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Clin Med II > GERD > Flashcards

GERD Flashcards

1
Q

What are some factors that exacerbate GERD?

A

Increased gastric volume after meals.
Increased gastric pressure due to obesity.
Recumbent or bending after meal (gastric contents are nearer the LES).
Delayed gastric emptying; gastroparesis.
Medications (some can lower LES pressure; others can cause esophagitis.)
Certain foods → heartburn by decreasing LES pressure

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2
Q

GERD pathophysiology:

A 
Pressure in stomach is able to overcome the LES:
transient sphincter relaxation
anatomical disruption
decreased sphincter strength
increased stomach pressure
   - (e.g. a large meal)
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3
Q

GERD clinical presentation

A

Most common symptoms are heartburn and/or regurgitation

Patients may be asymptomatic (not all have heartburn)

Occasional or transient heartburn is a common finding in many individuals without GERD

With GERD, the heartburn are more bothersome, frequent and prolonged

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4
Q

Heartburn

A

Location - retrosternal area
Character – burning sensation
Timing – usually 30-60 minutes after meals and on reclining
Alleviating - antacids

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5
Q

Regurgitation

A

Perception of flow of refluxed gastric content into the mouth

Usually regurgitate acidic material is mixed with small amounts of undigested food

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6
Q

Chest pain due to GERD

A

Location: substernally; epigastric
Character: squeezing or burning
Radiating: to the back, neck, jaw, or arms
Duration: lasting anywhere from minutes to hours
Alleviating: resolving either spontaneously or with antacids
Exacerbating: usually occurs after meals, awakens patients from sleep, and may be exacerbated by emotional stress

Always evaluate for CAD before attributing any chest discomfort to an atypical presentation of GERD.

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7
Q

GERD evaluation red flag symptoms!! DONT FORGET TO ASK ABOUT THESE!!

A 
Weight loss
Dysphagia
Odynophagia
Bleeding (hematemesis or melana) 
Anorexia (Loss of appetite)
Signs of systemic illness
Failure to respond to 4-6 weeks of PPI treatment
GERD lasting > 5 years
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8
Q

GERD: Diagnosis (classic GERD)

A 
Classic GERD can be diagnosed by taking a thorough history: 
Heartburn and regurgitation
Worsening of symptoms after a large meal
Worsening of symptoms while lying down
Relief of symptoms with OTC antacids
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9
Q

When is it appropriate to pursue diagnostic testing for GERD?

A
  1. Prevent misdiagnosis – patient with “red flags” or alarm symptoms
  2. Confirm diagnosis - patient with atypical symptoms
  3. Patient failure to respond to adequate medication trial
  4. Identify complications of reflux disease (e.g., in patients with long-standing GERD symptoms (2-5 years)
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10
Q

GERD diagnosis: Atypical symptoms

A

When atypical symptoms are present other diagnoses will need to be ruled out before attributing symptoms to GERD.

Look for temporal association with meals.

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11
Q

GERD Ddx

A

Esophageal dysmotility

Esophageal spasm

Scleroderma

Dyspepsia (that is not due to GERD) – PUD, gastric malignancy, NSAID induced

Bile Acid Reflux (Duodenogastroesophageal Reflux)

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12
Q

GERD ddx: Esophageal dysmotility

A

Dysphagia, chest pain, and regurgitation that may be worsened by cold liquids, emotional distress or hurried eating

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13
Q

GERD ddx: Esophageal spasm

A

Dysphagia and chest pain

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14
Q

GERD ddx: Scleroderma

A

Raynaud’s phenomenon, stiffness of the fingers and knees, and skin thickening

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15
Q

GERD ddx: Dyspepsia

A

Upper abdominal discomfort often associated with belching, nausea and/or bloating, and sometimes associated with food intake

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16
Q

GERD ddx: Bile acid reflux

A

Duodenal contents - biliary secretions, pancreatic enzymes, and bicarbonate flow up into the stomach and esophagus

Pyloric sphincter - normally prevents bile from entering the stomach from duodenum; in bile acid reflux, this sphincter doesn’t close properly → reflux

LES – a problem with this sphincter would then allow the fluid from stomach to esophagus

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17
Q

GERD physical exam

A

No specific physical findings specific for GERD.

As part of the evaluation look for evidence of systemic disease.

18
Q

GERD diagnostic evaluation: Complicated

A

Upper GI series (barium swallow)- Not recommended for diagnosis of GERD but can be used to rule out other disease.
Upper endoscopy
24 hour esophageal pH monitoring
Wireless capsule pH study

19
Q

Barrett’s esophagus

A

metaplastic changes in the squamous epithelium of the esophagus as a consequence of chronic GERD

risk for development of adenocarcinoma of the esophagus

20
Q

Ambulatory esophageal pH monitoring

A

Records the distal esophageal pH continuously using a transnasal probe or a pill-sized capsule (Bravo capsule) placed 5 cm above the LES

A battery-powered device carried by the patient records data from the probe, as well as the time of meals and symptom-onset

This allows correlation between patient-reported symptoms and objective signs of acid exposure in the distal esophagus

They are looking for the % of time during which the pH < 4.0 when patient is upright.

Provides the most sensitive test for identifying presence of acid in the esophagus
Only used in selected patients

21
Q

GERD treatment: Short term vs long term

A

Short-term is aimed at relief of symptoms and mucosal healing

Long-term: Symptom control and maintenance of esophageal healing.

22
Q

GERD lifestyle modifications

A

Weight loss for patients who are overweight or have had recent weight gain

Elevation of the head of the bed to raise head and upper thorax in individuals with nocturnal or laryngeal symptoms (e.g., cough, hoarseness, throat clearing). Can either by put 6 – 8 inches

Avoiding trigger foods, including alcohol, chocolate, coffee, high-fat content foods, oranges, peppermint, and tomato – patient notes correlation, then can eliminate the food and evaluate for symptom improvement

23
Q

GERD medication management

A

Choice of agent depends in part on severity of symptoms (no standard definition of severity).

24
Q

Mild GERD

A

Usually thought of as intermittent (< 2 episodes per week) symptoms that may be precipitated by dietary indiscretions

histamine-2 receptor antagonists (H2RAs) daily are the first line of therapy

Used in standard doses [equivalent to ranitidine (Zantac) 150 mg twice daily]

These drugs can achieve symptomatic relief in ~ 60% of patients, and endoscopic resolution of documented esophagitis in ~50% of patients

25
Q

Severe GERD

A

Symptoms that are associated with intense discomfort and/or significant esophageal pathology

26
Q

Moderate GERD

A

Somewhere in between the two

27
Q

Intermittent GERD

A

OTC antacids effective with ~20% of patients have long-term relief of symptoms

28
Q

What are the treatment management options

A

2 options –

Step-up therapy (increase potency of Rx until symptoms controlled): Typically used in mild GERD

Step-down therapy (start with most potent Rx and decrease until breakthrough symptoms)

29
Q

GERD management: PPI

A

When a PPI is used for treatment:
The choice of a specific oral PPI and whether OTC vs. prescription PPIs are prescribed are often determined by patient preference and payer coverage
Oral PPIs should be taken 30 - 60 minutes before breakfast for maximal inhibition of proton pumps
PPIs should not be administered concomitantly with H2-receptor antagonists
In general, PPIs should be prescribed at the lowest dose and for the shortest duration appropriate to the condition being treated
When discontinuing PPI therapy, taper the dose gradually in patients on PPIs for >6 months

30
Q

GERD management: Antacid

A

These DO NOT prevent GERD. They are NOT antisecretory Rx

Role is limited to intermittent (on-demand) use for relief of mild GERD symptoms that occur less than once a week

Usually contain a combo of magnesium trisilicate, aluminum hydroxide, or calcium carbonate

These neutralize gastric pH → decreasing exposure of esophageal mucosa to gastric acid during episodes of reflux

Antacids begin to provide relief of heartburn within 5 minutes. Have a short duration of effect of 30 - 60 minutes

Problematic if used in patients with kidney disease!

31
Q

Mild GERD step-up therapy

A

Start with H2RAs prn (cimetidine, rantidine, etc)
Assess in 2 weeks and if continued symptoms increase the dose for at least 2 weeks. If symptoms persist switch to PPI for 4-6 weeks.

32
Q

Severe GERD step down therapy

A

Treat with PPI for 4-8 weeks

If symptoms persist, refer to GI

33
Q

PPI long term use

A

Long-term PPI use has been associated with increased risk of fracture presumably because of decreased calcium absorption.
H2RAs have not shown the same association

Both PPIs and H2RAs have been associated with Cdiff infection, CAP, kidney Acute interstitial nephritis, CKD, and dementia/ cognitive decline.

34
Q

PPI side effects

A

HA, diarrhea, constipation, and abdominal pain.

35
Q

Discontinuing PPI

A

Start patient on twice daily maximum-dose H2RA treatment, such as ranitidine 300 mg BID or famotidine 40 mg BID, with antacids for breakthrough.

If on PPI > 6 months need to do a more gradual taper.

36
Q

Management of recurrent symptoms after discontinuing PPI

A

⅔ of GERD patients relapse when medication is discontinued. With recurrent symptoms resume medication dose that worked before.

IF symptoms recurred > 3 months go back to PPI for 8 weeks.

If < 3 months after discontinuation refer for to GI for EGD and long term maintenance.

37
Q

Complications of GERD

A

Esophageal erosions
Esophageal ulcers (can bleed and can stimulate fibrous tissue deposition with stricture formation, resulting in dysphagia)
If esophageal stricture develops, endoscopy with dilation may need to be performed
Barrett’s esophagus

38
Q

Barrett’s esophagus

A

In Barrett’s, distal esophagus is lined with metaplastic columnar epithelium and has a darker salmon-colored appearance; it also has “tongues” of mucosa reaching proximally in the esophagus

Puts the patient at an increased risk of developing adenocarcinoma.

39
Q

Barrett’s esophagus: Criteria for diagnosis

A

Endoscopic examination reveals columnar epithelium lining the distal esophagus

biopsy must show a metaplastic (i.e., the cells are normal in appearance and do not have any precancerous appearance or dysplasia, but are in the wrong location) intestinal-type epithelium

40
Q

Barrett’s esophagus treatmetn

A
  1. Surveillance
  2. Endoscopic ablation (or surgical resection) of the Barrett’s mucosa
  3. Acid Suppression
41
Q

Barrett’s esophagus monitoring

A

The role of endoscopy in Barrett’s esophagus is to detect dysplasia and early, curable adenocarcinoma

The American Council on Gastroenterology (ACG) recommends that patients with Barrett’s esophagus undergo surveillance endoscopy and biopsy at an interval determined by the presence and grade of dysplasia

42
Q

When to refer to GI

A
  1. The patient requires endoscopy or specialized testing (e.g., 24-hour pH testing)
  2. The patient fails PPI therapy (symptoms persist for 4-8 weeks of Rx)
  3. The patient requires a long-term management strategy
  4. Patients have red flag/worrisome symptoms

Clin Med II (7 decks)

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