GERD

Question 1

Halitosis that is worse when eating is a typical symptom of … ?

Answer 1

GERD

Question 2

What does GERD stand for?

Answer 2

Gastroesophageal reflux disease

Question 3

What is the role of the lower esophageal sphincter (LES) in GERD?

Answer 3

It prevents the back-flow of stomach contents into the esophagus.

GERD is the reflux of stomach contents into the esophagus, causing symptoms or complications due to lower esophageal sphincter (LES) dysfunction or transient LES relaxations.

Question 4

True or False: Smoking can exacerbate GERD symptoms.

Answer 4

True

Question 5

True or False: Nitroglycerin can exacerbate GERD symptoms.

Answer 5

True

Question 6

What are the major risk factors associated with GERD?

Answer 6

Major: Smoking and obesity

Note: not just smoking but nicotine alone can increase symptoms, which might be a consideration for patients using cessation therapy.

Others: Diet, hiatal herniation, pregnancy, EtOH, and medications like nitroglycerin, anticholinergics or CCBs.

Question 7

Fill in the blank: GERD is more common in individuals who are __________.

Answer 7

overweight or obese

Question 8

Fill in the blank: GERD can often be triggered by __________, which relaxes the LES.

Answer 8

certain foods or beverages

Question 9

What foods increase the risk of GERD?

Answer 9

Pepermint

Chocolate

Coffee

Fatty foods

Question 10

What is the effect of caffeine on GERD symptoms?

Answer 10

Caffeine can worsen GERD symptoms.

Question 11

Multiple choice: Which of the following is a common risk factor for GERD?

A) Age
B) High fiber diet
C) Regular exercise
D) Low body weight

Answer 11

A) Age

Question 12

What MSK related pathology has a GERD association?

Answer 12

Scleroderma

A systemic autoimmune disease characterized by vasculopathy and fibrosis of the skin and other organs. Typical manifestations include cutaneous thickening, Raynaud phenomenon, and esophageal dysmotility. Classified as limited or diffuse depending on the extent of cutaneous thickening.

Question 13

What is the primary symptom of GERD?

Answer 13

Heartburn (Pyrosis).

Retrosternal epigastric burning sensation radiating up into the chest is the most classic symptom associates with GERD. Pyrosis occurs often after meals or lying down. The other most common symptom is regurgitation.

Question 14

Fill in the blank: __________ is a symptom of GERD that involves a sour taste in the mouth.

Answer 14

Regurgitation.

This can lead to several other issues including, chronic nonproductive cough (especially at night), hoarseness, dental erosions, halitosis, belching, and nausea.

Question 15

What is the term used to describe epigastric pain or discomfort, postprandial fullness, early satiety, bloating and nausea?

Answer 15

Dyspepsia.

Question 16

What is the major association that dyspepsia has with GERD?

Answer 16

The classical association that GERD has with dyspepsia is that symptoms of dyspepsia worsen while lying down.

Question 17

How is aspiration pneumonia related to GERD?

Answer 17

Micro-aspiration of gastric contents into the lungs, leading to recurrent pneumonia.

This can lead to chronic cough and wheezing.

Question 18

True or False: GERD can cause respiratory problems such as asthma.

Answer 18

True

Question 19

What is the significance of odynophagia in GERD patients?

Answer 19

Odynophagia is pain with swallowing and may indicate esophageal malignancy or severe esophagitis.

Perform an upper endoscopy for a patient with GERD symptoms and pain upon swallowing.

Question 20

Multiple choice: Which of the following is NOT a symptom of GERD?

A) Regurgitation
B) Coughing
C) Abdominal pain
D) Fever

Answer 20

D) Fever

Question 21

A diabetic patient who has GERD-like symptoms likely has … ?

Answer 21

Diabetic gastroparesis

This requires an endoscope PRIOR to giving medication (metoclopramide) for gastroparesis.

Question 22

Can GERD present with dysphagia?

Answer 22

Difficulty swallowing may be a clinical symptom associated with a more extreme condition outside of GERD and warrants an upper EGD.

Question 23

A 45-year-old man presents to the emergency department with a 6-hour history of chest pain and vomiting coffee-ground colored material. The patient has had heartburn, food regurgitation, and occasional dysphagia for the past five months. Over-the-counter omeprazole has provided partial relief of symptoms. There is no associated diaphoresis, dyspnea, hemoptysis, or nausea. Past medical history is unremarkable. The patient takes no other medications and does not use tobacco or alcohol. Temperature is 36.7°C (98.1°F), pulse is 108/min, blood pressure is 110/60, and respirations are 18/min. Physical examination is remarkable for epigastric tenderness to palpation. Electrocardiogram and chest radiograph show no abnormalities. Laboratory evaluation shows microcytic anemia. Which of the following is the most appropriate next step in management of this patient?
A) Order a CT of the chest with angiography
B) Prescribe oral pantoprazole and schedule outpatient upper endoscopy in two weeks
C) Administer aspirin and heparin and consider emergent reperfusion therapy
D) Administer intravenous pantoprazole and perform upper endoscopy
E) Order a barium swallow test

Answer 23

Patients with a history suggestive of GERD who have alarm symptoms, like hematemesis, should first be stabilized. They should then be evaluated with an EGD with biopsies to identify complications of GERD and to rule out malignancy. This patient with a 6-hour history of chest pain, coffee-ground emesis (hematemesis), severe reflux symptoms, and microcytic anemia with a history of heartburn and dysphagia likely has gastroesophageal reflux disease (GERD) that may be complicated by erosive esophagitis. Patients with GERD who present with alarming (or alarm) features - gastrointestinal bleeding (hematemesis, melena, hematochezia, pallor), anorexia, unexplained weight loss, dysphagia, odynophagia, persistent vomiting, and the presence of gastrointestinal cancer in a first-degree relative - should have bloodwork and an EGD with biopsies done initially to rule out complications of GERD (like Barrett esophagus, erosive esophagitis, and underlying malignancy). If there are complications of GERD, a multidisciplinary management approach is recommended; which may include medical therapy with PPls, management of anemia (if present), Gl consultation for possible endoscopic therapies that may include dilation or ablation, and surgical consultation for possible laparoscopic fundoplication. All patients with GERD should be counseled on lifestyle modifications, including weight loss and tobacco cessation. Many patients with significant GERD will need to undergo endoscopic surveillance and screening.

Question 24

Name the important alarm symptoms of GERD.

Answer 24

• Signs of a GI bleed
  (iron deficiency anemia)
• Persistent vomiting
• Weight loss
• Dysphagia
• Odynophagia
• Older age >60
  (or >50 in Caucasian males with risk factors)
• Aspiration pneumonia
• Family history of malignancy

Question 25

and upper EDG would be warranted with a patient presenting with ___ years or more of GERD-like symptoms.

Answer 25

5

Question 26

Question 1: A 52-year-old man presents with a 6-month history of heartburn and regurgitation. He has been self-treating with over-the-counter antacids, but his symptoms persist. He reports unintentional weight loss of 15 lbs over the past 3 months and difficulty swallowing solid foods. He has a 20-pack-year smoking history. What is the next best step in management? A. Initiate a proton pump inhibitor (PPI) therapy B. Order an esophageal manometry C. Perform an upper endoscopy D. Prescribe a high-dose H2 receptor antagonist E. Refer for barium swallow study

Answer 26

Answer: Perform an upper endoscopy Explanation: This patient presents with GERD symptoms and alarm features, including unintentional weight loss and dysphagia, which necessitate upper endoscopy to evaluate for complications such as esophageal cancer or strictures. PPIs can be started after ruling out structural abnormalities.

Question 27

What are the major three considerations that will need to be ruled out with a patient presenting with dyspepsia and alarm symptoms?

Answer 27

Dyspepsia can occur in isolation or be associated with other "alarm features" like unintentional weight loss, persistent vomiting, dysphagia, evidence of gastrointestinal bleeding, or anemia. Under these circumstances, further investigation with an upper EGD is warranted to rule out organic causes like peptic ulcer disease, malignancy, or Helicobacter pylori infection.

Question 28

True or False: Antacids are a first-line treatment for GERD.

Answer 28

False

Question 29

What is the most effective lifestyle modification for GERD?

Answer 29

Weight loss, especially in overweight or obese patients. Lifestyle modifications are the first step in the process for minimizing the symptoms of mild GERD. If the patient smokes, reduce or eliminate with education or cessation aid.

Question 30

What dietary change is recommended for patients with GERD?

Answer 30

Avoiding spicy food, fatty food, EtOH, Coffee, and peppermint. Avoid eating at night. When symptoms are mild and occur less than 2 times a week, dietary or lifestyle modifications are considered in the first modality of treatment and coupled with a low dose H2 antagonist.

Question 31

What lifestyle habit should be avoided to reduce GERD symptoms?

Answer 31

Lying down immediately after eating

Question 32

What is the main purpose of using H2 receptor antagonists in GERD management?

Answer 32

To reduce stomach acid production. These are used for mild symptoms occuring 2 times or less a week and coupled with lifestyle modifications.

Question 33

What is a common non-pharmacological treatment for GERD?

Answer 33

Elevation of the head of the bed 6 to 8 inches.

Question 34

Which pharmacologic therapy is first-line for moderate to severe GERD?

Answer 34

Proton pump inhibitors (PPIs). When there are more than 2 episodes a week or severe symptoms, patients benefit from a daily PPI and will usually go on an 8 week trail as long as they are healthy and have no red flag symptoms.

Question 35

What diagnostic test is commonly used to after the failure of first line treatment for GERD?

Answer 35

After the introduction of a PPI and trial period of a PPI (8 weeks), ensure adherence, switch the PPI or try BID. Then perform an esophageal pH monitoring. When the diagnosis is very clear such as epigastric pain going under the sternum, bad taste, sore throat, etc., then confirmatory testing is not necessary. *Some resources state that switching a PPI is moot since all PPIs have the same efficacy.*

Question 36

What are the common complications of chronic GERD?

Answer 36

Esophagitis. Esophageal strictures. Extra-esophageal complications such as asthma, laryngitis, dental disease, and pneumonia. Barrett’s esophagus.

Question 37

What endoscopic findings are associated with Barrett’s esophagus?

Answer 37

Intestinal metaplasia of the esophageal squamous epithelium. It usually takes 5 years for the columnar metaplasia to occur. 0.5% of Barrett’s esophagus cases will progress to cancer.

Question 38

Which group of patients requires screening for Barrett's esophagus?

Answer 38

Men >50 with chronic GERD (>5 years) or other significant risk factors like smoking, obesity, family history of esophageal cancer or adenocarcinoma.

Question 39

What is the surgical procedure called that can treat severe or refractory GERD?

Answer 39

Fundoplication Surgical intervention is typically the next move after the patient is experiencing symptoms and PPIs have failed.

Question 40

What is the surveillance for Barrett's Esophagus without dysplasia?

Answer 40

Endoscopy with biopsies every 3-5 years to monitor for progression to dysplasia.

Question 41

What is the surveillance for Barrett's Esophagus with low grade dysplasia?

Answer 41

Endoscopy every 6-12 months if management is surveillance-based, with biopsies following the Seattle protocol.

Question 42

What is the surveillance for Barrett's Esophagus high grade dysplasia?

Answer 42

Resection.

Question 43

What are the important differential diagnosis for GERD?

Answer 43

Diabetic gastroparesis Cardiovascular origin Esophagitis Ulcers

Question 44

What is the mechanism of action of metoclopramide in diabetic gastroparesis?

Answer 44

Enhances gastric motility and accelerates gastric emptying.

Question 45

What is the first-line medication for diabetic gastroparesis?

Answer 45

Metoclopramide, a prokinetic agent.