GERD & Esophageal D/O Flashcards
GERD can facilitate the transition of normal squamous epithelial cells to intestinal columnar cells. This is called ____plasia, and leads to what esophageal condition?
Metaplasia
Barrett’s Esophagus
Barrett’s esophagus puts patients at 30x increased risk for what?
adenocarcinoma
On CXR you notice an air-fluid level above the diaphragm… what does this indicate?
hiatal hernia
what are three conditions that increase risk of GERD?
hiatal hernia
scleroderma
ZES
Pt. p/w:
- retrosternal CP
- regurgitation
- Burning sensation/pyrosis
- nocturnal asthma/cough/SOB
What GI condition is this concerning for?
GERD
The below are the 9 alarm sxs for GERD/Esophageal d/os that necessitate what study?
Dys/odynophagia GI bleed sxs wt. loss anemia poor tx response new onset dyspepsia > 60 prior surg intervention CA hx
EGD
Describe how GERD is typically diagnosed…
clincal diagnosis (pyrosis, cough, better upright, relief with antacids)
What body position can help alleviate GERD? What about while sleeping
upright after meals
elevate head of the bed 30 degrees (using blocks, don’t bend at the waist)
What approach to GERD therapy if mild sxs with 1-2 episodes a week?
Step up:
Lifestyle + H2RA
What approach to GERD therapy if mod/severe sxs and 2+ episodes a week?
Step Down:
lifestyle + PPI x 8 weeks
What dosing instructions should be given to patients taking a PPI?
take 30 minutes before 1st meal
What are 2 complications of PPIs?
increased infx (c. diff risk) Malabsorption
What 4 nutrients may be malabsorbed while taking PPIs, requiring you to monitor?
Mg, B12 (IF), Ca, Vit. D
After 8 weeks of PPI tx, sxs have resolved. How to you get the patient off the drug?
gradually
A patient’s GERD sxs have resolved after an 8 week course of a PPI, but they had severe sxs +/- Barrett’s Esophagus… what can be done next?
QD maintenance dose PPI
After 8 week trial of PPI, sxs haven’t improved. What diagnostics should be administered initially?
24 hr pH study + EGD/Bx
What are four indications for Nissen Fundoplication after EGD surveillance of GERD complications?
non-response to meds
esophagitis
Barrett’s
non-compliance w. meds
What are three complications of GERD?
Esophagitis (Barrett’s & Erosive)
Esophageal strictures
Esophageal CA (Adenocarcinoma, squamous cell carcinoma)
A pt. p/w the below… what can these be concerning for/included on your DDx?
laryngitis/hoarseness loss of dental enamel angina-like CP dysphagia water brash Globus
GERD
The below 5 meds worsen GERD sxs by what mechanism?
TCAs CCBs Nitrates Narcotics Anticholinergics/histamines
decreasing LES pressure
The below 5 meds worsen GERD sxs by what mechanism?
Bisphosphonates Fe NSAIDs K+ Tetracycline
injuring mucosa
What are the 5 risk factors for GERD development?
Obesity/fat rich diet
caffeine intake
EtOH, TOBB
A patient p/w GERD sxs + dysphagia or odynophagia should be concerning for…
esophagitis
What are the 5 types of esophagitis?
Pill induced Infectious Eosinophilic Caustic GERD induced
What are three complications of esophagitis?
bleed, stricture, barrett’s esophagus
A patient p/w GERD sxs + dysphagia or odynophagia … What diagnostics could be ordered? which is best?
EGD + barium esophagram
EGD best
Most cases of esophagitis necessitate tx with…
PPIs
This condition is caused by a recurrent acid injury to the esophagus
Barrett’s esophagus
GERD –> Squamous Damage –> columnar replacement –> metaplasia
How is barrett’s esophagus treated?
indifinite PPI +/- endoscopic resection or ablation
How is barrett’s esophagus monitored?
EGD to detect meta/dysplasia
Infectious esophagitis can be caused by fungal overgrowth… what three populations are at risk?
immunocompromised
inhaled CS users
recent abx users
Describe how systemic illness can lead to esophagitis
systemic sclerosis –> poor acid clearing –> esophagitis
this is a chronic, immune mediated cause of esophagitis…
eosinophilic
A patient with food allergy, rhinitis, asthma, atopic derm is at increased risk for what esophageal d/o?
eosinophilic esophagitis
A patient p/w the following, concerning for…
Dysphagia food impaction CP refractory GERD UGI Pain Atopic hx
eosinophilic esophagitis
You suspect eosinophilic esophagitis for a pt. w. GERD + esophagitis + atopic hx. What diagnostics should be ordered and what findings should support your Dx?
Hx + EGD showing stacked circular rings +/- stricture
How is eosinophilic esophagitis treated?
diet mods, PPI, topical CCS +/- esophageal dilation
Dysphagia, non-cardiac CP, refractory GERD are suggestive of what class of disorders?
esophageal motility d/o
A patient p/w progressive dysphagia (solids –> liquids) non-cardiac CP, refractory GERD necessitates what diagnostic and why?
EGD to r/o structural abnormality
If EGD is WNL for a patient w. dysphagia and motility d/o sxs, what treatment should be tried?
QD or BID PPI
A pt. w. dysphagia and motility d/o sxs has failed PPI tx… what diagnostics are indicated for refrectory sxs?
Manometry, barium esophagram + pH and impedence monitoring
Manometry for a patient w. refractory GERD and dysphagia shows:
increased pressure contractions in esophagus
normal esophagogastric junction relaxation
What does this suggest?
Hypercontractile/jackhammer esophagus
OR
distal esophageal spasm
increased pressure contractions in esophagus and normal esophagogastric junction relaxation in DES and jackhammer esophagus causes what sxs and when?
angina sxs during meals
What are two mechanisms/goals of medical tx of DES/jackhammer esophagus?
control GERD
Relax muscles
How is GERD controlled in tx of DES/jackhammer esophagus?
PPI
how is esophageal muscle relaxed in DES/jackhammer esophagus?
Diltiazem (CCB) or Imipramine (TCA) +/- botox
Peppermint oil b4 meals if no GERD
What combo therapy should be initiated for DES/jackhammer esophagus?
PPI + Diltiazem (CCB) or Imipramine (TCA) +/- botox
A patient p/w the below, concerning for…
dismotility sxs (non-cardiac CP, refractory GERD)
+ Gradual onset of (4 years or so):
Dysphagia
regurgitation
difficulty belching
Achalasia
You suspect achalasia on a patient w. gradual onset dysmotility sxs, dysphagia. What diagnostics should be ordered?
EGD (r/o malignancy/structural d/o)
Manometry + Barium Esophagram
What two signs on barium esophagram can indicate achalasia?
bird’s beak sign
aperistalsis
What two signs on manomentry can indicate achalasia?
aperistalsis in distal 2/3
incomplete LES relaxation
Which diagnostic for achalaisa is required for diagnosis?
manometry
Tx for achalasia is either mechanical or biochemical. They both try to disrupt the LES… What are two mechanical txs for achalasia?
pneumatic dilation Heller Myotomy (surg. release of LES)
Tx for achalasia is either mechanical or biochemical. They both try to disrupt the LES… What is the progression of biochemical treatments?
botox –> nitrates –> CCBs
This d/o is a mucosal laceration in distal esophagus or proximal stomach.
mallory-weiss syndrome
What are three disorders that can cause mallory-weiss syndrome?
EtOH abuse, hiatal hernia, bulemia
What physiological process is the cause of a mallory-weiss syndrome (not disorders that lead to it, what physical action)
repetitive vomiting/retching
How is mallory-weiss syndrome diagnosed and treated?
dx: EGD
tx: electrocoag, band ligation or epi
