GERD and esophagogastric motility

Question 1

The proximal 5% of the esophageal body is made of _____ muscle; the proximal third is a _______; the distal 2/3 is _____

Answer 1

striated muscle
transition mix of smooth and striated muscle
smooth muscle

Question 2

The two muscle layers of the esophagus are:

Answer 2

inner circular

outer longitudinal

Question 3

What is the excitatory neurotransmitter of the ENS?

Answer 3

ACh

causes contraction of muscle layers

Question 4

What is the inhibitory neurotransmitter of the ENS?

Answer 4

NO, VIP

causes relaxation of muscle layers

Question 5

List three considerations when classifying pathologic GERD

Answer 5

• Typical or Classic (heartburn/regurgitation) vs. Atypical reflux
• Mucosal disruption description: Erosive/Ulcerative vs. Non Erosive
• Extent of reflux: Esophageal vs. Laryngopharyngeal Reflux

Question 6

List classic symptoms of GERD

Answer 6

heartburn/ pyrosis
regurgitation
water brash

Question 7

When _____ and _____ occur together, it is 90% predictive of GERD

Answer 7

regurgitation and heartburn

Question 8

What are some atypical symptoms of GERD

Answer 8

asthma
chronic cough
chronic hoarseness
non-cardiac chest pain
loss of dental enamel

Question 9

_____ results from a multifactorial failure of the reflux barrier

Answer 9

GERD

Question 10

Progression of _______ over time leads to chronic LES changes

Answer 10

Transient lower esophageal sphincter relaxations

Question 11

______ disrupts diaphragmatic positioning at the LES and leads to loss of sphincter integrity

Answer 11

hiatal hernia

Question 12

Poor ____ of the esophagus leads to inadequate clearing of refluxed material

Answer 12

peristalsis

Question 13

Reduced epithelial resistance is caused by

Answer 13

decreased bicarbonate from saliva and mucosa

Question 14

List caustic substances (other than HCl) that can be present in refluxate from the stomach

Answer 14

deconjugated bile salts
pancreatic enzymes
pepsin
medications
ingested food

Question 15

presumptive diagnosis of ____ can be made based on symptoms alone

Answer 15

GERD

Question 16

When is further testing for GERD warranted?

Answer 16

if the patient has dysphagia or other “red

flag” symptoms, or who’s GERD symptoms have not responded to typical treatment regimen.

Question 17

_______ is the most sensitive test for viewing esophagitis, strictures, and findings of Barrett’s esophagus

Answer 17

upper endoscopy with biopsy

Question 18

_______ is a test that can give information about motility and amount of reflux

Answer 18

esophogram or GI x ray

Question 19

In ______, an acid sensor is used to quantify the amount of reflux and correlate to reported symptoms

Answer 19

24 hour pH monitoring

Question 20

List lifestyle changes that can be used in treatment of GERD

Answer 20

elevate head of bed
stop smoking, decrease alcohol
reduce fat intake
decrease size of meals
avoid meals before bed
avoid tea, coffee, citrus, chocolate, mint, tomato juice, cola
avoid anticholinergics, diazepam, theophylline, CCBs, narcotics

Question 21

List drug therapy for GERD

Answer 21

Antacids (OTC)
H2 antagonists (OTC and prescription)
PPIs (OTC and prescription, more potent acid suppression)

Question 22

What surgical procedure can be used electively by GERD patients?

Answer 22

Nissen fundoplication is an elective surgical procedure that can be performed either laparoscopically or as an open surgery. The fundoplication functions to correct any hiatal hernia and to re-establish the anti-reflux barrier by wrapping the stomach around the GEJ to recreate a high pressure barrier from gastric content reflux

Question 23

List complications of GERD

Answer 23

strictures
Barrett’s esophagus
bleedign
esophageal cancer

Question 24

______ are formed when chronic inflammation leads to scarring of the esophageal wall, compromising its diameter and function.

Answer 24

Strictures
most commonly found near GEJ
will lead to dysphagia more with solids than liquids

Question 25

How are strictures treated?

Answer 25

Will resolve with acid suppression if mild | More prominent strictures need balloon dilation

Question 26

Barrett's esophagus is metaplastic change from ____ to ____ epithelium and is a step on the way to developing adenocarcinoma of the esophagus

Answer 26

squamous to columnar

Question 27

What are symptoms of esophageal motility disorders?

Answer 27

dysphagia to BOTH solids and liquids chest pain (atypical) heartburn regurgitation

Question 28

How are esophageal motility disorders diagnosed?

Answer 28

Esophagram (barium study) Endoscopy Esophageal manometry following imaging study

Question 29

In _____, the LES cannot relax due to loss of neurons

Answer 29

achalasia

Question 30

What are the typical symptoms of achalasia?

Answer 30

``` Dysphagia vomiting undigested food chest pain weight loss regurgitation and aspiration at night pyrosis ```

Question 31

Achalasia involves a gradual loss of ____ neurons from the lower esophageal sphincter, which moves proximally. The LES loses the capability to relax, followed by a loss of esophageal body peristalsis

Answer 31

enteric

Question 32

How is achalasia treated?

Answer 32

Medications: CCBs, nitrates, anticholinergics used to relax the spastic LES Botulinum toxin Endoscopic balloon dilation of LES Surgical myotomy- most long lasting intervention

Question 33

The gastric pacemaker cells are the ________

Answer 33

interstitial cells of Cajal

Question 34

The _____ nervous system is responsible for the general motility pattern of the stomach. The ______ nervous system functions to modulate the automatic motility

Answer 34

Enteric | Central

Question 35

In addition to the circular and longitudinal layers of muscle, the stomach also has a 3rd layer of _______ muscle, which facilitates the forceful contractions needed for mixing and churning food.

Answer 35

oblique

Question 36

Describe the two motility patterns of the stomach

Answer 36

Fed pattern: accommodation and more random contraction of ingested food. Fasting pattern: increasing frequency and strength of sequential muscle contractions (peristaltic-like). Maximum cycling of this sequence is 3 cycles per minute. This phase functions to grind, mix, and ultimately empty stomach contents.

Question 37

Diabetes mellitus is the most common cause of ______, a disorder of "too slow" gastric motility

Answer 37

gastroparesis

Question 38

What is the pathophysiology of gastroparesis related to DM?

Answer 38

Hyperglycemia leads to abnormal nerve conduction

Question 39

List non-DM causes of gastroparesis

Answer 39

Medications: antidepressants, anticholinergics, nitrates, CCBs, phosphodiesterase inhibitors Iatrogenic: surgical vagotomy

Question 40

Because the signs/symptoms of gastroparesis can mimic __________, this must be ruled out first.

Answer 40

mechanical obstruction

Question 41

________ is the most useful study for diagnosing gastroparesis

Answer 41

gastric emptying study

Question 42

How is gatroparesis treated

Answer 42

glycemic control in DM adjusted gastroparetic diet- low in roughage and fatty foods, small meals medications: motilin analogues erythromycin and meoclopramide gastric pacemakers surgical options: partial gastrectomy, feeding tube

Question 43

The smooth muscle of the lower esophageal sphincter is tonically ______ at rest

Answer 43

contracted

Question 44

What are hypothesized causes of achalasia?

Answer 44

Virus, other infectious agents, autoimmune

Question 45

List other conditions on the differential diagnosis for achalasia

Answer 45

Malignancy: especially gastric cardia Chaga’s disease: trypanasomi cruzi Amyloidosis Chronic idiopathic intestinal pseudo-obstruction Post-radiotherapy Severe esophageal stricture/end-stage GERD

Question 46

What are dietary recommendations for a person with achalsia?

Answer 46

Liquid or semi-liquid foods only Small infrequent meals Increased time after meal prior to reclining

Question 47

What are causes for acute delayed gastric emptying

Answer 47

Opioids | Viral illness, hyperglycemia

Question 48

Describe the dietary recommendations for a person with gastroparesis

Answer 48

Small, frequent meals Reduced fiber to avoid bezoar Liquid and simple starch foods Liquid caloric supplementation if necessary