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

1. Heartburn (pyrosis) 2. Dysphagia 3. Odynophagia 4. Globulus sensation

GERD/Esophageal Disordes Flashcards by Katherine E Nordstrom

Identify the terms that coincide with the following definitions

burning feeling from epigastrum to the chest
difficulty swallowing or a sensation of food getting stuck
painful swallowing
sensation of having somethign in one’s thrat when ther is nothign actually there

Heartburn (pyrosis)
Dysphagia
Odynophagia
Globulus sensation

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What is GERD?

How is it commonly treated?

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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What are the 3 most common causes of GERD?

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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What are symptoms of GERD?

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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What is the common diagnostic criteria for GERD?

Symptoms suggestive of GERD

response to empiric treatment

likely gerd

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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?

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

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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How do you treat patients with intermittent or mild GERD?

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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Treatment for mild-moderate GERD?

Severe with erosive esophagitis?

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

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Treatment for GERD with extraesophageal of atypical symptoms?

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

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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What are risks associated with long term PPI use?

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

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

Transient reduction in LES relaxation?

What are other alterantive GERD treatments?

visceral pain
- tricyclics
- trazadone
- SSRI’s
- SNRI’s
Transient reduction in LES relaxation
- baclofen
others
- accupuncture
- psychological intervention

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What is the sequelae of GERD?

Esophagitis
Ulceration
Stricture
Barrett’s Esophagus

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What are the 3 general treatment goals for GERD?

Relieve symptoms
Heal esophagitis
Prevent sequelae

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What is Barrett’s Esophagus?

Particular risks associated with Barrett’s Esophagus?

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

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

How is Barrett’s Esophagus diagnosed?

Surveillance recommendations?

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

Treatment of Barett’s Esophagus

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

What type of disorder is Diffuse Esophageal Spasm?

Symptoms?

Diagnosis?

Treatmetn?

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

What type of disorder is Scleroderma?

Symptoms?

Diagnosis

Treatment?

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

What type of disorder is Achalasia?

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

What type of disorder is secondary achalasia?

Symptoms?

Diagnosis?

Treatment?

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

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

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

What is shown in the provided images?

Symptoms?

Diagnosis?

Treatment?

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

What are esophageal rings?

* 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

What are esophageal webs?

* 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

What are the symptoms of esophageal rings and webs? diagnosis? treatment?

* 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

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

* 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)