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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
Antacids
Do not prevent GERD and neutralize pH | Short lived benefit
26
H2 blockers/H2 antagonists
Block action of histamine at H2 receptors of gastric parietal cells (leads to decrease secretion of stomach acid) Ranitidine and Famotidine (Zantac and Pepcid)
27
Proton pump inhibitors
Reduce amt of acid produce by glands in the stomach | Take 30 min before 1st meal of day
28
Concerns associated with long term PPI use
Risk of infection (decreasing acid can increase risk of C diff and other infections) Malabsorption (Mg, Ca, Iron)
29
How long should a patient without severe erosive esophagitis and Barrett's esophagitis stay on meds?
Lowest dose and shortest duration appropriate | DC meds completely in pts without sxs
30
How long should a patient with severe erosive esophagitis and Barrett's esophagitis stay on meds?
Require maintenance acid suppression with a PPI (recurrent sxs and complications likely if med DC)
31
Indications for surgical management of GERD
Failed optimal med management GERD complications (esophagitis, Barrett's) Noncompliance
32
What is nissen fundoplication?
Surgical option for GERD | Passage of gastric fundus behind esophagus to encircle distal esophagus (allow LES to close all the way)
33
Thoughts behind starting a new GERD medication
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
Normal step up for GERD tx
H2 blocker-- PPI-- PPI BID-- close f/u with endoscopy
35
Most common cause of esophagitis
GERD
36
How does esophagitis happen?
Gastric acid, pepsin and bile irritate the squamous epithelium--can lead to irritation, inflammation, erosion or ulceration
37
Types of esophagitis
Reflux (most common cause) Infectious Pill (can't swallow pills) Eosinophilic (asthma, rhinitis, food allergies, eczema) Radiation Associated with systemic illness (sclerosis)
38
Sxs of esophagitis
Similar to GERD (heartburn, regurgitation, cough, CP)
39
Complications of esophagitis
Bleeding, stricture, barrett esophagus
40
What is Barrett esophagus?
Squamous epithelium in distal esophagus replaced with columnar epithelium (on biopsy) due to recurrent acid injury
41
What is a pt with Barrett esophagus predisposed to?
Adenocarcinoma of esophagus (10-15% of pts undering EGD with sxs)
42
Progression of Barrett's esophagus
GERD--Barrett's--low grade dysplasia--high grade dysplasia--adenocarcinoma
43
Tx for Barrett's esophagus
Indefinite use of PPI (aggressive anti-reflux tx may prevent cancer) EGD surveillance to detect evidence of dysplasia Endoscopic eradication therapy
44
What is endoscopic eradication therapy (EET)?
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
2 types of esophageal cancer
Squamous cell carcinoma | Adenocarcinoma
46
Epidemiology of squamous cell carcinoma
Higher in African American Men Higher in urban areas of US Incidence decreasing Risk factors like smoking and EtOH
47
Epidemiology of adenocarcinoma
Barrett's, smoking, obesity causes More common in Caucasians Increasing among white males in US in last 30 yrs
48
What sxs are important to worry about with cancer?
Dysphagia, weight loss, odynophagia, malnutrition, anorexia
49
What is recommended in all pts with dysphagia?
Endoscopy (EGD)
50
How do most pts with esophageal cancer present?
With incurable, unresectable or metastatic disease (palliative tx is main goal)
51
What is eosinophilic esophagitis?
Chronic, immune/ antigen mediated esophageal disease predominated by eosinophiils
52
Sxs of eosinophilic esophagitis
Dysphagia, food impaction, CP, refractory heart burn, upper abd pain
53
Strong connections of eosinophilic esophagitis
Other allergic diseases (food allergy, rhinitis, asthma, atopic dermatitis)
54
What might be seen on an EGD for eosinophilic esophagitis?
Stacked circular rings or stricture
55
Tx for eosinophilic esophagitis
``` DIET (avoid allergens) PPI Topical corticosteroids (spray and swallow not inhale) ```
56
What do you want to consider with dysphagia, non cardiac CP and refractory GERD sxs?
Esophageal motility disorders
57
Major disorders of esophageal peristalsis
Hypercontractile (jackhammer) esophagus | Achalasia
58
What is seen on a manometry for hypercontractile esophagus?
High pressure contractions in esophagus Normal relaxation of esophagogastric junction Mimics angina but usually with meals
59
Tx for hypercontractile esophagus
CCB or TCA and maybe botulinum toxin injection
60
Findings on barium esophagram for achalasia
Esophageal dilation Birds beak causes by persistently contracted LES Aperistalsis Poor emptying of barium
61
How does achalasia happen?
Progressive degeneration of esophageal neurons leading to failure of relaxation of LES and no peristalsis
62
Sxs of achalasia
Dysphagia, regurgitation, difficulty belching, CP, heartburn | Gradual onset
63
What must be seen for diagnosis of achalasia?
Manometry required and must see defect in LES relaxation and aperistalsis in distal 2/3 esophagus
64
What is necessary to r/o malignancy with achalasia?
EGD
65
What sort of pt makes you consider achalasia?
Pt unresponsive to PPI trial (4 wks) with dysphagia to solids and liquids and regurgitation
66
Tx for achalasia
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
What is the mallory weiss tear?
Mucosal laceration in distal esophagus and proximal stomach and see repetitive vomiting and retching
68
Predisposing factors for mallory weiss tear
``` Excessive alcohol consumption Hiatal hernia (increased abd pressure) ```
69
Tx for mallory weiss tear
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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