GERD Flashcards
GERD =
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
Pathogenesis
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
Factors that contribute to worsening of symptoms of GERD
- Transient lower esophageal sphincter (LES) relaxation
- Hiatal Hernia (Mechanical disruption of anatomy)
- Irritant Effects of Refluxate (Acid versus alkali)
- Abnormal Esophageal Clearance or Peristalsis
(i. e. achalasia) - Delayed Gastric Emptying (i.e. Gastroparesis)
Meds that can contribute to GERD symptoms by causing decrease or loss of LES tone and/or prolong gastric emptying time
-adrenergic agonists -adrenergic antagonists anticholinergics tricyclic antidepressants calcium channel blockers Progesterone Theophylline diazepam
Meds that can contribute to GERD symptoms by causing direct damage to the esophageal mucosa
Tetracycline Quinidine Potassium chloride tablets Iron salts NSAIDs Bisphosphonates
Mechanism of Reflux
The primary event in the pathogenesis of GERD is movement of gastric content from the stomach into the esophagus.
Factors affecting Mechanism of Reflux
Decrease esophageal clearance Incompetent LES Hiatal Hernia Increase intra-abdominal pressure Delayed Gastric emptying time
Mechanisms Causing GE Junction Incompetence
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
Clinical Findings
Heartburn
Regurgitation
Dysphagia
Extraesophageal Clinical Manifestations
Chest pain Hoarseness Chronic cough Sore throat Wheezing Throat clearing Laryngospasm Dental erosion
Heartburn Clinical Findings
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.
Regurgitation Clinical Findings
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)
Dysphagia Clinical Findings
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.”
Los Angeles Classification of Esophagitis
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
Management of GERD
Mild symptoms: Lifestyle modification Dietary modification PRN antacid use OTC H2 antagonists
More debilitating symptoms usually require more pharmacologically sustained acid-suppressive therapy
Lifestyle Modifications
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
Empirical Tx
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
Pharmacotherapy
Goal of Pharm tx is to maintain esophageal pH >4 to promote healing and reduce symptoms
Antacids
prompt but temporary relief
Prokinetics
Improvement of symptoms in mild GERD
Effective for healing only mild degrees of erosive esophagitis
Can be useful in a select patient population
H2RAs
Relief of heartburn symptoms in ~50% of patients
Indicated for the healing of erosive esophagitis
PPIs
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)
Surgery
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.
Esophyx
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
Diagnostic Testing
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
Testing
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
Upper Endoscopy
Technique of choice for determining the presence and severity of erosive esophagitis
Only reliable method for detection of Barrett’s Esophagus
Ambulatory pH Monitoring aka Espphageal Manometry
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
Complications of GERD
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
Barrett’s Esophagus
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
Esophageal Adenocarcinoma
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
Esophageal Stricture
narrowing of the esophagus due to scar formation, inflammation, or both. And, is considered the result of GERD
Tx often ballooning
When to Refer
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
