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X Clin Med III Exam I > GERD and Esophageal Disorders > Flashcards

GERD and Esophageal Disorders Flashcards

1
Q

When is reflux normal?

A

If it does not induce sxs or esophageal mucosal abnormalities

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2
Q

When is reflux considered GERD?

A

When reflux of the stomach contents cause troublesome sxs or complications

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3
Q

Typical GERD sxs

A

Heartburn (pyrosis) usually post prandial

Regurgitation

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4
Q

Extraesophageal manifestations of GERD

A

Bronchospasm
Laryngitis/ hoarseness
Chronic cough
Loss of dental enamel

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5
Q

Other sxs of GERD

A 
Chest pain (mimics angina)- squeezing, substernal, radiate to back, neck, jaws or arms- r/o cardic!
Dysphagia (r/o stricture)
Water brash or hypersalivation
Globus sensation
Odynophagia
Nausea
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6
Q

What can worsen GERD?

A 
Obesity
Gravity (elevate head of bed)
Pregnancy
Tobacco/ EtOH (LES pressure)
Meds
Foods
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7
Q

What meds increase GERD sxs by decreasing LES pressure?

A 
Anticholinergics
Tricyclic antidepressants (amitriptyline)
CCBs
Nitrates
Narcotics
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8
Q

What meds increase GERD sxs by injuring mucosa?

A 
Bisphosphonates (Fosamax, Actonel)
Iron supplements
NSAIDs/ aspirin
Potassium
Tetracycline
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9
Q

Types of hiatal hernia

A

Sliding (most common) where it just goes above diaphragm

Paraesophageal (may need surgery if causes entrapment)

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10
Q

Sxs of hiatal hernia

A

Usually asymptomatic and incidental finding

Can cause GERD (heartburn, cough, hoarseness, CP)

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11
Q

How do you see hiatal hernia on CXR?

A

Retrocardiac mass with or without an air fluid level (hard to make a diagnosis without air fluid level)

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12
Q

What can be seen with a barium contrast esophagram?

A

Hiatal hernia and strictures (use with dysphagia)

Cannot see mucosal inflammation (not used for GERD dx)

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13
Q

Best diagnostic study to evaluate mucosal injury

A

Esophagogastroduodenoscopy (EGD)

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14
Q

What is esophageal impedance testing used for?

A

Observation of bolus transit (complete or incomplete)

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15
Q

What is esophageal pH monitoring used for?

A

Quantify reflux and allow pt to log sxs
High sensitivity to detect reflux
-trans nasal catheter vs wireless capsule option

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16
Q

What is esophageal manometry used for?

A

Measures function of LES and peristalsis (pressures and pattern of esophageal muscle contractions)

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17
Q

Red flags for GERD dx

A

Dysphagia (may be because of a complication)
Hematemesis/ GI bleeding
Unexplained weight loss, fever or fatigue
Anemia
**Inadequate response to therapy
Prior anti-reflux surgery
Personal hx of cancer

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18
Q

What must be done with red flags for GERD?

A

Require further work up because they are not typical of GERD

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19
Q

How do you usually diagnose GERD?

A

Don’t need diagnostic studies with classic history without warning signs

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20
Q

Options for GERD tx

A

Lifestyle and dietary medications
Meds
Anti-reflux surgery

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21
Q

Lifestyle modifications for GERD tx

A

Adjust bed height
No food or drink within 3 hrs of bedtime
Weight loss
Selective elimination of dietary triggers

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22
Q

Med options for GERD tx

A

Antacids (TUMS)
H2 blockers (Ranitidine: Zantac)
Proton pump inhibitors (Prilosec, Prevacid, Nexium)

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23
Q

Tx for mild/intermittent GERD sxs (less than 1-2 episodes/ wk and no evidence of erosive esophagitis)

A

Step up therapy: lifestyle mod, H2Ra and maybe antacids

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24
Q

Tx for severe GERD sxs (over 2 episodes per week and impair quality of life)

A

Step down therapy: PPI daily for 8 wks and lifestyle– gradually decrease therapy (usually maintenance)

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25
Q

Antacids

A

Do not prevent GERD and neutralize pH

Short lived benefit

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26
Q

H2 blockers/H2 antagonists

A

Block action of histamine at H2 receptors of gastric parietal cells (leads to decrease secretion of stomach acid)
Ranitidine and Famotidine (Zantac and Pepcid)

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27
Q

Proton pump inhibitors

A

Reduce amt of acid produce by glands in the stomach

Take 30 min before 1st meal of day

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28
Q

Concerns associated with long term PPI use

A

Risk of infection (decreasing acid can increase risk of C diff and other infections)
Malabsorption (Mg, Ca, Iron)

29
Q

How long should a patient without severe erosive esophagitis and Barrett’s esophagitis stay on meds?

A

Lowest dose and shortest duration appropriate

DC meds completely in pts without sxs

30
Q

How long should a patient with severe erosive esophagitis and Barrett’s esophagitis stay on meds?

A

Require maintenance acid suppression with a PPI (recurrent sxs and complications likely if med DC)

31
Q

Indications for surgical management of GERD

A

Failed optimal med management
GERD complications (esophagitis, Barrett’s)
Noncompliance

32
Q

What is nissen fundoplication?

A

Surgical option for GERD

Passage of gastric fundus behind esophagus to encircle distal esophagus (allow LES to close all the way)

33
Q

Thoughts behind starting a new GERD medication

A

See what the pt has already tried

If full BID dosed H2 blocker was already used start PPI and if they haven’t tried that then do it!

34
Q

Normal step up for GERD tx

A

H2 blocker– PPI– PPI BID– close f/u with endoscopy

35
Q

Most common cause of esophagitis

A

GERD

36
Q

How does esophagitis happen?

A

Gastric acid, pepsin and bile irritate the squamous epithelium–can lead to irritation, inflammation, erosion or ulceration

37
Q

Types of esophagitis

A

Reflux (most common cause)
Infectious
Pill (can’t swallow pills)
Eosinophilic (asthma, rhinitis, food allergies, eczema)
Radiation
Associated with systemic illness (sclerosis)

38
Q

Sxs of esophagitis

A

Similar to GERD (heartburn, regurgitation, cough, CP)

39
Q

Complications of esophagitis

A

Bleeding, stricture, barrett esophagus

40
Q

What is Barrett esophagus?

A

Squamous epithelium in distal esophagus replaced with columnar epithelium (on biopsy) due to recurrent acid injury

41
Q

What is a pt with Barrett esophagus predisposed to?

A

Adenocarcinoma of esophagus (10-15% of pts undering EGD with sxs)

42
Q

Progression of Barrett’s esophagus

A

GERD–Barrett’s–low grade dysplasia–high grade dysplasia–adenocarcinoma

43
Q

Tx for Barrett’s esophagus

A

Indefinite use of PPI (aggressive anti-reflux tx may prevent cancer)
EGD surveillance to detect evidence of dysplasia
Endoscopic eradication therapy

44
Q

What is endoscopic eradication therapy (EET)?

A

Endoscopic ablation (thermal or photochemical energy to destroy mucosa) and/or endoscopic resection (remove segment or Barrett mucosa-therapeutic and provides info on depth of involvement)

45
Q

2 types of esophageal cancer

A

Squamous cell carcinoma

Adenocarcinoma

46
Q

Epidemiology of squamous cell carcinoma

A

Higher in African American Men
Higher in urban areas of US
Incidence decreasing
Risk factors like smoking and EtOH

47
Q

Epidemiology of adenocarcinoma

A

Barrett’s, smoking, obesity causes
More common in Caucasians
Increasing among white males in US in last 30 yrs

48
Q

What sxs are important to worry about with cancer?

A

Dysphagia, weight loss, odynophagia, malnutrition, anorexia

49
Q

What is recommended in all pts with dysphagia?

A

Endoscopy (EGD)

50
Q

How do most pts with esophageal cancer present?

A

With incurable, unresectable or metastatic disease (palliative tx is main goal)

51
Q

What is eosinophilic esophagitis?

A

Chronic, immune/ antigen mediated esophageal disease predominated by eosinophiils

52
Q

Sxs of eosinophilic esophagitis

A

Dysphagia, food impaction, CP, refractory heart burn, upper abd pain

53
Q

Strong connections of eosinophilic esophagitis

A

Other allergic diseases (food allergy, rhinitis, asthma, atopic dermatitis)

54
Q

What might be seen on an EGD for eosinophilic esophagitis?

A

Stacked circular rings or stricture

55
Q

Tx for eosinophilic esophagitis

A 
DIET (avoid allergens)
PPI
Topical corticosteroids (spray and swallow not inhale)
56
Q

What do you want to consider with dysphagia, non cardiac CP and refractory GERD sxs?

A

Esophageal motility disorders

57
Q

Major disorders of esophageal peristalsis

A

Hypercontractile (jackhammer) esophagus

Achalasia

58
Q

What is seen on a manometry for hypercontractile esophagus?

A

High pressure contractions in esophagus
Normal relaxation of esophagogastric junction
Mimics angina but usually with meals

59
Q

Tx for hypercontractile esophagus

A

CCB or TCA and maybe botulinum toxin injection

60
Q

Findings on barium esophagram for achalasia

A

Esophageal dilation
Birds beak causes by persistently contracted LES
Aperistalsis
Poor emptying of barium

61
Q

How does achalasia happen?

A

Progressive degeneration of esophageal neurons leading to failure of relaxation of LES and no peristalsis

62
Q

Sxs of achalasia

A

Dysphagia, regurgitation, difficulty belching, CP, heartburn

Gradual onset

63
Q

What must be seen for diagnosis of achalasia?

A

Manometry required and must see defect in LES relaxation and aperistalsis in distal 2/3 esophagus

64
Q

What is necessary to r/o malignancy with achalasia?

A

EGD

65
Q

What sort of pt makes you consider achalasia?

A

Pt unresponsive to PPI trial (4 wks) with dysphagia to solids and liquids and regurgitation

66
Q

Tx for achalasia

A

Disruption of LES muscle fibers (pneumatic dilation or heller myotomy-incision into muscles of LES)
Biochemical reduction in LES pressure (botulinum toxin, nitrates, CCB)

67
Q

What is the mallory weiss tear?

A

Mucosal laceration in distal esophagus and proximal stomach and see repetitive vomiting and retching

68
Q

Predisposing factors for mallory weiss tear

A 
Excessive alcohol consumption
Hiatal hernia (increased abd pressure)
69
Q

Tx for mallory weiss tear

A

Stabilize pt
Control bleeding if doesn’t stop on its own (epi or electrocoagulation)
Treat with PPI

X Clin Med III Exam I (5 decks)

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