Gastro - Online MedEd - GERD

Question 1

GERD - what is it?

Answer 1

Due to acid
Weekend LES for whatever reason
Acid is going to regurgitate and burn esophageal mucosa - burning hurts –> leads to esophagitis

Question 2

Patient presentation GERD

Answer 2

Typical symptoms: burning chest pain made worse with supine/recumbent/spicy foods; improved with sitting up and antacids; retrosternal chest pain, metallic taste
Atypical symptoms: acid can roll higher and touch larynx/trachea = hoarseness, cough, stridor *nocturnal asthma (key! same symptoms of asthma but only at night, not better with asthma meds)

Question 3

Dx of GERD

Answer 3

Dx is by treatment
No diagnostic step
PPI + lifestyle x 6 weeks
(better than H2 blocker)
Not lifestyle only first

If trial doesn’t work what to do next? EGD and biopsy = show esophagitis and eosinophils - will not show that esophagitis is product of acid
Best is: 24 hour pH monitor - keep a diary of symptoms –> if symptoms is with low pH
Manometry - not common

Question 4

Dx of GERD with alarm symptoms

Answer 4

Go straight to EGD and biopsy

No trial of PPI+lifestyle

Question 5

Treatment of GERD

Answer 5

1) PPI x 6 weeks
2) Metaplasia/Barrett’s esophagus - high dose PPI BID
3) Dysplasia/turning into cancer - need local ablative therapies - radiofrequency, laser, cryo - remove dysplastic tissue –> can turn into adenocarcinoma
4) Adenocarcinoma - resect
* For metaplasia and above - need surveillance EGD

Question 6

Why does GERD become cancer?

Answer 6

Acid –> inflammation constantly (years) –> damage –> esophagus changes to something different –> mucosa becomes columnar epithelium of duodenum (sees acid all the time), this is metaplasia –> this is Barrett’s esophagus (actually a physiologic response)
Terrible GERD –> then symptoms improve/no pain –> this is Barrett’s (because different tissue)
-Barrett’s is precancerous 30-50x increased risk of adenocarcinoma

Question 7

GERD algorithm

Answer 7

1) Dx of GERD
2) Trial 6 weeks PPI –> improve, stop PPI or continue on lowest dose
3) Fail to improve –> EGD with biopsy
4) However, patient has alarm symptoms: N/V/weight loss/anemia –> go straight to EGD and biopsy (cancer signs)

Question 8

EGD and biopsy of GERD - results?

Answer 8

1) GERD - lowest possible dose PPI
2) Metaplasia - Barrett’s - high dose PPI* keep surveillance with EGD
3) Dysplasia - local ablation and PPI* keep surveillance with EGD (frequency increases with closer to adenocarcinoma)
4) Adenocarcinoma - stage and resect

Question 9

Nissen fundoplication - when to use?

Answer 9

Cannot tolerate PPI
Grab stomach and wrap around self –> tighter LES (side effect: achalasia symptoms)
(Not resection)