1.3 MTB Step 3 - Esophageal Disorders (GERD & Barrett Esophagus)

Question 1

SAMPLE QUESTION

G.E.R.D.

“A patient comes with epigastric pain that is associated with substernal chest pain and an unpleasant metallic taste in the mouth.”

What is the Best NEXT Step in Management?

Answer 1

Proton Pump Inhibitors (PPIs)

i.e., Omeprazole

Question 2

PRESENTATION

G.E.R.D.

In addition to the Epigastric Pain and Substernal Chest Pain of GERD, what are (5) other symptoms associated with Acid Reflux?

Answer 2

1. Sore Throat
2. Metallic or Bitter Taste
3. Hoarseness
4. Chronic Cough
5. Wheezing

Question 3

BASIC SCIENCE CORRELATE

G.E.R.D.

What is the Mechanism of Bad Taste in GERD?

Answer 3

Sweet Taste receptors are on the Anterior 2/3 of the Tongue, and sweet taste is controlled by Cranial Nerve VII.

Bitter Taste receptors are on the Posterior of the Tongue, and bitter taste is controlled by Cranial Nerves IX and X.

Question 4

DIAGNOSTIC TESTING

G.E.R.D.

1. Which Diagnostic Test for GERD is also Therapeutic?
2. Which Diagnostic Test should only be done if there is no response to the answer from question 1?

Answer 4

1. PPI Trial
2. 24-Hr pH Monitor

Question 5

TREATMENT

G.E.R.D.

Mild GERD may be controlled with which (5) Lifestyle Modifications?

Answer 5

1. Losing Weight
2. Elevating the Head of the Bed
3. Quitting Smoking
4. Limiting Alcohol, Caffeine, Chocolate, and Peppermint ingestion
5. Not Eating within 3 hours of going to Sleep

Question 6

TREATMENT

G.E.R.D.

What is the Next BEST Therapy for GERD if Lifestyle Modifications don’t work?

Answer 6

Proton Pump Inhibitors (PPIs)

• PPIs control 90-95% of cases.
• All PPIs are equal in efficacy.

Question 7

TREATMENT

G.E.R.D.

Which Class of Medication should be used to control GERD only if a PPI is not available?

Answer 7

H₂ Blockers

• Examples: Ranitidine, Famotidine, Cimetidine, Nizatidine*
• These control GERD in about two-thirds of patients*

Question 8

TREATMENT

G.E.R.D.

What should be done if neither PPIs or H2 Blockers are able to control GERD?

Answer 8

Nissen Fundoplication

A surgical or endoscopic procedure to narrow the Distal Esophagus and Reconstrict the Lower Esophageal Sphincter (LES)

Question 9

PRESENTATION

BARRETT ESOPHAGUS

What Type of Lesion is Barrett Esophagus?

Answer 9

PRECANCEROUS

Approximately 0.5% of Barrett Esophagus cases will transform into Esophageal Cancer.

Question 10

PRESENTATION

BARRETT ESOPHAGUS

What Type of Cancer is an increasingly frequent histological type of Esophageal Cancer?

Answer 10

ADENOCARCINOMA

Question 11

PRESENTATION

BARRETT ESOPHAGUS

1. What are (4) Presenting Symptoms of suspected Barrett Esophagus that require Endoscopy?
2. What other presenting Symptom/History would be cause for Endoscopy?

Answer 11

Presenting Symptoms:

1. Weight Loss
2. Anemia
3. Heme-Positive stool
4. Dysphagia

Symptom/History:

• Anyone with symptoms of Reflux Disease for greater than 5 - 10 years

Question 12

DIAGNOSIS

BARRETT ESOPHAGUS

What is the ONLY way to diagnose Barrett Esophagus?

Answer 12

ENDOSCOPY w/ BIOPSY

Question 13

DIAGNOSIS

BARRETT ESOPHAGUS

1. What type of Epithelium does the Esophagus change from?
2. What type of Epithelium does the Esophagus change to?

Answer 13

1. SQUAMOUS Epithelium
2. COLUMNAR Epithelium

Question 14

TREATMENT

BARRETT ESOPHAGUS

What are the (2) Treatments for an Endoscopic Finding of Barrett Esophagus?

Answer 14

1. PPI
2. Repeat Endoscopy every 2 - 5 years

Question 15

TREATMENT

BARRETT ESOPHAGUS

What are the (2) Treatments for an Endoscopic Finding of Low-Grade Dysplasia?

Answer 15

1. PPI
2. Repeat Endoscopy every 3 - 12 months

Question 16

TREATMENT

BARRETT ESOPHAGUS

What are the (3) Treatments for an Endoscopic Finding of High-Grade Dysplasia?

Answer 16

1. Endoscopic Mucosal Resection
2. Ablative Removal
3. Distal Esophagectomy