AT** the **EGJ** or **1 cm ABOVE**

Question 67

When performing **SURVEILLANCE EGD** after complete Barrett's eradication, where and how do you biopsy?

Answer 67

**4 QUARDRANT** biopsies **AT** the **EGJ** (squamocolumnar area) and **2-3 cm** of **PROXIMAL** **NEO-SQUAMOUS** epithelium

Question 68

What are the **EREFS** (Endoscopic Reference Scores) for EoE?

Answer 68

**E**xudsates **R**ings **E**dema **F**urrows **S**trictures

Question 69

Histology findigs of **≥15 Eosinophills per HPF**, Eosinophil **Microabscesses**, **Basal Zone** Hyperplasia, **Dilated** Intracellular spaces, Subepithelial **Fibrosis**, **MAST** cells?

Answer 69

**EoE** (not specific, can see in GERD too)

Question 70

What component of **EoE** causes **PERSISTENT** symptoms?

Answer 70

**MAST** cells

Question 71

**ALLERGIC** conditions such as **ATOPIC** dermatitis, **ASTHMA** and **RHINITIS** are all associated with this GI disorder?

Answer 71

**EoE**

Question 72

The **CHANGE** of what, impacts symptoms of **EoE** the most?

Answer 72

**DIET** (elemental diet shown to improve symptoms the most, hence allergens in food) - **IL-4** **Th2** cytokyne stimulates esophageal **Eotaxin-3**

Question 73

What **immune component** attracts **EOSINOPHILS** to the **ESOPHAGUS**?

Answer 73

**EOTAXIN-3** (released by **IL-4**) IL-5 makes eosiniphills and IL-13, IL-4 makes EOTAXIN-3 that attracts the eosinophils to the esophagus

Question 74

**30%-50%** of patients with **EoE** respond to what **TREATMENT**?

Answer 74

**PPIs** (because EOTAXIN-3 can be blocked by PPIs) **Topical STEROIDS 6-8** weeks (budesonide, fluticasone) work but EoE **RECURS**

Question 75

Which **DIET** treats **91%** of **EoE** patients? Which **DIET** treats **72%** of **EoE** patients?

Answer 75

91%: **ELEMENTAL** (super expensive) 72%: **ELIMINATION** (foods: **MILK**, **GRAINS**, Eggs, Soy, Nuts, Seafood)

Question 76

Besides treating patients with **PPIs** for **EoE** (blocks **EOTAXIN-3**) what else is available which **DIRECTLY** blocks **IL-4 & IL-13** **PRODUCTION** of **EOTAXIN-3**?

Answer 76

**DUPILUMAB**

Question 77

If **DYSPHAGIA** persists in **EoE** patients after treatment, what else can be done?

Answer 77

Esophageal **DILATION**

Question 78

Middle-Aged **WHITE** woman with **ESOPHAGEAL** and **BUCCAL** whitish **PLAQUES** with **STRICTURES** that are not resolved by **PPIs** or **DILATION** and on biopsy you see **SUBEPITHELIAL LYMPHOCYTIC INFILTRATES** and **CIVATTE BODIES**?

Answer 78

**LICHEN PLANUS**

Question 79

**BELOW** what diameter do most people experience **DYSPHAGIA** and therefore **EGD DILATION** should be aimed for what **DIAMETER**?

Answer 79

**Below < 13 mm** = dysphagia Dilate **15-18 mm 45-54 F**

Question 80

What is the **DIFFERENCE** in **DILATION** method between an esophageal **STRICTURE** and a **SCHATZKI** ring?

Answer 80

**STRICTURE** is dilated **GRADUALLY** no more than 3 mm/session, repeat in 1-4 weeks. **SCHATZKI** ring is dilated **ABRUPTLY** to tear it in one session