GERD

Question 1

GERD =

Answer 1

Some dispute over definition, but many providers like this one:
GERD should be used to include all individuals who are exposed to the risk of physical complications from gastroesophageal reflux, or who experience clinically significant impairment of health-related well-being (quality of life) due to reflux-related symptoms, after adequate reassurance of the benign nature of their symptoms

Question 2

Pathogenesis

Answer 2

Extent of symptoms and of mucosal injury is proportional to the frequency of reflux events, the duration of mucosal acidification, and the caustic potency of refluxed fluid

Question 3

Factors that contribute to worsening of symptoms of GERD

Answer 3

1. Transient lower esophageal sphincter (LES) relaxation
2. Hiatal Hernia (Mechanical disruption of anatomy)
3. Irritant Effects of Refluxate (Acid versus alkali)
4. Abnormal Esophageal Clearance or Peristalsis
   (i. e. achalasia)
5. Delayed Gastric Emptying (i.e. Gastroparesis)

Question 4

Meds that can contribute to GERD symptoms by causing decrease or loss of LES tone and/or prolong gastric emptying time

Answer 4

-adrenergic agonists
-adrenergic antagonists
anticholinergics
tricyclic antidepressants
calcium channel blockers
Progesterone
Theophylline
diazepam

Question 5

Meds that can contribute to GERD symptoms by causing direct damage to the esophageal mucosa

Answer 5

Tetracycline
Quinidine
Potassium chloride tablets
Iron salts
NSAIDs
Bisphosphonates

Question 6

Mechanism of Reflux

Answer 6

The primary event in the pathogenesis of GERD is movement of gastric content from the stomach into the esophagus.

Question 7

Factors affecting Mechanism of Reflux

Answer 7

Decrease esophageal clearance
Incompetent LES
Hiatal Hernia
Increase intra-abdominal pressure
Delayed Gastric emptying time

Question 8

Mechanisms Causing GE Junction Incompetence

Answer 8

Transient lower esophageal sphincter relaxations (tLESRs)
A hypotensive lower esophageal sphincter (LES) –normal pressure is 15 to 25 mmHg-
Anatomic disruption of the gastroesophageal junction,
often associated with a hiatal hernia

Question 9

Clinical Findings

Answer 9

Heartburn
Regurgitation
Dysphagia

Question 10

Extraesophageal Clinical Manifestations

Answer 10

Chest pain
Hoarseness
Chronic cough
Sore throat
Wheezing 
Throat clearing
Laryngospasm
Dental erosion

Question 11

Heartburn Clinical Findings

Answer 11

Heartburn occurs predominantly after meals (30-60 minutes) and improves from taking antacids and baking soda
Heartburn often triggered by
unusually large meals
fatty, spicy, or acidic foods
bending, stooping, or lying down
lifting, straining, or other strenuous activities
When this symptom is dominant, the diagnosis
of GERD is established with a high degree of reliability.

Question 12

Regurgitation Clinical Findings

Answer 12

an effortless return of gastric contents into the esophagus and frequently into the mouth; often confused with vomiting.
(often contains acidic juice, bile, pepsin, food, and saliva etc)

Question 13

Dysphagia Clinical Findings

Answer 13

basically difficulty swollowing.
Pts may have a sensation that food is being hindered in passing from the mouth to the stomach
“I can’t swallow.” “feels like food is stuck in my throat.”

Question 14

Los Angeles Classification of Esophagitis

Answer 14

Grade A Mucosal break < 5 mm in length
Grade B Mucosal break > 5mm
Grade C Mucosal break continuous between > 2 mucosal folds
Grade D Mucosal break >75% of esophageal circumference

Question 15

Management of GERD

Answer 15

Mild symptoms:
Lifestyle modification
Dietary modification
PRN antacid use
OTC H2 antagonists

More debilitating symptoms usually require more pharmacologically sustained acid-suppressive therapy

Question 16

Lifestyle Modifications

Answer 16

Weight loss
H.O.B. elevation
Avoid supine position after meals
Eliminate Smoking
Decreased LES tone and increase Pylorus tone
Promote salivation: 
chew gum, oral lozenges
Dietary Modification:
Avoid:
Colas, red wine, o.j.
Chocolate
Mint and mint flavored products
Excessive alcohol
Caffeine and caffeinated products

Question 17

Empirical Tx

Answer 17

in pts with typical S&S of heartburn and regurgitation, empirical tx for 4 wks is sufficient with no need for dx testing
Response to tx confirms dx
further investigation is necessary for those who don’t respond

Question 18

Pharmacotherapy

Answer 18

Goal of Pharm tx is to maintain esophageal pH >4 to promote healing and reduce symptoms

Question 19

Antacids

Answer 19

prompt but temporary relief

Question 20

Prokinetics

Answer 20

Improvement of symptoms in mild GERD
Effective for healing only mild degrees of erosive esophagitis
Can be useful in a select patient population

Question 21

H2RAs

Answer 21

Relief of heartburn symptoms in ~50% of patients

Indicated for the healing of erosive esophagitis

Question 22

PPIs

Answer 22

Significantly more effective than H2RAs for both symptom resolution and healing of erosive esophagitis
Also effective in more severe cases of GERD
Most patients respond well to standard therapy, but some require prolonged and/or high-dose treatment (esp pts with nocturnal reflux)

Question 23

Surgery

Answer 23

2 common procedures, both done through intraabdominal, laparoscopic approach
1. Nissen fundoplication: which entitles a complete wrap of the gastric fundus around the esophagus
2. Gastropexy: which entitles a partial fundal wrap around the esophagus
Nissen has shown greater success aver gastropexy in the long run.

Question 24

Esophyx

Answer 24

newest modality in surgical teschniques
Trans-oral procedure, the stomach wall is suctioned into the device’s tissue port, creating a large plication. Non-resorbable fasteners are then deployed across the fold to hold the tissue in place

Question 25

Diagnostic Testing

Answer 25

Empiric tx Upper endoscopy Barium esophography - has little value Ambulatory Esophageal pH Monitoring - best study for documenting acid reflux, but unnecessary in most - helpful for 2 types of pts: document reflux in surg candidate with nrml scope, eval pt's unresponsive to PPI

Question 26

Testing

Answer 26

H. pylori–specific IgG (serum or salivary antibody) is a useful marker for epidemiologic studies of past or current infection, but its sensitivity is suboptimal. A positive antibody screen should be confirmed by a different test (such as fecal antigen, urea breath test, or endoscopy

Question 27

Upper Endoscopy

Answer 27

Technique of choice for determining the presence and severity of erosive esophagitis Only reliable method for detection of Barrett's Esophagus

Question 28

Ambulatory pH Monitoring aka Espphageal Manometry

Answer 28

Useful in patients with chest pain or pulmonary/upper respiratory symptoms with negative cardiac and pulmonary findings patients with refractory symptoms, unresponsive to medical management endoscopy-negative patients with persistent symptoms

Question 29

Complications of GERD

Answer 29

``` d/t constant exposure of the esophagus to the gastric content lead, as previously discussed, to the development of GERD, and if improperly diagnosed and treated patient may suffer from complications: Esophageal complications Barrett’s esophagus adenocarcinoma stricture ulceration and bleeding ```

Question 30

Barrett's Esophagus

Answer 30

A change in the esophageal epithelium of any length that can be recognized at endoscopy and is confirmed to have intestinal metaplasia by biopsy Normally the lower esophagus is lined with sqamous epithelial cell. It is believed that with constant exposure to gastric acid and as a result of lower esophageal damage, as an adaptation to this acidic environment exposure the sqamous cell transform to Columnar which is more resistant to acid. Columnar epithelium is found normally in the stomach and intestine, hence the term intestinal metaplasia In the study of LES metaplasia refers to change in the cell structure whereas dysplasia is cancerous

Question 31

Esophageal Adenocarcinoma

Answer 31

The development of cancerous lesion in the esophageal body; please note, that the incidence of esophageal adenocarcinoma increases with the severity of symptoms and directly proportional to low esophageal pH. Adenocarcinoma of the esophagus is independent of any other adenocarcinoma in the body. Treatment based on the degree and disease staging . Rarely radiation, surgery, stenting in the presence of esophageal tracheal fistula

Question 32

Esophageal Stricture

Answer 32

narrowing of the esophagus due to scar formation, inflammation, or both. And, is considered the result of GERD Tx often ballooning

Question 33

When to Refer

Answer 33

Patients with atypical GERD symptoms whose symptoms do not resolve with 3 months of high-dose proton pump inhibitor therapy Patients with significant metaplasia Patients with Barrett Esophagus for endoscopic surveillance Presence of Barrett esophagus with metaplasia or early mucosal cancer Endoscopy is needed Esophageal pH testing is needed Surgical fundoplication is considered