GERD: Gupta and Howden

Question 1

What is Barrett’s Esophagus?

Answer 1

Intestinal metaplasia of distal esophagus. (looks like ascending pink mucosa overtaking white SS epithelium of esophagus)
Predisposes to esophageal adenocarcinoma.
Obese white males.
Dx’d with endoscopy and biopsy

Question 2

What is a hiatus hernia (HH) and what is its relationship with GERD?

Answer 2

Hiatus hernia is a herniation of the stomach through the diaphragm inlet.

Most pts with esophagitis have a HH, but not all pts with GERD have a HH, and many pts with HH do not have esophagitis.

Question 3

Reflux of stomach contents into the esophagus occurs by three mechanisms:

Answer 3

1) Transient lower esophageal sphincter (LES) relaxations.
2) Abdominal strain, often associated with a weakened sphincter.
3) free reflux across an atonic LES

Question 4

What are the defense mechanisms to protect the esophagus from the effects of GERD?

Answer 4

1) competent gastro-esophageal junction
2) effective esophageal emptying of refluxed contents from the esophagus
3) neutralization of refluxed acid by salivary HCO3-
4) intact mucosa

Question 5

How do you tx pts with mild GERD?

Moderate/Severe GERD?

Answer 5

Mild:
Diet
Postural maneuvers (sleep inclined, don’t lay down after eating)
Antacids

Moderate/Severe:
Medicines
Surgery- laparoscopic Nissen fundoplication (reduces hiatal hernia and creates mechanical barrier to GER)

Question 6

What is eosinophilic esophagitis?

Answer 6

Chronic, immune/antigen-mediated esophageal dz characterized clinically by symptoms of esophageal dysfxn and histologically by eosinophil-predominant inflammation.

Adults present with dysphagia, food impaction, reflux symptoms.
Children present with refractory reflux symptoms, abd. pain, vomiting, and growth failure.

Question 7

When is the best time to take a PPI to tx GERD?

Answer 7

Before meal

Once a day, regularly

Question 8

Should clinicians initiate tx for typical symptoms of GERD w/ no alarming features before endoscopy.
When should you refer to a gastroenterologist?

Answer 8

Yes.
Refer:
atypical symptoms
poorly responsive symptoms
alarming features (change in chronic symptoms, dysphagia, vomiting, weight loss, concerns about cancer)
when you need Barrett's screening

Question 9

Is endoscopy sensitive and specific for GERD?

Answer 9

It is specific, but not very sensitive.

Question 10

How does eosinophilic esophagitis appear on endoscopy and histology?
How do you tx?

Answer 10

Concentric, ringed appearance on esophagus. (looks like a trachea)
Can have eosinophilic microabscesses appearing grossly as white plaques.
Linear furrows and narrowed caliber lumen.
Eosinophilic infiltrate (>20/hpf) on biopsy

Tx- PPIs (1st line tx), topical steroids

Question 11

Describe how to differentiate high grade dysplasia from Barrett’s metaplasia and the clinical course of esophageal adenocarcinoma.

Answer 11

High N:C
Hyperchromatic nuclei
Nuclear stratification that looks like pseudostratified epithelium.
Cribriform, gland-within-gland appearance.

By the time it is Dx’d, adenocarcinoma of the esophagus has often already spread to submucosal lymph vessels. As a result,

Question 12

Differentiate esophageal adenocarcinoma and SCC based on location.
How do they appear histologically?

Answer 12

Adeno- found in distal esophagus, often involving gastric cardia.
Histo: you will see an abundance of glands.

SCC- Involves mid-esophagus, causes strictures.
Histo: you will see and abundance of invasive SS epithelium.

Question 13

Risk factors for esophageal SCC.

Answer 13

Old (>45yo) black man who smokes/drinks and has received radiation therapy of mediastinum.

Question 14

Describe histologic changes associated with gastroesophageal reflux.

Answer 14

Eosinophils
Basal cell hyperplasia
Elongated LP papillae
Edema/spongiosis
Subepithelial vascular dilation