PANCE Blueprint GI and Nutrition (10%)

Gastroesophageal reflux disease

Patient will present with → heartburn, generally worse after meals and when lying down and often relieved with antacids. Regurgitation and dysphagia may occurs.

Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain.

  • Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia or cancer.
  • Gastroesophageal reflux disease (GERD) is common, occurring in 10 to 20% of adults. It also occurs frequently in infants, typically beginning at birth
  • Factors contributing to reflux include weight gain, fatty foods, caffeinated or carbonated beverages, alcohol, tobacco smoking, and drugs.

Drugs that lower LES pressure include anticholinergics, antihistamines, tricyclic antidepressants, Ca channel blockers, progesterone, and nitrates.

  • The PH Probe study is the gold standard for diagnosis
  • The upper GI study is a study for anatomy not for reflux
  • Chronic cough can be an easily overlooked symptom of GERD
  • Chronic GERD may predispose to Barrett's esophagus and cancer
"Once Barrett's esophagus has been identified, screening every 3 to 5 years by upper endoscopy is recommended to look for dysplasia or adenocarcinoma. There is an 11-fold increase in esophageal adenocarcinoma in a patient with Barrett's esophagus."
  • Patients with foul odor of the breath and increasing symptoms think Zenker's Diverticulum which is an outpouching of hypopharynx resulting in regurgitation of solid foods – needs surgical repair.

Patients with typical symptoms of GERD may be given a trial of therapy.

  • Patients who do not improve, or have long-standing symptoms or symptoms of complications, should be studied.

Endoscopy, with cytologic washings and biopsy of abnormal areas, is the test of choice.

  • Endoscopic biopsy is the only test that consistently detects the columnar mucosal changes of Barrett esophagus. Patients with unremarkable endoscopy findings who have typical symptoms despite treatment with proton pump inhibitors should undergo 24-h pH testing.

The PH Probe study is the gold standard for diagnosis

Management of uncomplicated GERD consists of elevating the head of the bed about 15 cm (6 in) and avoiding eating within 2 to 3 h of bedtime, strong stimulants of acid secretion (eg, coffee, alcohol), certain drugs (eg, anticholinergics), specific foods (eg, fats, chocolate), and smoking.

  • Weight loss is recommended for overweight patients and those who have gained weight recently.
  • Drug therapy is stepwise:
    • Start  with a low-dose histamine 2 receptor antagonists QD then increasing to BID if needed
    • Switch to a proton pump inhibitor if symptoms persist. Start low dose and increase to standard dose if needed.
    • Once symptoms are controlled, treatment should be continued for at least eight weeks.

GERD UP TODATE

gastroesophageal-reflux-disease-gerd-assessment_5058_1466983242 GERD is the reflux of gastric contents into the esophagus, which is characterized by inflammatory symptoms resulting from the irritating effects of gastric or duodenal contents on the esophageal mucosa. Patients who are obese are at increased risk for the disease due to increased intra-abdominal pressure, which allows the reflux (backward flow) of stomach contents into the esophagus.

Gastroesophageal Reflux Disease (GERD) Assessment Picmonic

Question 1
A 26 year old mildly obese woman presents with 2-month history of heartburn, 2 weeks history of regurgitation. She drinks alcohol and smokes occasionally. Which of the following would you not advise her to do?
A
Eating smaller meals at a time
Hint:
Eating smaller meals at a time reduces symptoms of GERD.
B
Elimination of acidic foods
Hint:
Elimination of acidic foods reduces symptoms of GERD.
C
Weight loss; stop smoking and alcohol ingestion
Hint:
Weight loss; stop smoking and alcohol ingestion reduces symptoms of GERD.
D
Lying down within 3 hours after meal
Question 1 Explanation: 
Lying down within 3 hours after meal is not advisable for patient with GERD as it worsen reflux. Patient should wait 3 hours after a meal before lying down.
Question 2
Which of the following drug class is most effective in relieving symptoms of GERD?
A
Proton pump inhibitors (PPI)
Hint:
are not as effective as PPIs.
B
The dopamine antagonist prokinetic agents
Hint:
The dopamine antagonist prokinetic agents are not as effective as PPIs.
C
H2-receptor antagonists
Hint:
H2-receptor antagonists are not as effective as PPIs.
D
Alginate-containing antacids
Hint:
Alginate-containing antacids are not as effective as PPIs.
Question 2 Explanation: 
Proton pump inhibitors (e.g. Omeprazole) are the most effective in symptom relief and more commonly used.
Question 3
Which of the following is a complication of GERD?
A
Barrett’s esophagus
B
Zenker’s diverticulum
C
Gastritis
D
Diffuse esophageal spasm
Question 3 Explanation: 
GERD may predispose to Barrett's esophagus and cancer. All other options are independent disease entities. They are not complications of GERD.
Question 4
Which of the following statements is false?
A
Hiatal hernia contributes to the development of GERD.
B
Excessive reflux is defined as a pH <4 for >4% of the time
C
In most patients with GERD, baseline LES pressures are normal (10–35 mm Hg).
D
Endoscopy is indicated in all cases of GERD.
Question 4 Explanation: 
Endoscopy is not indicated in all cases of GERD. Young patients who present with typical symptoms of GERD with ALARM symptoms can be treated empirically without investigation. Investigation is advisable if patients present in middle or late age, if symptoms are atypical or if a complication is suspected.
Question 5
True or False: PH Monitoring with intra-esophageal electrode is the GOLD STANDARD for diagnosing GERD.
A
True
B
False
Question 5 Explanation: 
Although we rarely order it, this is the GOLD standard for diagnosing GERD.
Question 6
A patient presents with reflux. When further questioned, he reports the regurgitation of small amounts of food back into his mouth. You notice he has very foul-smelling breath. What do you suspect?
A
Zenker's diverticulum
B
Peptic Ulcer Disease
C
Achalasia
D
Gastric Cancer
E
Pyloric stenosis
Question 6 Explanation: 
Zenker Diverticulum is an outpouching of the hypopharynx which causes foul smelling breath and regurgitation of solid foods.
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