GERD

Question 1

GER vs GERD

Answer 1

GER: passage of gastric contents from stomach into esophagus.
GERD: passage of gastric contents from stomach to esophagus that triggers bothersome symptoms.
Rumination: passage of gastric contents up into esophagus which then reaches the mouth.

Question 2

Mechanisms of GERD

Answer 2

Primary mechanism of GER: transient LES relaxation, impaired esophageal clearance.
Secondary mechanisms: increased intra-abdominal pressure, decreased gastric compliance, delayed gastric emptying, reduced esophageal capacitance.
Mechanisms of esophageal complications: defective tissue resistance. Noxious composition of refluxate.
Mechanisms of airway complications: vagal reflexes, impaired airway protection.

Question 3

Transient relaxation of LES tracing

Answer 3

Question 4

DDX of GERD (when to test?) answer: when GER becomes GERD

Answer 4

• Rumination
• Esophageal motility disorders
• Gastroparesis
• CNS disease
• CVS
• EOE
• CMPI
• Other: metabolic, genetic, urologic

Question 5

XR UGI

Answer 5

Advantages: anatomic abnormalities: malrotation, strictures, achalasia.
Disadvantages: cannot differentiate between physiologic and Non physiologic GER episodes.

Question 6

Esophageal pH monitoring

Answer 6

Advantages: how much acid, temporal association between GER and Sxs
assess adequacy of treatment,
Disadvantages: cannot detect non-acid reflux, cannot differentiate swallowed contents from refluxed contents.

In peds: non-acid reflux is very common

Question 7

Esophageal Impedance

Answer 7

Advantages: detects non-acidic and acidic reflux. differentiates reflux from swallows, can tell if liquid/gas, or mixed picture.
Limitations: no perfect normal values

Question 8

Gastric emptying scans and milk scans

Answer 8

Advantages: detects acidic and non-acidic GER, can show aspiration, can show liquid or solid emptying.
Limitations: lack of standardized techniques, lack of age-specific norms

Question 9

LA classification of erosions

Answer 9

Grade A and Grade B: no circumferential erosions.
Grade C: 75% of esophageal circumference.
Grade D: >75% of esophageal circumference is eroded.

Question 10

Histology for EOE, remember, GERD is diagnosed based on visible erosions, not a histologic diagnosis.

Answer 10

Question 11

GERD Complications

Answer 11

Question 12

Barrett’s Esophagus

Answer 12

Question 13

GERD Treatment Non-pharmacologic:

Answer 13

• thickening with rice cereal: stops regurgitation exiting the mouth. no reduction in reflux episodes by impedance. Also increased caloric density.
• only safe positioning is baby has to be on the back. left lateral position is better than right for decreasing reflux episodes. Answer to board quesiton: only on the back.

Question 14

GERD treatment: medications

Answer 14

• PPI: reduces symptoms, heart burn, epigastric pain. healing is better with PPI, still good with H2 blockers. PPI does not help with crying. PPI converts acid reflux to non-acid reflux.
  SE: URI, C diff, NEC, Pneumonia. commonly listed side effects: dementia, renal disease, bone health.

Question 15

Motility agents:

Answer 15

• do not prescribe metoclopramide for GER.
• EES: not more helpful than placebo.
• Fundoplication: reduces hiatal hernia, wraps fundus around LES to reinforce antireflux barrier, approximates diaphragmatic crurae, restores intra-abdominal segment of esophagus

Question 16

Candidates for fundoplication

Answer 16

• patient fails medical therapy due to GERD
• pt dependent on aggressive/prolonged medication therapy
• non adherent with medical therapy
• persistent asthma/pneumonia due to GERD, has life threatening complications of GERD.
  Success rates of this surgery are variable.