L7 GERD

Objectives

1. Pathophysiologic mechanisms causing GERD

2. Common Risk Factors that influence GERD development, Symptom exacerbation, Complications

3. Differentiate Typical, Atypical, and ALARM symptoms

Notes

1. What is Gastroesophageal Reflux Disease (GERD)

   • when the reflux of the stomach contents

2. T/F: Heartburn is included under GERD

   • False due to it’s non-erosive symptom

3. What age is GERD more prominent in

   • 40 +

4. What are the Risk Factors of GERD

   • Gender

   • FH

   • Smoking/Alcohol use

   • Medications

     • can affect LES pressure

   • Foods

   • Respiratory Diseases

   • Reflux Chest Pain Syndrome

   • Obesity

5. What are risk factors that may increase prevalence in females

   • Pregnancy and Nonerosive Reflux

6. What related disease states are more common in males

   • Erosive Esophagitis

   • Barrett’s Esophagus

   • Esophageal Adenocarcinoma

7. What is the Esophagastric (EG) Junction

   • barrier that prevents gastric reflux into esophagus

8. What helps maintain the Esophagastric Junction

   • Lower Esophageal Sphincter (LES)

9. What is the Lower Esophageal Spincter

   • muscular ring innervated by the vagus nerve → contraction (at rest) and relaxation (for swallowing)

10. Explain the pathophysiology of GERD

    • Excessive reflux → Breaks down Esophagus’ defense mechanisms over time → Irritation and Injury of Esophageal Mucosa

11. What are the different types of LES Pressure?

    • Spontaneous, Transient (short period) LES Relaxation

    • Intra-Abdominal Pressure

    • Atonic LES

12. When does Spontaneous, Transient LES Relaxation typically occur

    • Postprandial (after meals)

13. T/F: ST-LES is linked to abnormal LES pressure

    • False: more likely to occur with NORMAL LES pressure

14. What symptoms are typically seen with ST LES Relaxation

    • Esophageal Distention (enlargement/ballooning)

    • Vomiting, Belching, Retching

15. What factors can increase the probability of GERD

    • Degree of Sphincter Relaxation

    • Lower Esophageal Clearance

      • amount of time acid touches the esophageal mucosa

    • Position

      • Laying down

    • Increased Gastric Volume

    • Increased Intragastric Pressure

      • force exerted on the stomach walls by the contents within it, typically food, gas, or fluid

16. What are examples of Intra-Abdominal Pressure

    • Straining

    • Bending Over

    • Coughing

    • Eating

    • Pregnancy

17. What are other possible factors as to why pregnant women may experience GERD

    • Hormonal Effects on Esophageal Muscle

    • LES Tone

18. Explain what is Atonic LES

    • When the LES is continuously relaxed → no closure allows free reflux

19. T/F: Intra-Abdominal Pressure AND Atonic LES is more likely to occur with DECREASED LES pressures

    True

20. What Anatomic factors can contribute to GERD

    • Hiatal Hernia

      • protrusion of the stomach through the diaphragm → may cause LES displacement and trapped gastric contents

      

21. What factors are associated with Esophageal Clearance

    • Swallowing and Saliva

22. What factors may affect saliva production

    • Increased age and Sleep

23. What is the purpose of Mucus Secreting Glands

    • protects the esophagus

24. What happens when Mucus Secreting Glands interact with Acid

    • decreases protection and may result in inflammation (Esophagitis)

25. What reflux characteristic can lead to complications

    • (low) pH

26. What happens when Gastric Emptying is slowed down?

    • increased gastric volume, frequency and amount of reflux

27. What are contributing factors to slowed gastric emptying

    • DM, Smokers, high Fat meals

28. List examples that REDUCE LES Tone

29. What are examples that have direct irritant that could contribute to GERD

    • Medications (more acidic)

      • Bisphosphonates (ex. Alendronate, Risedronate, etc)

      • Chemotherapy

      • Iron

      • Aspirin and NSAIDs

        • inhibits prostaglandins which protect the GI tract

      • Potassium Chloride

      • Quinidine

    • Foods

      • Spice

      • Orange and Tomato Juice

      • Coffee

30. T/F: GERD has low morbidity

    • False, Significant morbidity

31. What are the possible complications with tissue injury of untreated GERD

    • Esophagitis

    • Esophageal Structures

    • Barrett’s Esophagus

    • Esophageal Adenocarcinoma

32. Explain the components for the screening of Barrett’s Esophagus

    • MALE

    • Chronic GERD symptoms > 5 years

    • Weekly symptoms and 2+ related risk factors

33. What are the risk factors Barrett’s Esophagus

    • > 50

    • White

    • Central Obesity

      • Waist > 102 cm

      • Waist-Hip ratio > 0.9 cm

    • Tobacco

    • FH

      • Barrett’s or Adenocarcinoma

34. What is it when there are GERD symptoms but no tissue injury or erosion

    • Non-Erosive Reflux Disease (NERD)

35. T/F: symptom and tissue injury based syndromes are independent of each other

    • True

36. What are the symptoms of GERD

    • Pyrosis — heartburn

      • hallmark symptom

    • Hypersalivation

      • “acid brash”

      • sour or bitter

    • Belching

    • Regurgitation

    • Reflux Chest Pain

37. What are the ALARM Symptoms for GERD

    • Dysphagia

      • difficulty swallowing

    • Odynophagia

      • painful

    • GI Bleeding

    • Weight Loss

38. What are Extraesophageal Syndromes

    • (GERD) manifests outside the esophagus

      • Chronic Cough

      • Asthmatic symptoms

      • Laryngitis

      • Dental Erosion

39. Is Extraesophageal Syndromes common

    • no, atypical

40. What are the general components for a diagnosis of GERD

    • Clinical symptoms

    • Response to acid suppression therapy

    • Diagnostic tests for complicated GERD

      • Patient specific

41. When is an Endoscopy used for diagnosis?

    • complicated symptoms present, NOT for typical symptoms

    Indications for endoscopy in patients with GERD

    Persistent of progressive symptoms despite appropriate treatment

    Dysphagia or odynophagia

    Involuntary weight loss >5%

    GI bleeding

    Mass, stricture or ulcer

    Suspected extra-esophageal symptoms

    Screening for Barrett’s esophagus in high risk patients

    Placement of wireless pH monitoring

    Recurrent symptoms post-endoscopy or post-surgical anti-reflux procedures

42. What is a noninvasive endoscopic procedure

    • PillCam ESO

      • Eliminated in stool

      • can’t obtain biopsy

43. What is used to confirm reflux with persistent symptoms (excluding mucosal damage) or atypical symptoms

    • Ambulatory pH Monitoring

      • pH probe passed transnasally 5 cm above LES

      • Symptom diary used to correlate timing of symptoms to pH measurements

44. What is combined impedance monitoring

    • measuring both acid and non-acid reflux

45. What does a Radiotelemtry Capsule do?

    • wirelessly attached to mucosa to monitor pH

46. For pH monitoring, what should be discontinued a week prior to therapy?

    • PPI

47. What is a Manometry test

    • measures the pressure of organs or body systems to assess the function of the esophagus, stomach, or rectum

    • used for more complex situations

48. When is Manometry or High-Resolution Esophageal Pressure Topography (HREPT) used?

    • Failed twice daily PPI therapy

    • Normal endoscopy results

    • Identifying Motor Disorders

    • Evaluating Peristalsis for Antireflux Surgery

    • Finding pH probe placements

49. What is Impedance manometry used for

    • evaluates Esophageal Clearance, Retention through Bolus Transit, LES and Upper Esophageal Sphincter Pressures

Quiz
Question 1

1 / 1 pts

A patient (5’5”, 140 lbs.) with GERD and type 2 diabetes complains of heartburn, belching and regurgitation. The patient is a current smoker and denies alcohol use. Symptoms occur only after eating high fat meals and often feels full after eating a small amount of food. Which of the following pathophysiologic mechanisms of GERD is mostly likely occurring based on the patient’s presentation? (LO # 1, 4)

Atonic LES due to hormonal changes

Decreased esophageal clearance due to age

Delayed gastric emptying

Increased abdominal pressure

Question 2

1 / 1 pts

A patient is in her third trimester of pregnancy. Her PMH is noncontributory. She is not taking any medications. She reports frequent symptoms of pyrosis, which is causing significant discomfort. She would like to know why her symptoms have worsened over the past few months. What is the likely reason for her symptoms? (LO # 1, 2)

Hormonal changes during pregnancy decrease esophageal clearance

Hormonal changes increase gastric emptying

Pregnancy causes increased intra-abdominal pressure

Pregnancy increases the risk of hiatal hernias

Question 3

1 / 1 pts

A patient reports worsening symptoms of GERD, complaining of heartburn, belching, increased salivation and difficulty swallowing. Which of the following best characterizes the patient’s GERD based on symptom presentation? (LO # 3)

Increased risk for extraesophageal complications

Increased risk of tissue injury-based GERD syndromes

Typical GERD symptoms

Atypical GERD symptoms

Question 4

1 / 1 pts

Which of the following patients experiencing chronic GERD symptoms should be screened for Barrett's esophagus?

45-year-old Asian man with current tobacco use

55-year-old Caucasian man with central obesity

65-year-old African American woman with central obesity

40-year-old Caucasian woman with tobacco use