GERD PDF

Gastroesophageal Reflux Disease GNT Block Editing File Color index : Main text ( black) Female Slides (Pink) Male Slides (Blue) Important ( Red) Dr’s note (Green) Extra Info ( Grey) OBJECTIVES Define reflux esophagitis its pathogenesis, gross and microscopic features, clinical features and its co...

Gastroesophageal Reflux Disease GNT Block Editing File Color index : Main text ( black) Female Slides (Pink) Male Slides (Blue) Important ( Red) Dr’s note (Green) Extra Info ( Grey) OBJECTIVES Define reflux esophagitis its pathogenesis, gross and microscopic features, clinical features and its complications Be familiar with Barrett’s esophagus. Its definition, main cause, pathological gross and microscopic features along with its complications (dysplasia and adenocarcinoma) This lecture was presented by Dr.Maha Arafah & Dr.Ahmed Alhumaidi If You want to read the lecture from Robbins If You want to read the lecture from First aid If You want to watch ninja nerd explanation Need ninja nerd board ? Click here If You want to read osmosis summary Reflux Esophagitis Female Slides Definition According to the American College of Gastroenterology (ACG): Symptoms OR mucosal damage (inflammation or ulceration ) produced by the abnormal reflux of gastric contents into the esophagus. -Often chronic and relapsing. -may see complications of GERD in patients who lack typical symptoms. Epidemiology of 1 GERD ❖ ❖ ❖ ❖ ❖ About 44% of the US adult population have heartburn at least once a month 14% have symptoms weekly Hiatal hernia under X Ray 7% have symptoms daily Approximately 80% of pregnant women have GERD Hiatal hernia present in ~70% of people with GERD. Risk Factors Smoking, alcohol Factors Caffeine, fatty foods. chocolate Hiatal hernia Pregnancy, obesity Hiatal hernia: Herniation of a portion of the stomach into the lower thorax. Schematic diagram of different types of hiatal hernia. A: Normal anatomy. B: Pre-stage. C: Sliding hiatal hernia. D: Paraesophageal hiatal hernia Reflux Esophagitis Difference Reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux Occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury. Gastroesophageal reflux disease (GERD) Types ● ● Female Slides Esophagitis is rarely caused by agents other than reflux Acute Esophagitis may be caused by: Bacterial infection is very rare, but fungal, infection (mainly by Candida albicans) is common. Viral infections of the esophagus (particularly by herpes simplex and cytomegalovirus) are seen in AIDS patient Infective agents Physical agents Irradiation Chemical agents Ingestion of caustic agents, chemotherapy Immunological agents Eosinophilic esophagitis, Crohn’s disease Physiologic vs Pathologic Physiological Pathological Asymptomatic symptomatic Short lived Mucosal injury No nocturnal symptoms Nocturnal symptoms Postprandial (After a meal) - Reflux Esophagitis Pathophysiology Of GERD A. Abnormal lower esophageal sphincter (LES) B. Increase abdominal pressure The most common cause of GERD: -Functional: frequent transient LES relaxation. -Mechanical: hypotensive LES. -Obesity Decrease LES pressure: -Foods: coffee, smoking, alcohol. -Meds: calcium channel blockers (relax -Pregnancy -Increased gastric volume -Delayed gastric emptying SM in HTN so it’ll relax the sphincter as well) -Location: hiatal hernia (x ray shows gas behind the heart) Primary barrier to gastroesophageal reflux is the lower esophageal sphincter. LES normally works in conjunction with the diaphragm. If barrier disrupted, acid goes from stomach to esophagus Clinical presentations Clinical Manifestations Atypical symptoms Wheezing (Asthma) and chest pain Coughing (nocturnal) Because the patient is lying down thus increase the reflux Most common symptoms Heartburn: retrosternal burning discomfort and chest pain Age: Older than 40 years but also occurs in infants and children. Regurgitation: effortless return of gastric contents into the pharynx without nausea, retching or abdominal contractions Reflux Esophagitis Diagnostic Evaluation If classic symptoms of heartburn and regurgitation exist, in the absence of alarm symptoms the diagnosis of GERD can be made clinically and treatment can be initiated. Endoscopy (EGD) Esophagogastroduodenoscopy (with biopsy if needed): -In patients with unusual alarm signs/ symptoms. (nocturnal asthma) -Those who fail a medication trial. -Those who require long term treatment. pH 24-hour pH monitoring: - Accepted standard for establishing or excluding presence of GERD for those patients who do not have mucosal changes. -Trans-nasal catheter or a wireless capsule shaped device. Clinical Note X-Ray with barium can be used to identify complications like ulcer or stenosis with being careful that is contraindicated in patients with renal diseases Reflux Esophagitis Morphology Grossly Simple hyperemia: redness Microscopically 1. 2. 3. basal zone hyperplasia Elongation of lamina propria papillae Eosinophils and neutrophils 1 2 3 Treatment 01 H 2 receptor Blockers 02 Proton pump inhibitors 03 Antireflux surgery to make more tension in the sphincter Clinical Note Surgical intervention include : ● Nissen fundoplication : upper part of the stomach wrapped around LES : strengthens the sphincter ● LINX reflux management system : titanium beads with magnetic cores wrapped around weak native LES : attractive force between beads closing the sphincter & force peristaltic wave causes by swallowing can be transiently open beads Reflux Esophagitis Complications Complications GERD Melena Passing black stool because of bleeding Stricture (fibrosis) Barrett esophagus • Result of healing of erosive esophagitis • May need dilation Erosive esophagitis and ulceration Hematemesis • Responsible for 40-60% of GERD symptoms • Severity of symptoms often fail to match severity of erosive esophagitis • Red mucosa with erosions and ulceration in severe cases with hematemesis and melena Deep Focus Question Deep Focus Question What is one recommendation for the conservative management of GERD? A. Increasing coffee intake B. Avoiding eating within three hours of bedtime C. Eating a large breakfast D. Antacid medication E. Maintaining weight Answer: B What is a surgical technique used to manage GERD? A. Whipple B. Fundoplication C. Gastroduodenal ligament suspension D. Gastric bypass E. Gastrohepatic ligament suspension Answer: B Barrett esophagus Definition In 8-15% of cases is a complication of chronic GERD that is characterized by intestinal metaplasia within the esophageal squamous mucosa Epidemiology Female Slides The incidence of Barrett esophagus is rising Patches of red area , you would see the intestinal metaplas ia here Occur in 10% of individuals with symptomatic GERD Most common in white males and typically presents between 40 and 60 years Barrett esophagus can only be identified through endoscopy and biopsy, due to GERD symptoms Pathophysiology 1 Acid damages lining of esophagus and causes chronic esophagitis 2 Damaged area heals in a metaplastic process and abnormal columnar cells replace squamous cells 3 4 Associated with the development of dysplasia and adenocarcinoma (Barrett esophagus is a precursor lesion to cancer) Molecular studies suggest that Barrett epithelium may be more similar genetically to adenocarcinoma than to normal esophageal epithelium Barrett esophagus ● ● Female Slides Epithelial dysplasia, a preinvasive change, develops in 0.2% to 1% of individuals with Barrett esophagus each year The presence of dysplasia is associated with prolonged symptoms, longer segment length, increased patient age and Caucasian race. Hyperemia Erosions Morphology Metaplasia Adenocarcinoma Many patients with Barrett’s are asymptomatic Grossly Microscopically Endoscopic image of Barrett's esophagus: An area of red mucosa Barrett’s esophagus is marked by the presence of columnar epithelium with goblet cells in the lower esophagus, replacing the normal squamous epithelium. Intestinal type metaplasia Low-grade dysplasia: Cytological changes e.g. nuclear stratification, hyperchromasia and increased nuclear-to-cytoplasmic ratio. High-grade dysplasia: Architectural irregularities, including gland-within-gland, or cribriform pattern in addition to cytological changes. Barrett esophagus Female Slides Complications Complications Of Barrett esophagus adenocarcinoma Dysplasia The most common malignant tumors of the esophagus are squamous carcinomas and adenocarcinomas The prognosis for both types of carcinoma is poor Adenocarcinoma ● ● ● ● ● ● ● Esophageal squamous cell carcinoma Most esophageal Adenocarcinomas arise from Barrett’s esophagus. Other risk factors include: tobacco use and radiation exposure. Risk is reduced by diets rich in fresh fruits and vegetables. Morphology: Occurs in the distal third of the esophagus and may invade adjacent gastric cardia. Microscopically: well to poorly differentiated adenocarcinoma. Present with pain or difficulty in swallowing, progressive weight loss, hematemesis, chest pain, or vomiting Prognosis depends on the stage Summary GERD Barrett esophagus (specialised intestinal metaplasia of esophagus) ● ● ● ● Most common in the middle and lower esophagus. Mostly develop in men who are heavy alcohol drinkers or heavy smokers, and may be preceded by epithelial dysplastic changes. Benign -> Dysplasia —> Cancer. Not related to GERD Barrett Esophagus with high grade dysplasia Adenocarcinoma Keywords GERD ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● Barrett’s esophagus Adenocarcinoma smoker , pregnant Lower esophagus Hiatal hernia Heartburn Retrosternal burning pain Epigastric discomfort Regurgitation Nocturnal Coughing Chest pain Wheezing Gross view : Simple hyperemia Microscopic view : Eosinophils and neutrophils , Basal zone hyperplasia (Barrett’s esophagus) , Elongation of lamina propria papillae Erosive esophagitis and ulceration Melena Stricture (fibrosis) Barrett’s esophagus Adenocarcinoma ● ● columnar epithelium with goblet cells in the lower esophagus Replacement of normal squamous epithelium Basal zone hyperplasia ● ● in distal third of the esophagus well to poorly differentiated ● If You want A summary click here Dr. Maha Case & Questions click here YOU MCQs What is the primary barrier to gastroesophageal reflux? A- LES B- Diaphragm C- Stomach contents D- Lamina propria Which symptom is most commonly associated with GERD? A- Wheezing B- Dysphagia C- Regurgitation D- Coughing Which of the following is a risk factor for the development of GERD? A- Regular exercise B- Low body mass index (BMI) C- Obesity D- Consumption of spicy foods Barrett's esophagus is a complication of chronic GERD that is associated with the development of? A- Squamous cell carcinoma B- Adenocarcinoma C- Dysplasia D- Hiatal hernia 1-A / 2-C / 3-C / 4-B YOU MCQs Which of the following is not a complication of reflux esophagitis? A- Hematemesis B- Melena C- Barrett's esophagus D- Hiatal hernia What is the most common cause of GERD in pregnant women? A- Hiatal hernia B- Hormonal changes C- Increased abdominal pressure D- Dietary factors Which of the following is a specific histopathological feature of Barrett's esophagus? A- simple hyperemia B- Basal zone hyperemia C- Aplasia D- Goblet cells What will be the changes in a patient with GERD? A- Eosinophils B- Macrophages C- Hypoemia D- ‫ﻣﺎﻋﺮﻓﺖ وش اﺣﻂ‬ 1-D / 2-C / 3-D / 4-A YOU CASES 1. A 45-year-old man presents with long-standing heartburn and dyspepsia. An X-ray film of the chest shows a retrocardiac, gas-filled structure. This patient most likely has which of the following conditions? A.Boerhaave syndrome B.Esophageal varices C.Esophageal webs D.Hiatal hernia 2.A 70-year-old woman presents with difficulty swallowing and a 9-kg (20-lb) weight loss over the past several months. Endoscopy reveals irregular narrowing of the lower third of the esophagus. A biopsy shows markedly atypical cuboidal cells lining irregular gland-like structures. Which of the following is the most likely diagnosis? A.Adenocarcino ma B.Esophageal stricture C.Leiomyosarco ma D.Squamous cell carcinoma 3.A 50-year-old obese man (BMI = 32 kg/m2) comes to the physician complaining of indigestion after meals, bloating, and heartburn. Vital signs are normal. A CT scan of the abdomen reveals a hiatal hernia of the esophagus. Endoscopic biopsy shows thickening of the basal layer of the squamous epithelium, upward extension of the papillae of the lamina propria, and an increased number of neutrophils and lymphocytes. Which of the following is the most likely diagnosis? A.Esophageal varices B.Mallory-Weiss syndrome C.Reflux esophagitis D.Squamous cell carcinoma 4.A 30-year-old man with AIDS complains of severe pain on swallowing. Upper GI endoscopy shows elevated, white plaques on a hyperemic and edematous esophageal mucosa. Which of the following is the most likely diagnosis? A.Candida esophagitis B.Herpetic esophagitis C.Reflux esophagitis 1-D / 2-A / 3-C / 4-A D.Squamous cell carcinoma in situ Need explanation ? Click here YOU CASES Extra Cases May Require extra info 1.A 42-year-old man presents to the emergency department with a 2 month history of chest pain and cough. The patient reports he frequently wakes up coughing with a substernal burning sensation. He has no significant past medical history but reports a 20-pack-year smoking history. Temperature is 37°C (98.6°F), pulse is 68/min, respirations are 14/min and blood pressure is 130/82 mmHg. Physical examination shows faint end-expiratory wheezing bilaterally on chest auscultation. Initial troponin level is normal, and an ECG reveals normal sinus rhythm. Which of the following best describes the mechanism of action of the medication used to treat this patient's condition? A.Stimulates angiogenesis and the formation of granulation tissue B.Dilatation of large coronary arteries and arterioles C.Beta-2 agonist of bronchial smooth muscle cells D.Inhibition of the parietal cell H+/K+ ATP pump 2.A 46-year-old man presents to the primary care physician with a 6 month history of worsening retrosternal burning pain and coughing after eating. The patient reports he has had similar symptoms over the past 10 years but states they have never been this severe. The patient has smoked 1 pack of cigarettes daily for 30 years. The patient's family history is significant for esophageal adenocarcinoma in his older brother. An esophagogastroduodenoscopy is performed, and an image of the gastroesophageal junction is shown : biopsy of this lesion is most likely to demonstrate which of the following pathological changes? A.Columnar epithelium with cilia B.Columnar epithelium with goblet cells C.Transitional epithelium D.Non-keratinize d squamous epithelium 1-D / 2 - B ‫‪Pathology Team‬‬ ‫زﻳﺎد اﻟﻌﺘﻴﱯ‬ ‫ﻋﺎﺋﺸﺔ إﺑﺮاﻫﻴﻢ‬ ‫اﻟﺪاﻧﺔ ﻋﺒﺪهللا‬ ‫‪er‬‬ ‫‪ad‬‬ ‫‪Le‬‬ ‫ﻟﻤﻰ اﻟﻌﺘﻴﱯ‬ ‫ﻋﺒﺪاﻟﺮﺣﻤﻦ اﻟﻤﺴﻠَّﻢ‬ ‫‪r‬‬ ‫‪de‬‬ ‫‪a‬‬ ‫‪Le‬‬ ‫ﻧﻮرة اﻟﻤﺤﻴﻤﻴﺪ‬ ‫رﻏﺪ اﻟﻤﺼﻠﺢ‬ ‫ﻟﻴﺎن اﻟﺮوﻳﲇ‬ ‫رﻳﻤﺎ اﻟﻤﻄﲑي‬ ‫ﻓﻴﺼﻞ اﻟﺸﻮﻳﻌﺮ‬ ‫رﻳﻤﺎز اﻟﻤﺤﻤﻮد‬ ‫زﻳﺎد ﺣﻜﻤﻲ‬ ‫ﺳﻠﻄﺎن اﻟﺒﻘﻤﻲ‬ ‫ﻋﺮوب اﻟﻤﺤﻤﻮد‬ ‫ﺧﺎﻟﺪ اﻟﺮﺷﻴﺪ‬ ‫ﻋﺒﺪهللا اﻟﻀﻮﻳﺤﻲ‬ ‫اﻟﺠﻮﻫﺮة اﻟﻮﻫﻴﱯ‬ ‫ﻟﺆي اﻟﺤﺪﻳﱻ‬ ‫ﻫﻴﺎ اﻟﺰﻳﺮ‬ ‫ﻋﺒﺪهللا اﻟﻜﻮدري‬ ‫ﻣﺤﻤﺪ اﻟﺴﻼﻣﻪ‬ ‫ﻣﻌﺎذ اﻟﺤﻀﻴﻒ‬ ‫إﻳﻼف ﻣﻌﺘﱯ‬ ‫ﻳﻮﺳﻒ ﺑﺎدﻏﻴﺶ‬ ‫ﺳﺎره اﻟﻌﺠﺎﺟﻲ‬ ‫ﻳﺰﻳﺪ ال ﻃﻠﺤﻪ‬ ‫أﻓﻨﺎن اﻷﺣﻤﺮي‬ ‫رﻧﺪ اﺑﺎ اﻟﺨﻴﻞ‬ ‫رزان اﻟﺴﻄﻴﺤﻲ‬ ‫ﻫﺪى ﺑﻦ ﺟﺪﻋﺎن‬ ‫ﻣﻨﺼﻮر اﻟﻌﺘﻴﱯ‬ ‫زﻳﺎد اﻟﺴﻮﻳﻠﻢ‬ ‫ﻣﺤﻤﺪ اﻟﻌﺮﻓﺞ‬ ‫داﻧﻪ اﻟﻤﺤﻴنس‬ ‫ﻋﺒﺪاﻟﺮﺣﻤﻦ اﻷﺣﻴﺪب‬ ‫ﻧﻮره اﻟﻤﺎﻟﻚ‬ ‫دﻳﻨﺎ اﻟﻤﻬﻮس‬ ‫ﻋﺒﺪاﻟﻤﺤنس اﻟﺪاﻳﻞ‬ ‫ﺷﻮق اﻟﺨﻠﻴﻔﺔ‬