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Summary Gastroenterology- Internal medicine
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Gastroenterology Notes for medstudents.
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1. GERD.De nition: Gastroesophageal re ux disease (GERD) is a chronic condition in which
retrograde ow of stomach contents into the esophagus causes irritation to the epithelial
lining. Insu cient lower esophageal sphincter.
- NERD: non erosive
- ERD: erosive-> re ux esophagitis
Etiology:
- main mechanism: transient lower esophageal sphincter relaxations
- decreased ability to contstrict, which allows stomach content to uncontrollably ow
back into the esophagus
- primary: unknown pathogenesis; often due to hiatal hernia.
- secondary: surgery in area of esophagocardial junction, gastric stenosis, autonomic
neuropathy, systemic sclerosis, pregnancy, obesity, drugs ( CCBs, nitrates usw.)
Clinical features:
- heartburn in supine position
- epigastric pain
- regurgitation
- hoarseness
- smelly breath
- advanced: peptic stenosis with dysphagia and odynophagia ( pain while swallowing)
Complications:
- Ulcers
- stenosis
- chronic or acute GI bleeding
- Barret esophagus: dysplasia-> shortened esophagus; increased risk for ulcers
- Aspirationen at night: cough, hoarseness, asthmatic attacks
- Boerhaave- syndrom: rupture ( rare)
Diagnostics:
- Empirical therapy: If GERD is clinically suspected and there are no indications for
endoscopy, empiric therapy – ranging from lifestyle modi cations to a short trial with
PPIs – should be initiated. A GERD diagnosis is assumed in patients who respond to
this therapeutic regimen.
- Upper endoscopy (esophagogastroduodenoscopy (EGD))
- Used to classify re ux esophagitis and conduct biopsies
- Indications for endoscopy
- Signs of complicated disease (e.g., dysphagia, painful swallowing, weight loss,
iron de ciency anemia, and aspiration pneumonia)
- Extended course of symptoms
- Noncardiac chest pain
- No response to PPI treatment
- Esophageal pH monitoring
- Measured over 24 hours via nasogastric tube with a pH probe
- Sudden drops to a pH ≤ 4 are consistent with episodes of acid re ux into the
esophagus
- Indications
- To con rm suspected NERD
- Before endoscopic or surgical treatment options are initiated in patients with NERD
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, - GERD is diagnosed when drops in esophageal pH correlate with symptoms of acid
re ux and precipitating activities noted in the patient's event diary.
- Esophageal manometry
- A pressure-sensitive nasogastric tube measures the muscle contractions in several
sections of the esophagus while the patient swallows
- Indications:
- Ensure correct placement of pH probes
- Evaluate peristaltic function prior to anti-re ux surgery
- Exclude motor disorders that may mimic the symptoms of GERD
DD:
- infectious esophagitis
- drug induced esophagitis
- eosinophilicesophagitis
- cardiac: dd for angina
- GI
- di use esophageal spasm
- achalasia
- osteochondrosis
- da costas syndrome
Classi cation:
- Savary Miller
- MUSE ( metaplasia, ulcers, stenosis, erosion)
- 0-3 points for each criteria ( 0= missing, 1= mild, 2= moderate, 3= severe)
- Los angeles classi cation
- A: mucosal lesions <5mm
- B: >5mm
- C: uctuating lesions
- D: circulatory defects >75%
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, Treatment:
Lifestyle modi cations
- Dietary
- Small portions; avoid eating (< 3 hours) before bedtime
- Avoid foods with high fat content
- Physical
- Normalize body weight
- Elevate the head of the bed for patients with nighttime symptoms
- Avoid toxins: nicotine, alcohol, co ee, and certain drugs (e.g., calcium channel
blockers, diazepam)
Medical therapy
- Treatment of choice: Standard-dose of PPI for at least 8 weeks (once-daily therapy)
- No response: further diagnostic evaluation
- Partial response: increase the dose (to twice daily therapy) or switch to a di erent
PPI
- Good response: discontinue PPI after 8 weeks
- Maintenance therapy: if symptoms recur after discontinuation of PPIs and in the case
of complications (see “Complications” below)
- After 8 weeks of initial treatment, reduce PPI to lowest e ective dose or switch to
H2RAs (only in patients without complications!)
Surgical therapy
- Indications
- Equally e ective alternative to medical therapy in certain patients with chronic GERD
- Complications (e.g., Barrett esophagus, strictures, recurrent aspiration)
- Fundoplication
- Symptoms resolve in 85% of cases, but recurrence is possible
- Technique: The gastric fundus is wrapped around the lower esophagus and secured
with stitches to form a cu , leading to a narrowing of the distal esophagus and the
gastroesophageal junction (GEJ)and prevents re ux.
- Nissen fundoplication (= complete fundoplication)
- Complications
- Intraoperative damage to the stomach and/or surrounding organs, especially the
esophagus, spleen, lungs/pleura (→ pneumothorax)
- Gas bloat syndrome: inability to belch, leading to bloating and an increase in
atulence
- Dysphagia (especially to solids)
- Telescope phenomenon ("slipped Nissen"): the esophagus slides out of the
wrapped stomach portion
- Gastric denervation: Vagal nerve injury leads to bloating and cardiac complaints,
resembling Roemheld syndrome
- If hiatal hernia is present
- Hiatoplasty: margins of the widened hiatus are sutured together
- Fundopexy or gastropexy: the protruding part of the stomach is tethered to the
diaphragm → keeps it in place and relieves the tension placed on the cu
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, 2. Esophageal cancer.
De nition: Esophageal cancer typically assumes the form of adenocarcinoma or
squamous cell carcinoma, although there are some rarer tumors. Adenocarcinomas are
considered the fastest-growing neoplasia in Western countries, while squamous cell
carcinoma is still most common in the developing world. Adenocarcinoma, which usually
a ects the lower third of the esophagus, may be preceded by Barrett's esophagus, a
complication of gastroesophageal re ux disease (GERD)
Etiology:
- adenocarcinoma: often in lower third
- Barrets esophagus
- obesity
- smoking
- achalasia
- Squamos cell carcinoma: mostly in upper two thirds
- Alcohol consumption
- Smoking
- Diet low in fruits and vegetables
- Drinking hot beverages
- Achalasia
- Nitrosamines exposure (e.g., cured meat, sh, bacon) [5]
- Plummer-Vinson syndrome
- Caustic strictures
- Diverticula (e.g., Zenker's diverticulum)
- Radiotherapy
- Esophageal candidiasis
- Betel or areca nut chewing
Clinical features:
- early: often asymptomatic but may present with dysphagia or retrosternal discomfort
- late
- progressive dysphagia with possible odynophagia
- weight loss
- retrosternal chest pain or back pain
- anemia due to bleeding
- hematemesis, melena
- hoarseness
Diagnostics:
- esophagogastroduodenoscopy
- direct visualization of tumor
- biopsy
- Barium swallow
- staging
- transesophageal endoscopic US
- chest and abdominal CT and/ or PET
- bronchoscopy
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