GERD Flashcards
What are some factors that exacerbate GERD?
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
GERD pathophysiology:
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)
GERD clinical presentation
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
Heartburn
Location - retrosternal area
Character – burning sensation
Timing – usually 30-60 minutes after meals and on reclining
Alleviating - antacids
Regurgitation
Perception of flow of refluxed gastric content into the mouth
Usually regurgitate acidic material is mixed with small amounts of undigested food
Chest pain due to GERD
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.
GERD evaluation red flag symptoms!! DONT FORGET TO ASK ABOUT THESE!!
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
GERD: Diagnosis (classic GERD)
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
When is it appropriate to pursue diagnostic testing for GERD?
- Prevent misdiagnosis – patient with “red flags” or alarm symptoms
- Confirm diagnosis - patient with atypical symptoms
- Patient failure to respond to adequate medication trial
- Identify complications of reflux disease (e.g., in patients with long-standing GERD symptoms (2-5 years)
GERD diagnosis: Atypical symptoms
When atypical symptoms are present other diagnoses will need to be ruled out before attributing symptoms to GERD.
Look for temporal association with meals.
GERD Ddx
Esophageal dysmotility
Esophageal spasm
Scleroderma
Dyspepsia (that is not due to GERD) – PUD, gastric malignancy, NSAID induced
Bile Acid Reflux (Duodenogastroesophageal Reflux)
GERD ddx: Esophageal dysmotility
Dysphagia, chest pain, and regurgitation that may be worsened by cold liquids, emotional distress or hurried eating
GERD ddx: Esophageal spasm
Dysphagia and chest pain
GERD ddx: Scleroderma
Raynaud’s phenomenon, stiffness of the fingers and knees, and skin thickening
GERD ddx: Dyspepsia
Upper abdominal discomfort often associated with belching, nausea and/or bloating, and sometimes associated with food intake
GERD ddx: Bile acid reflux
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
GERD physical exam
No specific physical findings specific for GERD.
As part of the evaluation look for evidence of systemic disease.
GERD diagnostic evaluation: Complicated
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
Barrett’s esophagus
metaplastic changes in the squamous epithelium of the esophagus as a consequence of chronic GERD
risk for development of adenocarcinoma of the esophagus
Ambulatory esophageal pH monitoring
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
GERD treatment: Short term vs long term
Short-term is aimed at relief of symptoms and mucosal healing
Long-term: Symptom control and maintenance of esophageal healing.
GERD lifestyle modifications
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
GERD medication management
Choice of agent depends in part on severity of symptoms (no standard definition of severity).
Mild GERD
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
Severe GERD
Symptoms that are associated with intense discomfort and/or significant esophageal pathology
Moderate GERD
Somewhere in between the two
Intermittent GERD
OTC antacids effective with ~20% of patients have long-term relief of symptoms
What are the treatment management options
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)
GERD management: PPI
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
GERD management: Antacid
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!
Mild GERD step-up therapy
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.
Severe GERD step down therapy
Treat with PPI for 4-8 weeks
If symptoms persist, refer to GI
PPI long term use
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.
PPI side effects
HA, diarrhea, constipation, and abdominal pain.
Discontinuing PPI
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.
Management of recurrent symptoms after discontinuing PPI
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.
Complications of GERD
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
Barrett’s esophagus
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.
Barrett’s esophagus: Criteria for diagnosis
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
Barrett’s esophagus treatmetn
- Surveillance
- Endoscopic ablation (or surgical resection) of the Barrett’s mucosa
- Acid Suppression
Barrett’s esophagus monitoring
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
When to refer to GI
- The patient requires endoscopy or specialized testing (e.g., 24-hour pH testing)
- The patient fails PPI therapy (symptoms persist for 4-8 weeks of Rx)
- The patient requires a long-term management strategy
- Patients have red flag/worrisome symptoms
