management of GERD Flashcards by mohamed nascer

what is GER?

gastroesophageal reflux

Physiologic process by which gastric contents move retrograde from the stomach to esophagus

GER itself is not a disease and occur multiple times each day without producing symptoms or mucosal damage –> COULD BE NORMAL

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what is GERD?

gastroesophageal reflux disease —> GERD

Spectrum of diseases

Failure of normal anti-reflux barrier to protect against frequent and abnormal amount of reflux

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what are the main symptoms of GERD?

Heartburn –> retrosternal burning sensation

acid regurgitation —> bitter acidic content

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risk factors for GERD?

Demographic factors :

Female –> 40% higher than males

Age

Environmental factors :

Obesity

Physical activity

Smoking

Alcohol

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what medications reduce lower esophageal sphincter leading to GER?

alpha blockers

B agonists

Cholinergic blockes

Barbiturates

Calcium channel blockers

Diazepam

Dopamine

Meperidine

Morphine

Theophylline

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what are the factors that prevent acid reflux ( anti reflux barrier )?

LES –> MOST IMP ( not a true sphincter but specialized muscles )

Crural diaphragm

Phreno-esophageal ligaments

Intra-abdominal esophagus

Angle of his ( act like a valve )

THESE WILL PRODUCE HIGH PRESSURE PREVENTING ACIDS from going back

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what are some protective factors against GERD?

Esophageal acid clearance –> Gravity and Esophageal peristalsis ( help push the content that came up back down )

Saliva –> Can have weak basic ph ( 6.4 to 7.8 ) to neutralize acid

Esophageal submucosal gland secretions :

Rich in bicarbonate , stimulated by acid reflux

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what are the mechanisms of reflux ?

Transient lower esophageal sphincter

Swallow associated LES relaxation

Hypotensive LES

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Describe Transient lower esophageal sphincter?

Natural phenomenon

Mechanism of belching

Accounts for nearly all reflux episodes in healthy people

When Prolonged and frequent might be associated with GERD

Les maintains a tone and remain closed but occasionally during the day it relaxes to help accumulate gas to ESCAPE –> BURP

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describe swallow associated LES relaxation?

Reflux associated with defective or incomplete peristalsis

More common with hiatal hernia

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describe hypotensive LES?

strain-Induced or free reflux

Reflux worsens with increased intra-abdominal pressure due to coughing straining or bending over

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what else can contribute to reflux?

stomach filling
or delayed emptying

if you fill up the stomach too much and up to the brim = might spill out

if theres delayed emptying = more content = chance of reflux

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what is hiatal hernia?

herniation of intraabdominal content into chest cavity through hiatus

HIGH RISK FACTOR FOR GERD

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What are the types of hiatal hernia ?

type 1= SLIDING –> Gastro-esophageal junctions and LES moved up into chest cavity

Type 2 = Rolling –> position is preserved and its the fundus of the stomach that goes up not the junction

Type 3= MIXED

type 4 = Mixed with bowel content herniation

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what is the most common complication with hiatal hernia?

up to 94%:

Reflux esophagitis

Barrets esophagus

adenocarcinoma

Many individuals with HH doesnt have GERD
Many individuals with GERD doesnt have HH

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what are the gastric factors associated with REflux?

Gastric acid secretion

Duodenogastric bile reflux

Delayed gastric emptying

what are the associated conditions with Reflux?

Pregnancy –> reduce LES pressure ( hormonal ) and increase intra-abdominal pressure

Scleroderma ( Crest syndrome ) –> reduces LES by fibrosis , wake or absent peristalsis

Zollinger Ellison syndrome
-Increased acid secretion

Bariatric surgery –> sleeve gastrectomy

Heller myotomy –> achalasia

Prolonged nasogastric intubation : Interfere with LES closure and acid reflex along tube

what are the typical clinical features of GERD?

Heartburn :

Feeling rising from the stomach or lower chest radiating toward throat
Usually occurs postprandially
Associated with large meals or after ingesting spicy,food,citrus products
Exacerbated in supine position

Regurgitation

Perception of flow or refluxed gastric contents into the mount or pharynx

what are less common symptoms ?

Dysphagia

Weight loss
Water brash
Odynophagia
burping
hiccups
nausea and vomitting
chest pain

OLD PAITENTS ARE FREQUENTLY ASYMPTOMATIC

What is the relation between gerd and pulmonary disorders?

pulmonary disorders are either caused or worsened by GERD:

Asthma

Reflux induced asthma

Exacerbation of underlying asthma

Aspiration

Pneumonia

Interstitial pulmonary fibrosis

Chronic bronchitis

Bronchiectasis

Worsening of obstructive sleep apnea

what disease associated with GERD and upper respiratory system?

Laryngeal inflammation

Posterior laryngitis with edema and redness

Hoarseness

Globus sensation

Frequent throat clearing

Recurrent sore throat

Prolonged voice warm up

Vocal cord ulcers , granulomas leukoplakia and carcinoma

what are diseases related GERD?

Sleep disorders

Chronic cough

Dental erosions

differential diagnosis ?

Achalasia

Eosinophilic esophagitis

Zenker diverticulum

Gastroparesis

PUD and functional dyspepsia

Angina pectoris

Identified by failure to respond to aggresive PPI therapy and by appropriate diagnostic tests

how do you diagnose GERD?

Tests are unnecessary because the classic symptoms of heartburn and acid regurgitation are sufficiently specific to identify reflux disease and begin medical treatment

what are possible tests and investigations that can be done for GERD?

GERD questionnaires Empirical PPI tests Esophageal manometry Barium swallow Endoscopy Histology pH monitoring catheter --> Confirm, gold standard Intraluminal impedance Mucosal impedance

what are 2 types of GERD?

non erosive Erosive

describe nonerosive disease ?

Predominant type of GERD -- 70% Normal esophageal finding on endoscopy ( non erosive ) Good response to anti secretory treatment 3 subtypes : Non erosive reflux disease ( NERD) Reflux hypersensitivity Functional heart burn

describe eorisve disease ?

Associated with age, male, sex, obesity, hiatal hernia Frequently develop complications of GERD

what test is used to confirm GERD?

pH monitoring 3 indications : Patient not responding to PPI Patient with atypical symptoms Before acid reflux disease to confirm GERD diagnosis

complications of GERD?

hemorrhagic esophagitis Esophageal ulcer perforation and ruptue Peptic esophageal strictures Barrets esophagus ( intestinal, gastric/ risk factors include obesity, male , smoking ) Aspiration pneumonia

what are the nonprescription therapies of uncomplicated GERD?

Lifestyle modifications : Always included in the initial management of GERD elevation of the head of the bed Left lateral decubitus positioning lose weight if overweight Restricting alcohol and smoking making dietary changes Refrain from lying down after meal avoid bedtime snacks eating several hours b4 sleeping reduce meal size and avoid fat Avoid citrus drinks and spicy food

What are the surgical therapies for GERD?

Nissen fundoplication anterior wrap posterior wrap

indications of surgery in GERD?

healthy patient with typical/atypical GERD symptoms ARE CONTROLLED WITH PPIS BUT WISH ALTERANTIVE CUZ DRUG IS EXPENSIVE OR CANT COMPLY ELL patients with volume regurgi and aspiration symptoms NOT CONTROLLED WITH PPI Recurrent peptic strictures Patients with refractory GERD less likely to benefit from surgery ---> alternative diagnosis should be considered

what are preoperative tests before surgery?

Endoscopy --> exclude stricture, barrets esophagus, dysplasia , carcinoma Barium esophagogram --> check for hernia, shortened esophagus Esophageal manometry 24 pH monitoring and IMPENDENCE STUDY ---> CONFIRMS GERD b4 surgery

what are the benefits of surgery?

Relieves reflux symptoms Reduces the need for stricture dilation Barret esophagus rarely regresses and the risk of developing esophageal cancer is unchanged

what are the novel treatments?

Esophyx --> endoscopic fundoplication Stretta - radio frequency ablation Laparoscopic magnetic sphincter augmentation Electrical stimulation therapy

what could cause refractory GERD?

Medication timing and adherence - non compliance Differences in PPI metabolism - rapid metabolizers Residual acid reflux Alkaine reflux Reflux hypersensitivity Functional heartburn Alternative diagnosis ( MAYBE ITS NOT GERD )