Gabriel-GERD
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| CREST syndrome | characterized by calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia
rheumatologic disease: tight leathery skin; smooth muscle around GI tract becomes fibrotic
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| esophageal scleroderma | autoimmune disorder
primary defect: smooth muscle atrophy and fibrosis due to severe GERD secondary to distended LES and hypomotile esophagus
smooth muscle replaced by scar tissue-->loss of peristalsis and a weakening of LES
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| hiatal hernia | an etiology of GERD
removes augmentation of crural diaphragm on LES-->results in lower threshold for TLESRs to occur
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| gastric factors that can cause GERD | delayed gastric emptying: gastroparesis, gastric outlet obstruction
overproduction of acid (rare): Zollinger-Ellison syndrome
abdominal straining
low gastric volume: gastric stapling/bariatric surgery
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| Zollinger-Ellison syndrome | triad: 1) gastric acid hypersecretion 2) sever peptic ulceration 3) non-beta cell islet tumor of pancreas
common cause is gastrinoma of duodenum or pancreas
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| intrinsic mucosal factors that prevent GERD | stratified squamous epithelium
intercellular tight junctions
growth factors: maintain integrity of epithelium
production of mucin, bicarbonate, epidermal growth factors
*when these factors are overwhelmed: GERD causes reflux esophagitis
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| esophageal symptoms of GERD | common: heartburn, acid regurgitation
less common: waterbrash (hypersalivation), dysphagia, odynophagia, chest pain
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| heartburn | retrosternal burning sensation
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| acid regurgitation | sour/bitter return of gastric contents
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| typical symptoms of GERD | heartburn and acid regurgitation-->justifies medical therapy
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| esophageal chest pain | GERD most common cause of non-cardiac chest pain
occurs at any part of chest and radiates to neck, arm, or back
ALWAYS RULE OUT CARDIAC CAUSES
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| airway symptoms of GERD/LPR-laryngopharyngeal reflux | cough, wheezing, sore throat, repetitive throat clearing, post-nasal drip, neck or throat pain, globus sensation, apnea, otalgia
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| Barrett's esophagus | change in esophageal epithelium: no inflammation, just change in cell type (squamous-->columnar)
prevalence increases with duration of reflux symptoms-->can lead to adenocarcinoma
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| endoscopy | direct visualization of esophageal mucosa-->always done if alarm symptoms are present
linear erosions seen in esophagitis
biopsies can be taken
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| alarm symptoms | bleeding, dysphagia, odynophagia, weight loss, anemia
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| barium swallow | used to ID strictures and hiatal hernias
insensitive for detection of erosions
low-yield procedure for evaluation of GERD symptoms
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| ambulatory esophageal pH studies | pH probe placed in esophagus for 24-48hrs-->patient keeps diary-->look for correlation between symptoms and pH<4
indicates atypical symptoms, ENT symptoms, frequent atypical chest pain, refractory symptoms, pre-op confirmation of GERD
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| gastroesophageal scintigraphy | rarely used: Rarely used, feed patient technetium 99m sulfur meal-->obtain post-prandial images-->aspiration can be detected
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| Bernstein test | rarely used: infuse HCl via NG (naso-esophageal) tube and look for symptoms-->water and acid alternatively infused-->water will relieve symptoms
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| treatment of GERD | lifestyle modication, acid neutralization, chewing gum, PPIs (omeprazole, lansoprazole), prokinetics (metoclopramide), H2-blockers (cimetidine, ranitidine), surgery/endoscopic therapy
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| fundoplication | surgical GERD treatment: wrap fundus of stomach around lower esophagus to tighten LES
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| proton pump inhibitors | inhibit basal and stimulated acid production of parietal cell
pronounced and long-lasting; most potent inhibitors of acid secretion
ex) omeprazole, lansoprazole
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| metoclopramide | treatment for GERD-->a prokinetic: promotes gastric emptying
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