Cm 3 Gerd & Infectious Esophagitis

GERD is a common problem occuring in 10-20? of people in the west (5% in Asia) for people with weekly symptoms. Up to 60% of the population experiences "heartburn" at some point.  In infants, about 50% have reflux, but less than 10% have evidence of esophagitis.

• True

• False

GERD has the most common presenting feature (of CP):

• Tightness

• Squeezing

• Feeling of impending doom

• Heartburn

A clinical diagnosis can typically be made based on:

• Family history

• Undigested food remniants on pillow

• A history of heartburn, regurgitation of gastric contents... especially if relieved by antacids.

• A person's affinity for spicy foods

Endoscopy in patients with HSV reveals: _____________________.

• Large, deep ulcers

• Multiple shallow ulcers

• White plaques

GERD: Reflux esophagitis is the recurrent reflux of gastric contents into the distal esophagus because of mechanical functional abnormality of the ____________________

• Pyloric sphincter

• Lower esophageal sphincter

• Pylorus

• Upper esophageal sphincter

What is the treatment for Candida sp. Infectious Esophagitis?

• Acyclovir

• Ganciclovir

• Fluconazole or ketoconazole. Treat for at least 21+ days to ensure clearance. Repeat labs to ensure clearance.

What is the treatment for CMV Infectious Esophagitis?

• Acyclovir

• Ganciclovir

• Fluconazole or ketoconazole. Treat for at least 21+ days to ensure clearance. Repeat labs to ensure clearance.

What is the main clinical feature of Infectious Esophagitis?

• Odynophagia

• Dysphagia

• Both

What is a long term symptom of GERD?

• Diffuse esophageal spasm

• Neurogenic dysphagia

• Zenker's diverticulum

• Dysphagia

What should be avoided with GERD?

• B-agonists

• A-adrenergic antagonist

• Nitrates

• Calcium channel blockers

• All of the above

As a Tx for GERD weight loss has been shown to be as effective as a PPI.

• True

• False

The etiology/Pathophysiology of GERD is Weekly heartburn and mucosal damage that develops produced by ________ of gastric contents into the esophagus.  Can be caused by problems with LES pressure or Hiatal Hernia.

• Heartburn

• Undigested

• Stalled portions

• Abnormal reflux

Endoscopy in patients with Candidal infection reveals: _____________________.

• Large, deep ulcers

• Multiple shallow ulcers

• White plaques

Most times GERD presents as _________.  You must rule out everything else before you diagnose GERD.

• Cough

• Cold

• Gnawing burning pain

• Chest pain

Surgical & Endoscopic Techniques are available for ____________ but have NOT been shown to prevent complications of the disease.  Surgical Treatment for resolution of GERD is useful when the causative mechanism is a Hiatal Hernia.

• Refractory cases

• Active cases

• Latent cases

When taking a PPI what may not be absorbed by the body?

• Salts

• Electrolytes

• Magnesium

• Calcium

• A & b

• C & d

What is not a complication of GERD

• Peptic ulcer disease

• Barrett's Esophagitis/Malignancy

• Ulcers/Strictures

• Vocal Cord Errosion

What is not a common cause of Infectious Esophagitis:

• Candida sp. (fungus)

• Cytomegalovirus (CMV)

• Herpes simplex virus (HSV)

• HIV

• EBV

• Mycobacterium tuberculosis

• Mycobacterium avium intracellulare

• Trick question... all of the above can be causes although we primarily talked about HSV, HIV, CMV, and Candida sp. in class.

What is the treatment for HSV Infectious Esophagitis?

• Acyclovir

• Ganciclovir

• Fluconazole or ketoconazole. Treat for at least 21+ days to ensure clearance. Repeat labs to ensure clearance.

Corrosive Esophagitis is caused by:

• E. coli

• S. pyogenes

• Low pH

• Alkalis or acids

What is needed for definitive diagnosis of infectious esophagitis?

• Endoscopy

• Cytology or culture from endoscopic brushings

• Dexa scan

• O&P

In GERD, what is typically chosen to monitor the extent of tissue damage?

• The lower GI

• The Upper GI

• The lower esophageal sphincter

• The entire esophagus via endoscopy

Endoscopy in patients with CMV or HIV reveals: _____________________.

• Large, deep ulcers

• Multiple shallow ulcers

• White plaques

Check all that exacerbate GERD

• Obesity

• Caffeine

• Alcohol

• Smoking

• IV drug use

• Fatty meals

• Medications

• Pregnancy

What is not a factor that protects the esophagus?

• Mucus

• Gravity

• Lower esophageal sphincter tone

• Esophageal motility

• Salivary flow

• Gastric emptying

• Tissue resistance

___________________ i warranted in patients older than 45 years with a new onset of symptoms, long-standing or frequently recurring symptoms and failure to respond to therapy or symptoms, indicating more severe conditions such as anemia, dysphagia, or recurrent vomiting.

Medical Management for GERD:

• Suggest lifestyle modifications: stop smoking, avoidance of eating at bedtime (6pm), avoidance of large meals, avoidance of alcohol, avoidance of irritating foods, raise the head of the bed, lose weight, posture changes.

• Mild Symptomatic Tx: Anatacids or alginic acid

• Mild GERD Tx: Histamine (H2 Blockers): may be used but in larger doses than for PUD. H2-blockers are the first-line treatment for mild GERD.

• An Acid-suppressant proton pump inhibitor (PPI). The most powerful anti-GERD medication. PPIs are first-line Tx in moderate to severe disease or in patients who are unresponsive to H2-blockers or have evidence of erosive gastritis.

• A combination of an H2 blocker at bedtime and a PPI in the daytime may be helpful in patients with significant nighttime symptoms.

If oral thrush is present in Infectious Esophagitis, you would think the cause would be from:

Check all of the below possible mechanisms that result in GERD:

• Sphincter incompetence

• Poor digestion

• Malabsorption

• Transient LES relaxation (common GERD)

• Hypotensive LES (More severe GERD)

• Anatomical Disturbance of LES (Hiatal Hernia)

• Obesity

What is the "big culprit" causing Pill-induced esophagitis?

• NSAIDS

• Steriods

• Doxycylcine

• Acids

In a minority of patients: Reflux causes erosion of the esophagus that leads to ________________.  Which is replacement of normal squamous epithelium with metaplastic columnar epithelium and can predispose to malignancy.

Check all the symptoms of GERD

• Increases at nighttime and when laying down

• Often relieved with antacids

• Worse before meals

• Worse after meals

• Regurgitation or dysphagia may occur.

• Hematemisis may occur.

• Hoarseness, halitosis, cough, hiccupping and atypical CP are less common symptoms of reflux.

• More severe disease is generally caused by severe impairment of the lower esophageal sphincter tone: occurs spontaneously when supine.

• Less severe GERD is associated with a pattern of heartburn following meals, but not associated with nighttime Sx's.

• Can have asymptomatic "silent reflux" that is typically noticed by a dentist due to dental decay

• May cause loss of hair if nutritional needs are not adequate

• Main symptom is heartburn approx 30-60 min. after meals.

• Patients may also present with asthma, globus sensation, recurrent laryngitis, sore throat, acid brash, waterbrash. Reterosternal CP

Check ALL of the warning Sx's suggesting that complications have occurred in GERD:

• Dysphagia

• Rhinorrhea

• Bleeding

• Weight loss

• Chest pain

• Weight gain

• Choking

• Coughing, SOB, Hoarseness (caused by acid)

• Lesions in the mouth

• Longstanding symptoms requiring continuous treatment

Patient education to give to patients should include:

• Avoid acidic foods

• Avoid alcohol

• Avoid caffeine

• Avoid chocolate

• Avoid sleeping

• Avoid garlic

• Avoid onions

• Avoid salt

• Avoid peppermint

• Avoid illegal drugs

• Avoid smoking

• Lose weight

• Raise the head of the bed

• Decrease fat intake

• Drink moonshine