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S2B1: MEDI > GERD/Esophageal Disordes > Flashcards

GERD/Esophageal Disordes Flashcards

1
Q

Identify the terms that coincide with the following definitions

  1. burning feeling from epigastrum to the chest
  2. difficulty swallowing or a sensation of food getting stuck
  3. painful swallowing
  4. sensation of having somethign in one’s thrat when ther is nothign actually there
A
  1. Heartburn (pyrosis)
  2. Dysphagia
  3. Odynophagia
  4. Globulus sensation
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2
Q

What is GERD?

How is it commonly treated?

A

When the LES is open, stomach contents can backflow into the esophagus, causing heartburn

GERD= reflux of gastric contents up into the esophagus

Treatment: PPIs & H2 blockers

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3
Q

What are the 3 most common causes of GERD?

A
  • Physiologic: after eating because of temporary lower esophageal sphincter relaxation
  • Inadequate baseline lower esophageal sphincter pressure
  • Stress Reflux: due to increases in intrabdominal pressure adn inadequate LES pressure
    • pregnancy, extra weight, lying down
  • Other causes
    • hiatal hernia
    • Esophageal motility disorder
    • delayed gastric emptying
    • decreased salivation
      • bicarb in saliva that helps to neutralize the acid in the saliva
    • duodenogastroesophageal reflux
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4
Q

What are symptoms of GERD?

A
  • Common Symptoms
    • heartburn
    • water brash
    • sour/bitter taste
    • regurgitation
  • Other symptoms
    • chest pain
    • chronic cough
    • asthma
    • chronic sore throat
    • hoarseness
    • globulus senstation
    • belching
    • dysphasia
    • odynophagia
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5
Q

What is the common diagnostic criteria for GERD?

A

Symptoms suggestive of GERD

+

response to empiric treatment

=

likely gerd

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6
Q

Why is an endoscopy not commonly used to diagnose GERD?

In what situations would you perform an endoscopy for GERD?

What are you looking for when you do the endoscopy?

A
  • Endoscopy
    • low sensitivity
    • often no evidence
  • You WOULD perform if there were alsrm symptoms
    • weight loss
    • anorexia
    • dysphagia (trouble swallowing)
    • odynophagia (pain swallowing)
    • upper GI bleeding
  • Looking for
    • Barrett’s Esophagus
    • Erosive Esophagitis
    • Eophageal ulcer
    • Esophageal Stricture
    • Esophageal Adnocarcinoma
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7
Q

What steps could you take to further evaluate patients for GERD?

A
  • Further Evaluation - (GERD that didn’t respond to treatment/or is longstanding)
    • EGD (not usually done)
    • pH monitoring- shows acid reflux
      • antireflux surgery candidates
    • Esophageal Manomery
      • exclude motility disorder
    • Gastric Emptying Study
      • warranted if vomiting
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8
Q

How do you treat patients with intermittent or mild GERD?

A
  • Lifestype modification
    • weight loss
    • smokign cessation
    • avoidance of certain foods
      • caffeinated, carbonated, chocolate, spicy
    • avoid eating for 3 hours before reclining
    • elevate head of the bed
  • Antacid medications
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9
Q

Treatment for mild-moderate GERD?

Severe with erosive esophagitis?

A
  • mild-moderate
    • H2 blockers
    • PPI therapy
  • Treatment of severe with erosive esophagitis
    • PPI
    • Sometimes even BID dosing
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10
Q

Treatment for GERD with extraesophageal of atypical symptoms?

For patients unable to tolerate antireflux medications or unwilling to take long term medication?

A
  • extraesophageal of atypical symptoms
    • initial treatment with double doses of PPI
    • improvement may take up to 6 months
  • unable to tolerate antireflux medications or unwilling to take long term medication
    • antireflux surgery
      • Standard Fundoplication
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11
Q

What are risks associated with long term PPI use?

A
  • risks
    • CKD, pneumonia, fractures, dementia
      • iron deficiency, low magnesium, diarrhea
  • Need to weigh these against the risks of untreated GERD
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12
Q

What drugs can be used to treat the visceral pain associated with GERD?

Transient reduction in LES relaxation?

What are other alterantive GERD treatments?

A
  • visceral pain
    • tricyclics
    • trazadone
    • SSRI’s
    • SNRI’s
  • Transient reduction in LES relaxation
    • baclofen
  • others
    • accupuncture
    • psychological intervention
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13
Q

What is the sequelae of GERD?

A
  • Esophagitis
  • Ulceration
  • Stricture
  • Barrett’s Esophagus
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14
Q

What are the 3 general treatment goals for GERD?

A
  1. Relieve symptoms
  2. Heal esophagitis
  3. Prevent sequelae
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15
Q

What is Barrett’s Esophagus?

Particular risks associated with Barrett’s Esophagus?

A
  • intestinal metaplasia of the esophageal epithelium
    • confirmed by biopsy – see columnar cells instead of stratified squamous
  • Premalignant change can lead to adenocarcinoma
    • esp w/ smoking or obesity
  • Most common in caucasians
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16
Q

What are the two classification systems for biopsies of Barrett’s Esophagus?

A
  • Prague circumference and maximum length criteria
  • Short (<3cm) or long (>3cm) segment Barrett’s Esophagus
  • increased risk of dysplasia and malignancy with increasing length
17
Q

How is Barrett’s Esophagus diagnosed?

Surveillance recommendations?

A
  • Diagnosis
    • endoscopic biopsy
    • multiple biopsies every 2 cm in 4 quadrants
    • should be reviewed by pathologist knowledgeable about Barrett’s
    • categorized as with or without dysplasia
      • if dysplasia given a grade (low, high, indeterminate)
  • Surveillance
    • if not dysplasia: 3-5 year intervals
    • with high or low grade dysplasia: repeat within 6 months an if nochange ablative therapy
18
Q

Treatment of Barett’s Esophagus

A
  • Treatment
    • PPI therapy
    • If dysplasia: confirm by second pathologist specializing in Barrett’s
    • once confirmed, repeat within 6 months and if no change ablative therapy
      • radiofrequency ablation (preferred)
      • Photodynamic therapy
      • Argon Plasma Coagulation
      • Cryoablation
      • may consider close surveillance for low grade dysplasia
19
Q

What type of disorder is Diffuse Esophageal Spasm?

Symptoms?

Diagnosis?

Treatmetn?

A
  • Esophageal Motility Disorder
  • Symptoms
    • chest pain, dysphagia
  • Diagnosis
    • imaging, manometry (showing normal LES pressure, but diffuse non-peristaltic contractions of the body)
  • Treatment
    • first line: calcium channel blocker, or tricyclic antidepressant
    • Second line: botulinum toxin or nitrox oxide contributing drug
      • isosorbide, sildenafil
20
Q

What type of disorder is Scleroderma?

Symptoms?

Diagnosis

Treatment?

A
  • Esophageal Motility Disorder
    • chronic autoimmune connective tissue disease. In the Esophagus can result in dysmotility as well as Sicca Syndrome (decreased saliva)
  • Symptoms: Severe GERD, dysphagia
  • Diagnosis
    • imaging or manometry with low LES resting pressure and no or low-amplitude peristalsis of the body, or peptic stricture
  • Treatment
    • Treat GERD with PPI, decreased peristalsis with prokinetic agent or stricture with dilation
21
Q

What type of disorder is Achalasia?

A
  • Esophageal Motility Disorder
    • failure of the LES to relax and loss of esophageal peristalsis. Degenerative changes in teh nerve fibers. Most often occurring between age 30-60
  • Symptoms
    • long standing dysphasia (solids adn liquids), chest pain, regurgitation, aspiration and weight loss
  • Diagnosis
    • imaging or manometry showing high pressure / contraction at the LES and low amplitude contractions or widening in body
  • Treatment
    • medical treatment
      • calcium channel blocker
      • PPI
      • Nitrates
    • botulinum toxin injection to LES
    • Pneumatic dilation
    • Surgical Esophageal Myotomy
22
Q

What type of disorder is secondary achalasia?

Symptoms?

Diagnosis?

Treatment?

A
  • Esophageal Motility Disorder
    • syndrom with symptoms similar to achalasia, but with a secondary cause. Can be caused by malignancy, intestinal pseudo-obstruction, Chaga’s disease
  • Symptoms
    • same as achalasia, except more sudden onset
  • Diagnosis
    • appears like achalasia on imaging and manometry. Differentiated by EGD findings
  • Treatment
    • treat the underlying disease
23
Q

What are the most common etiological agents responsible for esophageal infection?

A
  • Etiological agents
    • Candida
      • ​Diagnosi: white spots on EGD, fungal hyphae on brushings
      • Treatment: oral fluconazole
    • Cytomegalovirus
      • Diagnosis: distal, large, single ulcer with viral inclusions on biopsy (often organ transfer patients)
      • Treatment: foscarnet and ganciclovir
    • Herpes simplex virsus- severe odynophagia
      • Diagnosis: multiple esophageal ulcerations on EGD, confirmed histopathologically
      • Treatment: acyclovir
  • Symptoms
    • odynophagia primarily plus or minus dysphagia
  • uncommon except in immunocompromised individuals
24
Q

What is shown in the provided images?

Symptoms?

Diagnosis?

Treatment?

A
  • Eosinophilic Esophagitis
    • thick infiltrate of eosinophils in submucosa causing structural changes includign mucosal furrows, corrugations, strictures, an dsmall caliber esophagus
    • delayed hypersensitivity to food allergens
  • Symptoms
    • Dysphagia, chest pain, nausea, heartburn or even food impaction
  • Diagnosis
    • confirmed with biopsies from middle adn sistal esophagus showing 15-25 eosinophils per high power field
  • Teatment
    • Treatment
      • PPI up to BID adn steroids (primarily topical but may consider oral systemic therapy if severe). Don’t forget these patients need allery evaluations
      • elimination diets
25
Q

What are esophageal rings?

A
  • Concentric ring of tissue extending into the lumen of the esophagus
  • occurs int eh distal esophagus at the GE junction (therefore having squamous mucosa on one side adn columnar on the other)
    • except Schatzki’s ring, which usually occurs 2cm proximal to GE junction
26
Q

What are esophageal webs?

A
  • membrane covered by squamous mucosa extending into the esophageal lumen
  • most commonly occur incervial esophagus
  • may be associated with iron deficiency anemia
    • known as plummer-vinson or paterson kelly syndrome
27
Q

What are the symptoms of esophageal rings and webs?

diagnosis?

treatment?

A
  • Symptoms
    • most asymptomatic
    • others have intermittent, non-progressive dysphagia for solids
  • Diagnosis
    • may be seen on imaging or EGD
  • Treatment
    • ring’s may be helped with PPI therapy, webs usually disrupted by EGD
28
Q

What are the two different types of dysphasia and the possible causes of each?

A
  • Oropharyngeal dysphasia
    • trouble getting food from the mouth to the esophagus
    • cause
      • neuromuscular cause (more common)
        • stroke
        • amyotrohic lateral sclerosis
        • parkinson’s
        • brain tumors
        • myotonic dystrophy
        • occulopharyngeal muscular dystrophy
        • tardive dyskinesia
        • myasthenia gravis
      • structrual cause
        • Zenker’s Diverticulum
        • Esophageal webs
        • Cervical osteophytes
        • Tumors
        • Scarring from radiation
  • Esophageal Dyspagia
    • Trouble getting the food from the esophagus into the stomach
    • causes
      • structural disorders (trouble with solids more common)
      • Motility disorder (commonly have trouble with both solids and liquids)

S2B1: MEDI (15 decks)

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