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Mechanisms contributing to GERD (5) 1. dec LES fxn, 2. impaired esophageal clearance, 3. excess gastric acidity, 4. dec gastric emptying, 5. abnl esophageal barriers to acid exposure
Complications associated with GERD (3) 1. peptic stricture, 2. Barrett esophagus, 3. extraesophageal complications
peptic stricture narrowing of the esophagus (usu due to damage of esophageal lining)
Barrett's esophagus; what is it? Increased risk for what? chronic acid to lower end of esophagus --> esophageal damage --> metaplasia of squamous epithelium to columnar epithelium (intestinal-type lining) --> inc risk for esophageal adenoCA
hoarseness and wheezing in AM in someone with GERD pharyngeal reflux with silent aspiration, r/o oropharyngeal and vocal cord pathology (see ENT)
PPI produces relief of sx's in what percent of population with GERD? 0.95
How to diagnose GERD? Endoscopy, 24h pharyngeal pH monitoring (supports silent aspiration -- how?)
Extraesophageal complications of GERD (4) laryngitis, reactive airway dz, recurrent pna, pulmonary fibrosis
describe the pressure around the LES LES serves as a zone of increased P between the positive pressure in stomach and the negative pressure in chest;
Who should get worked up for GERD? Self-limiting or mild sx's do not require w/u. Those who do need it: 1. longstanding sx's, 2. atypical sx's (wheezing, cough, or hoarseness), 3. recurrance after cessation of medical therapy, 4. unrelieved sx's while on max dose PPI's
If pt is to undergo surgical anti-reflux procedure, what is the standard w/u? (4) 1. endoscopy, 2. manometry, 3. 24h pH probe testing, 4. barium esophagography
What is the purpose of endoscopy in GERD w/u? evaluates for erosive esophagitis or Barrett esophagus or alternative pathology. Bx for suspected dysplasia or malignancy.
What is the purpose of barium esophogram in GERD w/u? (5) 1. ID location of GE junction in relation to diaphragm, 2. ID hiatal hernia, 3. ID shortened esophagus, 4. eval gastric outlet obstruction, 5. can demonstrate spontaneous reflux.
When is a fundoplication contraindicated in GERD pts? (2) 1. in gastric outlet obstruction (seen on barium esophagogram), 2. aperistalsis (see on manometry)
What is the purpose of 24h pH monitoring in GERD pt? Correlates sx's with episodes of reflux. Also quantifies reflux severity.
What is the purpose of pharyngeal pH monitoring in GERD pt? Correlates respiratory sx's with abnl pharyngeal acid exposure
What can manometry evaluate in GERD pt? (3) 1. competency of LES, 2. adequacy of periostalsis prior to planned antireflux surg, 3. ddx motility d/o such as achalasia or diffuse esopahgeal spasm
If pH monitoring in pt being evaluated for GERD cannot be performed, what can be done instead? Nuclear scintigraphy - evaluates reflux and gastric emptying
What is initial tx for pt with GERD sx's? behavioral therapy and PRN meds
For pts with esophagitis or frequent GERD sx's, what is the tx? PPI's - acid suppression
When is surgery indicated in pt with GERD? (3) 1. documented GERD with persistent sx's despite max PPI dosing, 2. can't tolerate PPI's, 3. don't want to take lifelong meds
What surgery is done to tx severe GERD? laproscopic Nissen fundoplication - 360-degree wrap of fundus of the stomach around the GE jxn to create a valve effect.
What is the longterm success with antireflux surgery (lap Nissen)? 0.9
What are lifestyle changes pts can make to tx GERD? (5) 1. foods - avoid caffeine, EtOH, high fat, 2. avoid meals 2-3 h before bedtime, 3. elevate head while sleeping/lying down, 4. if obese --> wt loss, 5. smoking cessation
What groups of meds can you give GERD pts? (4) 1. PPI, 2. H2-antag, 3. antacids, 4. prokinetic agents
pt with GERD on H2 blocker becomes symptomatic and is found to have Barrett's esophagus on endoscopy - what do you do next? start PPI and do interval endoscopic surveillance of the Barrett's
for GERD, when should diagnostic endoscopy be performed? When pts have longstanding GERD and when sx's are refractory to meds
what has better long term efficacy for reducing development of esophageal cancer in GERD pts - PPI or surgery? they are equivalent
longstanding GERD increases risk of what CA? esophageal adenoCA
what is one of the most reliable clinical indicators that a person has GERD? relief of sx's with PPI
What is the most reliable objective indicator of GERD? 24hr pH monitoring
Created by: christinapham



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