GERD Flashcards
General findings
Incidenza del 15–30%, senza variazioni legate al genere.
La sequela più comune del reflusso è l’esofagite, e le strictures sono la sequela più comune dell’esofagite!
Gastroesophageal reflux disease (GERD) is a chronic condition in which retrograde flow of stomach contents into the esophagus causes irritation to the epithelial lining. Reflux episodes are primarily caused by inappropriate, transient relaxation of the lower esophageal sphincter (LES). Risk factors include smoking, alcohol consumption, stress, obesity, and anatomical abnormalities of the esophagogastric junction (e.g., hiatal hernia). The chief complaint is retrosternal burning pain (heartburn), but a variety of other symptoms, such as dysphagia and a feeling of increased pressure, are also common. Suspected GERD should already receive empirical treatment, but further diagnostic steps, such as an upper endoscopy and/or 24-hour pH test, may be indicated to confirm the diagnosis. Management involves lifestyle modifications, medications, and possibly surgery. Proton pump inhibitors (PPIs) are the treatment of choice, although other agents – such as histamine H2-receptor antagonists (H2RAs) – may also be helpful. In addition to relieving symptoms, treating esophagitis is especially important, as chronic mucosal damage can lead to a premalignant condition known as Barrett’s esophagus, further progressing to adenocarcinoma of the esophagus.
Definition
Gastroesophageal reflux: regurgitation of stomach contents into the esophagus (can also occur in healthy individuals, e.g., after consuming greasy foods or wine)
Gastroesophageal reflux disease (GERD): A condition in which reflux causes troublesome symptoms (typically including heartburn or regurgitation) and/or esophageal injury/complications. The most common endoscopic finding associated with esophageal mucosal injury is reflux esophagitis.
✔NERD (non-erosive reflux disease): characteristic symptoms of gastroesophageal reflux disease in the absence of esophageal injury, such as reflux esophagitis, on endoscopy (50–70% of GERD patients)
ERD (erosive reflux disease): gastroesophageal reflux with evidence of esophageal injury, such as reflux esophagitis, on endoscopy (30–50% of GERD patients)
Risk factors
All three substances decrease LES tone. Alcohol also has toxic-inflammatory effects on the esophageal mucosa and decreases esophageal motility. Coffee increases stomach acid production! (stimola il rilascio di istamina che agisce sui recettori H2)
Il progesterone induce decreased LES tone!
-Main mechanism: transient lower esophageal sphincter relaxations .
The dysfunctional LES loosens independent of swallowing and has a decreased ability to constrict, which allows stomach contents to uncontrollably flow back into the esophagus (otherwise known as sphincter insufficiency).
Causes ∼⅔ of reflux episodes
Risk factors/associations
- Lifestyle habits such as smoking, caffeine and alcohol consumption
- Stress
- Obesity
✔Pregnancy (GERD is present in up to 80% 👓 of pregnancies. Underlying pathophysiology includes increased abdominal pressure, decreased LES tone (due to high estrogen and progesterone levels during pregnancy) and prolonged gastric emptying resulting from affected gastric motility.)
-Diaphragm dysfunction
-Angle of His enlargement (> 60°)
-Iatrogenic (e.g., after gastrectomy)
-Inadequate esophageal protective factors (i.e., saliva, peristalsis)
-Gastrointestinal malformations and tumors: gastric outlet obstruction, gastric cardiac carcinoma
👓Scleroderma (in asssociazione a disfagia)
💥Sliding hiatal hernia: ≥ 90% of patients with severe GERD (ernia da scivolamento, con alterazione della funzionalità del LES)
Clinical findings
-Chief complaint: retrosternal burning pain (heartburn) that worsens while lying down (e.g., at night) and after eating
Pressure sensation in the chest Belching, regurgitation Dysphagia Chronic non-productive cough and nocturnal cough Nausea and vomiting Halitosis Triggers: Bending down, supine position Habits: smoking and/or alcohol consumption Psychological factors: especially stress
Diagnosis
Ph < di 4 è considerato evento diagnostico, e la gravità è maggiormente correlata con la durata di un singolo evento rispetto al numero di eventi di reflusso.
✔Empirical therapy: If GERD is clinically suspected and there are no indications for endoscopy, empiric therapy – ranging from lifestyle modifications to a short trial with PPIs – should be initiated. A GERD diagnosis is assumed in patients who respond to this therapeutic regimen.
✔Upper endoscopy
Used to classify reflux esophagitis and conduct biopsies!
Indications for endoscopy
-Signs of complicated disease (e.g., dysphagia, painful swallowing, weight loss, iron deficiency anemia, and aspiration pneumonia)
-Extended course of symptoms
-Noncardiac chest pain
-No response to PPI treatment
✔Esophageal pH monitoring
Measured over 24 hours via nasogastric tube with a pH probe
Sudden drops to a pH ≤ 4 are consistent with episodes of acid reflux into the esophagus
Indications
!To confirm suspected NERD (essendo presenti i sintomi ma non l’esofagite erosiva, permette di correlare l’episodio di reflusso con la comparsa dei sintomi)
Before endoscopic or surgical treatment options are initiated in patients with NERD
GERD is diagnosed when drops in esophageal pH correlate with symptoms of acid reflux and precipitating activities noted in the patient’s event diary.
DDX
Alendroato può indurre esofagite!👓
✔Infectious esophagitis: generally in immunocompromised patients
- Esophageal candidiasis: Endoscopy shows white or yellowish adherent plaques.
- Herpes esophagitis: Endoscopy shows superficial ulcers in the upper or mid esophagus in the absence of plaques.
- CMV esophagitis: Endoscopy shows distal mucosal erosions and ulcers; viral inclusion bodies in cell nuclei on biopsy.
✔Drug-induced esophagitis: Some medications may cause esophageal mucosal irritation, leading to erosions and ulcers.
Causes:
-Antibiotics (e.g., tetracycline, doxycycline, and clindamycin)
-Anti-inflammatory drugs (e.g., Aspirin)
-Bisphosphonates (e.g., Alendronate)💥
Others (e.g., potassium chloride, quinidine, and iron compounds)
Endoscopic findings: punched-out ulcers with mild inflammatory changes of the surrounding mucosa
✔Eosinophilic esophagitis
Associated with allergic disease (allergic asthma, allergic rhinitis) in 50% of cases
Endoscopic findings
Circumferential mucosal lesions (rings/corrugations)
Mucosal fragility
Histological finding: increased number of eosinophils
Medical therapy
8 weeks of PPI!
Treatment of choice: Standard-dose of PPI for at least 8 weeks (once-daily therapy)
1.No response: further diagnostic evaluation
Partial response: increase the dose (to twice daily therapy) or switch to a different PPI
- Good response: discontinue PPI after 8 weeks
- Maintenance therapy: if symptoms recur after discontinuation of PPIs and in the case of complications, e.g. Barret’s esophagus
- After 8 weeks of initial treatment, reduce PPI to lowest effective dose or switch to H2RAs (only in patients without complications!)
Surgical therapy
Indications
- Equally effective alternative to medical therapy in certain patients with chronic GERD 💥
- Complications (e.g., Barrett esophagus, strictures, recurrent aspiration) (anche se per il trattamento delle strictures si parte con la dilatazione pneumatica)
Nissen fundoplication!
If hiatal hernia is present :
- Hiatoplasty: margins of the widened hiatus are sutured together
- Fundopexy or gastropexy: the protruding part of the stomach is tethered to the diaphragm → keeps it in place and relieves the tension placed on the cuff
Esophageal stricture
Solid food dysphagia!!
Bisogna eseguire sempre una egds con biopsie multiple per escludere esofagite eosinofila ma soprattuto un adenocarcinoma!💥
👓Most common sequela of reflux esophagitis!
-Clinical features: cause solid food dysphagia
- Diagnostics
1. Barium esophagram (best initial test): narrowing of the esophagus at the gastroesophageal junction
2. Endoscopy with biopsies: to rule out malignancy and eosinophilic esophagitis - Treatment
1. First-line treatment: dilation with bougie dilator/balloon dilator + proton pump inhibitors in patients with reflux
2. In refractory cases (multiple recurrences): steroid injection prior to dilation, endoscopic electrosurgical incision
Altre complicanze
Esophageal ring:
👓Schatzki rings at the squamocolumnar junction are the most common type
Clinical features and management similar to that of an esopahgeal stricture
- Aspiration of gastric contents leads to:
1. Aspiration pneumonia
2. Chronic bronchitis
3. Asthma (exacerbation): esiste una correlazione bidirezionale tra le due patologie. Da una parte la GERD causa microaspirazioni bronchiali inducendo una reazione irritativa di tipo asmatica , mentre il soggetto con asma ha un’iperinflazione polmonare con riduzione dell’efficacia della barriera antireflusso rappresentata dal LES e inoltre il trattamento dell’asma mediante i broncodilatatori può inficiare il tono muscolare del LES
4. Laryngitis and hoarseness
Barrett esophagus
Precancerous condition for adenocarcinoma!
Ricorda che in high grade dysplasia, dopo la conferma (3 mesi) si procede con esofagectomia!
Reflux esophagitis → stomach acid damages squamous epithelium → squamous epithelium becomes replaced by columnar epithelium and goblet cells (intestinal metaplasia, Barrett’s metaplasia)
The physiological transformation zone (“Z-line”) between squamous and columnar epithelium is shifted upward
- Short-segment Barrett’s esophagus (< 3 cm of columnar epithelium between Z-line and GEJ)
- Long-segment Barrett’s esophagus (> 3 cm of columnar epithelium between Z-line and GEJ) → higher cancer risk!
