GERD Flashcards
Halitosis that is worse when eating is a typical symptom of … ?
GERD
What does GERD stand for?
Gastroesophageal reflux disease
What is the role of the lower esophageal sphincter (LES) in GERD?
It prevents the back-flow of stomach contents into the esophagus.
GERD is the reflux of stomach contents into the esophagus, causing symptoms or complications due to lower esophageal sphincter (LES) dysfunction or transient LES relaxations.
True or False: Smoking can exacerbate GERD symptoms.
True
True or False: Nitroglycerin can exacerbate GERD symptoms.
True
What are the major risk factors associated with GERD?
Major: Smoking and obesity
Note: not just smoking but nicotine alone can increase symptoms, which might be a consideration for patients using cessation therapy.
Others: Diet, hiatal herniation, pregnancy, EtOH, and medications like nitroglycerin, anticholinergics or CCBs.
Fill in the blank: GERD is more common in individuals who are __________.
overweight or obese
Fill in the blank: GERD can often be triggered by __________, which relaxes the LES.
certain foods or beverages
What foods increase the risk of GERD?
Pepermint
Chocolate
Coffee
Fatty foods
What is the effect of caffeine on GERD symptoms?
Caffeine can worsen GERD symptoms.
Multiple choice: Which of the following is a common risk factor for GERD?
A) Age
B) High fiber diet
C) Regular exercise
D) Low body weight
A) Age
What MSK related pathology has a GERD association?
Scleroderma
A systemic autoimmune disease characterized by vasculopathy and fibrosis of the skin and other organs. Typical manifestations include cutaneous thickening, Raynaud phenomenon, and esophageal dysmotility. Classified as limited or diffuse depending on the extent of cutaneous thickening.
What is the primary symptom of GERD?
Heartburn (Pyrosis).
Retrosternal epigastric burning sensation radiating up into the chest is the most classic symptom associates with GERD. Pyrosis occurs often after meals or lying down. The other most common symptom is regurgitation.
Fill in the blank: __________ is a symptom of GERD that involves a sour taste in the mouth.
Regurgitation.
This can lead to several other issues including, chronic nonproductive cough (especially at night), hoarseness, dental erosions, halitosis, belching, and nausea.
What is the term used to describe epigastric pain or discomfort, postprandial fullness, early satiety, bloating and nausea?
Dyspepsia.
What is the major association that dyspepsia has with GERD?
The classical association that GERD has with dyspepsia is that symptoms of dyspepsia worsen while lying down.
How is aspiration pneumonia related to GERD?
Micro-aspiration of gastric contents into the lungs, leading to recurrent pneumonia.
This can lead to chronic cough and wheezing.
True or False: GERD can cause respiratory problems such as asthma.
True
What is the significance of odynophagia in GERD patients?
Odynophagia is pain with swallowing and may indicate esophageal malignancy or severe esophagitis.
Perform an upper endoscopy for a patient with GERD symptoms and pain upon swallowing.
Multiple choice: Which of the following is NOT a symptom of GERD?
A) Regurgitation
B) Coughing
C) Abdominal pain
D) Fever
D) Fever
A diabetic patient who has GERD-like symptoms likely has … ?
Diabetic gastroparesis
This requires an endoscope PRIOR to giving medication (metoclopramide) for gastroparesis.
Can GERD present with dysphagia?
Difficulty swallowing may be a clinical symptom associated with a more extreme condition outside of GERD and warrants an upper EGD.
A 45-year-old man presents to the emergency department with a 6-hour history of chest pain and vomiting coffee-ground colored material. The patient has had heartburn, food regurgitation, and occasional dysphagia for the past five months. Over-the-counter omeprazole has provided partial relief of symptoms. There is no associated diaphoresis, dyspnea, hemoptysis, or nausea. Past medical history is unremarkable. The patient takes no other medications and does not use tobacco or alcohol. Temperature is 36.7°C (98.1°F), pulse is 108/min, blood pressure is 110/60, and respirations are 18/min. Physical examination is remarkable for epigastric tenderness to palpation. Electrocardiogram and chest radiograph show no abnormalities. Laboratory evaluation shows microcytic anemia. Which of the following is the most appropriate next step in management of this patient?
A) Order a CT of the chest with angiography
B) Prescribe oral pantoprazole and schedule outpatient upper endoscopy in two weeks
C) Administer aspirin and heparin and consider emergent reperfusion therapy
D) Administer intravenous pantoprazole and perform upper endoscopy
E) Order a barium swallow test
Patients with a history suggestive of GERD who have alarm symptoms, like hematemesis, should first be stabilized. They should then be evaluated with an EGD with biopsies to identify complications of GERD and to rule out malignancy. This patient with a 6-hour history of chest pain, coffee-ground emesis (hematemesis), severe reflux symptoms, and microcytic anemia with a history of heartburn and dysphagia likely has gastroesophageal reflux disease (GERD) that may be complicated by erosive esophagitis. Patients with GERD who present with alarming (or alarm) features - gastrointestinal bleeding (hematemesis, melena, hematochezia, pallor), anorexia, unexplained weight loss, dysphagia, odynophagia, persistent vomiting, and the presence of gastrointestinal cancer in a first-degree relative - should have bloodwork and an EGD with biopsies done initially to rule out complications of GERD (like Barrett esophagus, erosive esophagitis, and underlying malignancy). If there are complications of GERD, a multidisciplinary management approach is recommended; which may include medical therapy with PPls, management of anemia (if present), Gl consultation for possible endoscopic therapies that may include dilation or ablation, and surgical consultation for possible laparoscopic fundoplication. All patients with GERD should be counseled on lifestyle modifications, including weight loss and tobacco cessation. Many patients with significant GERD will need to undergo endoscopic surveillance and screening.
Name the important alarm symptoms of GERD.
- Signs of a GI bleed
(iron deficiency anemia) - Persistent vomiting
- Weight loss
- Dysphagia
- Odynophagia
- Older age >60
(or >50 in Caucasian males with risk factors) - Aspiration pneumonia
- Family history of malignancy
and upper EDG would be warranted with a patient presenting with ___ years or more of GERD-like symptoms.
5
Question 1:
A 52-year-old man presents with a 6-month history of heartburn and regurgitation. He has been self-treating with over-the-counter antacids, but his symptoms persist. He reports unintentional weight loss of 15 lbs over the past 3 months and difficulty swallowing solid foods. He has a 20-pack-year smoking history. What is the next best step in management?
A. Initiate a proton pump inhibitor (PPI) therapy
B. Order an esophageal manometry
C. Perform an upper endoscopy
D. Prescribe a high-dose H2 receptor antagonist
E. Refer for barium swallow study
Answer: Perform an upper endoscopy
Explanation: This patient presents with GERD symptoms and alarm features, including unintentional weight loss and dysphagia, which necessitate upper endoscopy to evaluate for complications such as esophageal cancer or strictures. PPIs can be started after ruling out structural abnormalities.
What are the major three considerations that will need to be ruled out with a patient presenting with dyspepsia and alarm symptoms?
Dyspepsia can occur in isolation or be associated with other “alarm features” like unintentional weight loss, persistent vomiting, dysphagia, evidence of gastrointestinal bleeding, or anemia. Under these circumstances, further investigation with an upper EGD is warranted to rule out organic causes like peptic ulcer disease, malignancy, or Helicobacter pylori infection.
True or False: Antacids are a first-line treatment for GERD.
False
What is the most effective lifestyle modification for GERD?
Weight loss, especially in overweight or obese patients.
Lifestyle modifications are the first step in the process for minimizing the symptoms of mild GERD.
If the patient smokes, reduce or eliminate with education or cessation aid.
What dietary change is recommended for patients with GERD?
Avoiding spicy food, fatty food, EtOH, Coffee, and peppermint.
Avoid eating at night.
When symptoms are mild and occur less than 2 times a week, dietary or lifestyle modifications are considered in the first modality of treatment and coupled with a low dose H2 antagonist.
What lifestyle habit should be avoided to reduce GERD symptoms?
Lying down immediately after eating
What is the main purpose of using H2 receptor antagonists in GERD management?
To reduce stomach acid production.
These are used for mild symptoms occuring 2 times or less a week and coupled with lifestyle modifications.
What is a common non-pharmacological treatment for GERD?
Elevation of the head of the bed 6 to 8 inches.
Which pharmacologic therapy is first-line for moderate to severe GERD?
Proton pump inhibitors (PPIs).
When there are more than 2 episodes a week or severe symptoms, patients benefit from a daily PPI and will usually go on an 8 week trail as long as they are healthy and have no red flag symptoms.
What diagnostic test is commonly used to after the failure of first line treatment for GERD?
After the introduction of a PPI and trial period of a PPI (8 weeks), ensure adherence, switch the PPI or try BID.
Then perform an esophageal pH monitoring.
When the diagnosis is very clear such as epigastric pain going under the sternum, bad taste, sore throat, etc., then confirmatory testing is not necessary.
Some resources state that switching a PPI is moot since all PPIs have the same efficacy.
What are the common complications of chronic GERD?
Esophagitis.
Esophageal strictures.
Extra-esophageal complications such as asthma, laryngitis, dental disease, and pneumonia.
Barrett’s esophagus.
What endoscopic findings are associated with Barrett’s esophagus?
Intestinal metaplasia of the esophageal squamous epithelium.
It usually takes 5 years for the columnar metaplasia to occur.
0.5% of Barrett’s esophagus cases will progress to cancer.
Which group of patients requires screening for Barrett’s esophagus?
Men >50 with chronic GERD (>5 years) or other significant risk factors like smoking, obesity, family history of esophageal cancer or adenocarcinoma.
What is the surgical procedure called that can treat severe or refractory GERD?
Fundoplication
Surgical intervention is typically the next move after the patient is experiencing symptoms and PPIs have failed.
What is the surveillance for Barrett’s Esophagus without dysplasia?
Endoscopy with biopsies every 3-5 years to monitor for progression to dysplasia.
What is the surveillance for Barrett’s Esophagus with low grade dysplasia?
Endoscopy every 6-12 months if management is surveillance-based, with biopsies following the Seattle protocol.
What is the surveillance for Barrett’s Esophagus high grade dysplasia?
Resection.
What are the important differential diagnosis for GERD?
Diabetic gastroparesis
Cardiovascular origin
Esophagitis
Ulcers
What is the mechanism of action of metoclopramide in diabetic gastroparesis?
Enhances gastric motility and accelerates gastric emptying.
What is the first-line medication for diabetic gastroparesis?
Metoclopramide, a prokinetic agent.
