GERD Flashcards
sx of GERD
pyrosis (heartburn)* regurgitation* chest pain (mimics angina) - r/o cardiac cause dysphagia - r/o stricture water brash/hypersalivation globus sensation odynophagia nausea
Extraesophageal sx:
- bronchospasm
- laryngitis/hoarsness (consider laryngoscopy)
- chronic cough
- loss of dental enamel
worsens GERD
obesity gravity (elevate HOB) pregnancy tobacco/ETOH (pressure to LES) meds foods
Decrease LES pressure meds (worsen GERD)
anticholinergic (ditropan) TCA (amitriptyline) CCB Nitrates Narcotics
(CANNT)
Injure mucosa meds (worsen GERD)
bisphosphonates****(Fosamax, actonel) iron supplements NSAIDs/ASA potassium Tetracycline
(by the PIN)
hiatal hernia: what is it?
portion of stomach enters above diaphragm into chest
Most common hiatal hernia
sliding
types of hiatal hernias
sliding (most common) paraesophageal hernia (may require surgery)
Sx of hiatal hernias
asymptomatic
GERD
CXR of hiatal hernia
incidental
seen as retrocardiac mass w/ or w/o air fluid levels
dx difficult w/o air fluid levels
tests for GERD
barium contrast esophagram (not often used) EGD Esophageal impedence testing Esophageal pH monitoring Esophageal manometry
Barium contrast esophagram
shows hernia and strictures; mucosal inflammation NOT seen
EGD
BEST dx study to evaluate mucosal injury
dx mucosal injury
EGD
esophageal impedence testing
observation of bolus transit: complete or incomplete
Esophageal pH monitoring
quantify reflux and allow pt to log Sxs
high sensitivity for detecting reflux
mechanism: trans nasal cath vs. wireless capsule
(find non-acidic reflux)
Esophageal manometry
measure function of LES and peristalsis- pressure and pattern of esophageal mm contractions
Red flags for GERD
dysphagia hematemesis/GI bleed unexplained weight loss, fever, fatigue anemia inadequate response to tx** prior anti-reflux surgery personal hx of CA
dx for GERD
labs usually not needed w/ GERD w/o warning signs
Tx for GERD
lifestyle/diet mod (adjust bed, no food/drink 3 hrs before bed, weight loss, eliminate diet triggers)
Meds:
- antacids (TUMS)
- H2 blockers (ranitidine)
- PPI (prilosec, prevacid, nexium)
anti-reflux surgery
tx for mild/intermittenet sx (<1-2x/week, no esophagitis)
STEP UP tx:
lifestyle mod
H2RA’s
+/- antacids
severe sx (>2/week; impairs QOL)
STEP DOWN tx:
- PPI daily x 8 weeks + lifestyle mod
- gradually decrease tx (unless maintenance necessary)
when to take PPI
30 min before breakfast - better on empty stomach
antacids
don’t prevent GERD
neutralize pH
short lived benefit
H2 blockers/antagonists MOA
block action of histamine at H2 receptors of gastric parietal cells
leads to decrease secretion of stomach acid
H2 blocker drugs
ranitidine (zantac)
Famotidine (pepcid)
PPI MOA
reduce amount of acid produced by glands in the stomach
TAKE 30 MIN BEFORE 1ST MEAL OF DAY
PPI drugs
Omeprazole (prilosec)
Lansoprazole (prevacid)
Esomeprazole (nexium)
Pantoprazole (protonix)
Risk of PPI
infection (acid is protective- C. diff, etc)
Malabsorption (Mg*, Ca, B12, Fe)
F/u for PPI
Mg level periodically
yearly B12?
bone density scan?
Length of medication w/o esophagitis/barett’s
lowest down and shortest duration; dc meds in pts w/o sxs
Duration of pts w/ severe esophatitis or barett’s
maintenance PPI
Indications for acid-reflux surgery
failed med management
GERD complication (esophagitis, barrett’s)
noncompliance
Type of surgery for GERD
Nissen fundoplication- passage of gastric fundus behind esophagus to encircle the distal esophagus (open vs laparoscopic)
Most common cause of esophagitis
GERD- gastric acid, pepsin and bile irritate squamous epithelium
Types of esophagitis
reflux * most common infectious pill eosinophilic radiation
S/sx of esophagitis
GERD sx (heartburn, regurgitation, cough, CP)
Complications of esophagitis
bleeding
stricture
barrett’s
Barrett’s Esophagus definition
Squamous epithelium in distal esophagus is replaced w/ columnar epithelium * (due to recurrent acid injury)
M>F (~55 YO)
Barrett’s predisposed to
adenocarcinoma of esophagus (repeat EGD frequently)
Tx of Barrett’s
- indefinite use of PPI (qd vs bid)
- EGD surveillance to detect dysplasia
- Endoscopic Eradication Therapy (EET) = Endoscopic ablation (EA) and/or Endoscopic resection (ER)
ER
remove segment of barrett mucosa – therapeutic and provides info on involvement
EA (esophageal ablation)
thermal or photochemical energy to destroy barrett mucosa
Esophageal CA types
squamous cell carcinoma (SCC)
adenocarcinoma
SCC epidemiology
higher in urbanc
African american men
incidence decreasing
Risk factors of SCC
smoking** ETOH low fruit/veggies deficiency selenium, Sn caustic esophageal injury (hot coffee) HPV
Cause of adenocarcinoma
Barrett’s **
smoking
obesity
Epidemiology of Barrett’s
Caucasians
M>F (6:1)
incidence increasing
PREVENTION AND EARLY DETECTION
Prognosis of esophageal CA
50-80% have incurable, unresectable or metastatic disease
palliative tx- chemo, radiation, surgery depending on stage
Dysphagia
GET EGD!!!!
need to prevent
Infectious esophagitis
DM
Asthma
Tb
Pill esophagitis
pill gets stucked
Systemic illness
sclerosis- poor acid clearance leads to epithelial damage
Eosinophilic esophatitis causes
asthma, rhinitis, food allergy, chronic eczema
chronic, immune/antigen-mediated esophageal disease- EOSINOPHIL predominant inflammation
Sxs of eosinophilic esophagtitis
DYSPHAGIA, food impaction, CP, refractory GERD
Dx of eosinophilic esophagitis
Clinical + EGD (stacked circular rings, stricture)
Tx of eosinophilic esophagitis
diet (avoid allergens)
PPI topical corticosteroids (ICS: spray and swallow, not inhale)
+/- Esophageal dilation
Sx of esophageal motility disorders
dysphagia
noncardiac CP
refractory GERD
Major disorders of esophageal peristalsis
hypercontractile (Jackhammer) esophagus
Achalasia
Dx tests for motility
manometry
barium swallow
esophageal pH?
impedence monitoring
Manometry results for jackhammer (hypercontractile)
high pressure (high amplitude) contractions in esophagus normal relaxation of esophagogastric junction mimics angina (w/ meals)
Tx of Jackhammer esophagus
CCB (diltiazem)
TCA (imipramine)
+/- botulinum toxin
Achalasia
aperistalsis on manometry: no contraction on distal 2/3 of esophagus and incomplete LES relaxation
esophageal dilation
BIRD’S BEAK (persistently contracted LES)
Aperistalsis
Poor emptying of barium
Cause of achalasia
progressive degeneration of esophageal neurons leading to failure of relaxation of LES and no peristalsis
Sx of achalasia
dysphagia regurg difficulty belching, CP, heartburn gradual onset 4.7 yrs til dx
Dx of achalasia
Manometry
EGD necessary to r/o malignancy
barium swallow: dilation of esophagus and BIRD”s BEAK
Tx of achalasia
disrupt LES mm fibers (pneumatic dilation, heller myotomy)
Biochemical reduction in LES pressure (botulinum toxin, nitrates, CCB)
Mallory Weiss tear
mucosal laceration in distal esophagus and proximal stomach – associated w/ repetitive vomiting, retching
Predisposing factors for mallory weiss
excessive alcohol consumption hiatal hernia (increased abdominal pressure)
Boerhaave’s Syndrome
esophageal rupture
EMERGENCY
Dx of mallory weiss
EGD
clinical if issue already resolved
Tx of Mallor weiss
stabilize pt
control bleeding - EPI or electrocoagulation
address predisposing factors
