GERD (Exam 2)

Question 1

Reflux esophagitis

Answer 1

Repeat exposure to refluxed material for long periods of time

Question 2

Reflux esophagitis may progress into

Answer 2

erosion of squamous epithelium (erosive esophagitis)

Question 3

Causes of GERD

Answer 3

Defective LES pressure
Mucosal defense mechanism problems
Hiatal hernia

Question 4

Mucosal defense mechanism problems

Answer 4

Prolonged clearing time from esophagus
Delayed gastric emptying
Reduced mucosal resistance

Question 5

Foods that decrease LES pressure

Answer 5

fatty meals
garlic, onions, chili peppers
carminatives
chocolate
coffee, cola, tea

Question 6

Medications that decrease LES pressure

Answer 6

ethanol + nicotine
anticholinergics
barbiturates
nitrates
DHP CCB
progesterone
dopamine
tetracycline
estrogen
theophylline

Question 7

Direct food irritants to esophageal mucosa

Answer 7

spicy foods
tomato + orange juice
coffee

Question 8

Direct medication irritants to esophageal mucosa

Answer 8

alendronate
iron
aspirin
quinidine
NSAIDs
potassium chloride

Question 9

Which comorbidities are not necessarily risk factors but can mimic GERD-like symptoms

Answer 9

Respiratory diseases
Chest pain

Question 10

Severity of symptoms correlates with

Answer 10

duration of reflux

Question 11

Typical symptoms of GERD

Answer 11

HEARTBURN
water brash
belching
regurgitation

Question 12

Heartburn may be aggravated by

Answer 12

recumbent position
bending over
fatty meal

Question 13

Atypical symptoms of GERD

Answer 13

Nonallergic asthma
chronic cough
hoarseness
pharyngitis
chest pain
dental erosions

Question 14

Alarm symptoms of GERD

Answer 14

Continual pain
Choking
Dysphagia
Odynophagia

Question 15

Complications of GERD

Answer 15

Barrett’s esophagus
Esophageal strictures
Esophageal adenocarcinoma

Question 16

GERD Stage 1 (Mild) Symptoms

Answer 16

Heartburn + regurgitation occurring less than once a week

Question 17

GERD Stage 1 (Mild) Treatment

Answer 17

Lifestyle modifications
OTC antacids PRN

Question 18

GERD Stage 2 (Moderate) Symptoms

Answer 18

Heartburn + regurgitation occurring a few times a week

Question 19

GERD Stage 2 (Moderate) Treatment

Answer 19

Lifestyle modifications
OTC H2RA or PPI
PPI preferred if > 2x week

Question 20

GERD Stage 3 (Severe) Symptoms

Answer 20

Heartburn + regurgitation
difficulty swallowing
cough, change in voice
chest pain

Question 21

GERD Stage 3 (Severe) Treatment

Answer 21

Lifestyle modifications
QD - BID prescription H2RA or PPI
PPI or PCAB > H2RA
GERD specialist

Question 22

GERD Stage 4 (Complications) Symptoms

Answer 22

Heartburn + regurgitation
difficulty swallowing
cough, change in voice
chest pain
strictures, barrett’s esophagus, cancer

Question 23

GERD Stage 4 (Complications) Treatment

Answer 23

Lifestyle modifications
BID prescription H2RA or PPI
PCAB > PPI in erosive
GERD specialist

Question 24

Which stages of GERD have relapsing disease?

Answer 24

Severe/Complicated

Question 25

Relapsing disease requires ______ therapy

Answer 25

long-term maintenance

Question 26

Potassium-competitive acid blocker (PCAB)

Answer 26

Vanoprazan

Question 27

PCAB MOA

Answer 27

reversibly bind to K+ ions and block H+/K+ ATPase --> inhibits acid secretion

Question 28

Typical symptoms treatment

Answer 28

Initial empiric trial of acid-suppression therapy Diagnosis of patient responds to therapy

Question 29

Tests for GERD diagnosis

Answer 29

24 hr ambulatory pH monitoring Endoscopy Barium/Iodine contrast PillCam ESO

Question 30

24 hr ambulatory pH monitoring useful in ____ and ____ patients

Answer 30

typical symptoms not improving atypical symptoms

Question 31

Endoscopy

Answer 31

preferred for assessing mucosa, identifying barrett's, and complications Alarm symptoms

Question 32

Barium/Iodine contrast radiography

Answer 32

Lacks sensitivity and specificity

Question 33

PillCam ESO

Answer 33

Camera-containing barium contrast No radiation exposure

Question 34

GERD therapy is directed at

Answer 34

decreasing acidity + gastric volume improving gastric emptying increasing LES pressure enhancing acid clearance protecting mucosa

Question 35

Esophageal clearance medications

Answer 35

Bethanechol Cisapride

Question 36

Esophageal mucosal resistance medications

Answer 36

Alginic acid Sucralfate

Question 37

Gastric emptying medications

Answer 37

Metoclopramide Cisapride

Question 38

LES pressure medications

Answer 38

Bethanechol Metoclopramide Cisapride

Question 39

Gastric acid medications

Answer 39

Antacids H2RAs PPIs PCAB

Question 40

Lifestyle modifications with GERD

Answer 40

Elevate head of bed Diet changes Weight reduction Smoking cessation Avoid alcohol Avoid tight-fitting clothes

Question 41

Phase I Treatments

Answer 41

Lifestyle modifications PLUS OTC antacids AND/OR Low dose OTC PPIs or H2RAs

Question 42

Phase II Treatments

Answer 42

Lifestyle modifications PLUS Standard dose H2RAs for 6-12 weeks OR PPIs for 4-8 weeks OR PCAB for 4 or 8 weeks

Question 43

Phase III Treatments

Answer 43

Interventional Surgeries

Question 44

Antacids

Answer 44

Maalox or Mylanta Calcium carbonate Gaviscon

Question 45

H2RAs

Answer 45

Cimetidine Famotidine Nizatidine

Question 46

PPIs

Answer 46

Omeprazole Lansoprazole Esomeprazole Pantoprazole Rabeprazole Deslansoprazole

Question 47

Antacid combined with alginic acid MOA

Answer 47

Protective barrier for esophagus against reflux by forming highly viscous solution

Question 48

Mucosal Protectants

Answer 48

Sucralfate (Carafate)

Question 49

Mucosal Protectants is limited to management of GERD in ______.

Answer 49

pregnancy

Question 50

If no response to Phase I after ______, start phase II

Answer 50

two weeks

Question 51

PCAB for nonerosive esophagitis

Answer 51

Vanoprazan for 4 weeks

Question 52

PCAB for erosive esophagitis

Answer 52

Vanoprazan for 8 weeks

Question 53

Efficacy of H2RA in Phase II GERD

Answer 53

symptomatic improvement in 60% of patients endoscopic healing of 50%

Question 54

Initial therapy for severe/complicated symptoms

Answer 54

PPIs >>>> H2RAs 83% improvement and 78% healing

Question 55

_____ is an alternative for treating sever or frequent reflux-like symptoms

Answer 55

PCAB vanoprazan

Question 56

When is vanaprazan therapy preferred?

Answer 56

Erosive esophagitis

Question 57

Promotility agents

Answer 57

Cisapride (Propulsid) Bethenchol (Urecholine) Metoclopramide (Reglan)

Question 58

Cisapride (Propulsid)

Answer 58

increases LES pressure, esophageal clearance, and gastric emptying

Question 59

Cisapride (Propulsid) side effects

Answer 59

life-threatening cardiac arrhythmias

Question 60

Cisapride (Propulsid) is contraindicated in

Answer 60

mechanical obstruction anticholinergic agents (can get through limited access program)

Question 61

Bethenchol (Urecholine)

Answer 61

increases LES pressure and esophageal clearance selectively stimulates muscarinic receptors --> increases ACh

Question 62

Bethenchol (Urecholine) is contraindicated in

Answer 62

mechanical obstruction anticholinergic agents

Question 63

Which promotility agent has an off label indication for GERD

Answer 63

Bethenchol (Urecholine)

Question 64

Metoclopramide (Reglan)

Answer 64

dopamine antagonist increases LES tone and accelerates gastric emptying

Question 65

Metoclopramide (Reglan) side effects

Answer 65

tachycardia EPS syndrome

Question 66

Metoclopramide (Reglan) is contraindicated in

Answer 66

parkinson's disease mechanical obstruction dopamine + anticholinergic agents

Question 67

Maintenance therapy is with the ____ effective dose for _____ patients.

Answer 67

lowest relapse

Question 68

Preferred maintenance drugs

Answer 68

PPIs or PCAB >> H2RAs

Question 69

Surgical intervention of GERD

Answer 69

reestablish anti reflux barrier to position LES within abdomen