GERD and esophageal cancer – Flashcards
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GERD
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-The condition that results when the reflux of gastric material into the esophagus or oropharynx causes symptoms, tissue injury, or both. -the free reflux of gastric contents into the esophagus composed of acid, non-acid secretions (bile, pancreatic enzymes, pepsin, mucus) and ingested gastric contents
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Physiological reflux
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Type of reflux occurs many times each day with everyone during meals
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Pathologic GERD
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-Typical or classic (heartburn/regurgitation) versus atypical symptoms -mucosal disruption description: erosive/ulcerative versus non-erosive -extent of reflux: esophageal versus laryngopharyngeal reflex
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prevalence of GERD
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-40% of the US adult population has heartburn at least once per month -5 to 10% of the US population has episodes of heartburn at least once daily
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Complications associated with esophageal reflux
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-Strictures -bleeding -Barrett's esophagus (intestinal metaplasia) -esophageal cancer -damage to the esophagus, pharynx, larynx, and respiratory tract
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Classic symptoms of GERD
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-Heartburn (Pyrosis) -regurgitation or acid brash; gross reflex experienced with a sense of liquid passing up into the chest and sometimes the mouth -water brash; increased elevation caused by stimulation of esophageal reflux -chest pain; indistinguishable from cardiac angina -can be completely asymptomatic (25%)
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2 symptoms that when they occur together are ;90% predictive of GERD
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Heartburn and regurgitation
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Endoscopic or radiographic descriptions of reflux:
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Non-erosive reflux disease (NERD) erosive reflux disease
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NERD
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-Imaging of esophageal mucosa is normal -most common pathologic reflux -50% with GERD sx -No visible damage -Must not have alarm symptoms/ conditions -Reassure and treat -Will not cause complications
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Erosive reflux disease
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-Esophageal erosions noted on endoscopy or barium esophagram -may lead to the complications of reflux disease because of chronic inflammation -severity of symptoms does not necessarily correspond to severity of esophagitis
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Atypical or extra esophageal manifestations of GERD presentation
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-Asthma -chronic cough -chronic coarseness -noncardiac chest pain -chronic hiccups -night sweats -a loss of dental enamel
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Differential diagnosis of esophageal reflux symptoms
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-Infectious esophagitis -pill esophagitis -eosinophilic esophagitis -peptic ulcer disease -non-ulcer dyspepsia -biliary tract disease -coronary artery disease -esophageal motor disorders
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Peptic strictures
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-form when chronic inflammation leads to scarring of the esophageal wall -compromises the viable diameter of the esophageal lumen -most commonly found near the gastroesophageal junction (GEJ) -patients present with difficulty swallowing; solids ;liquids -may result with acid suppression or may require endoscopic disruption would balloon dilation
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Intestinal metaplasia (Barrett's esophagus)
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-premalignant condition -Chronic reflux over many years leads to metaplastic change in the distal esophagus -squamous cells ? columnar epithelium -1/10 patients with chronic reflux develop this -has the potential to become adenocarcinoma of the esophagus; 1/200 patients with this develop cancer -monitor with biannual endoscopy with biopsy to monitor progression towards dysplasia
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Upper esophageal sphincter
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-Striated muscle -close to prevent esophageal reflux into pharynx and aerophagia
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Esophageal body
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-Striated muscle = proximal 5% -mix of striated and smooth muscle = proximal 1/3 -smooth muscle = distal 2/3 -25 cm long by 3 cm in diameter -within negative pressured thorax -primary and secondary peristalsis clears reflux materials
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Lower esophageal sphincter
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-Smooth muscle -closed at rest to prevent reflux of gastric contents -distinct area of the esophagus and diaphragm -muscle is quite thick here -tonically contracted and relaxes with swallowing
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Diaphragmatic sphincter
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Diaphragm squeezed into LES to further bolster pressure at GEJ
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Epithelial resistance factors
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Salivary bicarb esophageal and gastric mucosal bicarbonate
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pathophysiology of reflux
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-Multi-factorial = failure of reflux barrier -abnormal LES function -hiatal hernia -poor peristalsis of the esophagus leading to inadequate clearing of refluxate -caustic substances -reduced epithelial resistance
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Abnormal LES function
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-Transient lower esophageal sprinkler relaxations (TLESR) believed to play a major role in initiating GERD -many stimuli increased frequencies of relaxations, including gastric this tension, burning zeal stimulation, stress, posture, and sleep -TLESR ? reflux and inflammation ? weakened LES
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Hiatal hernia
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disrupts diaphragmatic positioning at LES
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Reduced epithelial resistance
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Decreased bicarbonate from saliva and mucosa
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Caustic substances
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-In addition to HCL secreted by the stomach, non-acid or weak acid refluxate includes the conjugated bile salts, pancreatic enzymes, pepsin, medications, or ingested foodstuffs that may be responsible for symptoms or damage
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Diagnoses of GERD
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-Appropriate symptom complex (heartburn+reflux) -upper endoscopy with possible biopsy -esophagram or upper G.I. x-ray -24-hour monitoring -impedance plethysmography/24 hour ph
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upper endoscopy with possible biopsy
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Gold standard for esophagitis Most sensitive test for seeing esophagitis, complications, and finding Barrett's esophagus
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esophagram or upper G.I. x-ray
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Not sensitive for mild refluc Gives information about motility and amount of reflux
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24 hour monitoring
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-Small tube place down the nose into the esophagus and stomach -acid sensor at the lower and quantifies the amount of reflux into the esophagus and correlates to reported symptoms
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impedance plethysmography/24 hour ph
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-Sensors placed along the length of the probe to detect movement of fluid into the esophagus and to correlate to risk ported symptoms -Quantifies reflux -Helpful in patients unresponsive to empiric therapy and may have non-acid reflux
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Lifestyle changes recommended for patients with GERD
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-Elevate head of bed at least 4-6 inches -stop smoking -decrease alcohol consumption -reduce fat intake -decreased size of meals -avoid bedtime snacks are eating 2 hours prior to lying down -avoid: tea, coffee, citrus, chocolate, mint, tomato juice, and cola -avoid these drugs as much as possible: anti-cholinergic, diazepam, theophyliine, calcium channel blockers, narcotics
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Drug therapy for GERD
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-;80% of patients will require chronic reflux medications - antacids: neutralize acid in the esophagus and stomach -H2 receptor antagonists: decrease acid content of the gastric refluxate and make it less noxious to the epithelium -proton pump inhibitors: cause irreversible blockade of parietal cell hydrogen-potassium ATPase
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Nissen Fundoplication
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Surgery to reestablish the reflex barrier by wrapping the stomach around the GEJ to create a high-pressure zone
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Incidence of esophageal cancer
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300,000 deaths/year worldwide -in China, annual rate is 130/100,000 -in the US, 90%
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Symptoms of esophageal cancer
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-Dysphagia -GERD -thoracic back pain -bleeding -weight loss
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Pathology of esophageal cancer
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-Rate of adenocarcinoma of the GEJ is increasing at a greater rate than any other malignancy in the Western world
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Squamous cell cancer
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-Arises from the squamous lining of the upper esophagus -most common in the proximal esophagus -most common type of esophageal cancer in Asia
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Risk factors for squamous cell cancer
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-Tobacco -alcohol -pickled foods and smoked meats -caustic injury of the esophagus -head and neck cancer -tylosis palmaris and plantaris
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Adenocarcinoma
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-Currently the most common esophageal cancer in the Western world -fastest rising incidence of any solid tumor -found at or near the GEJ where columnar cells are found -Barrett's metaplasia is a precancerous change -reflux is the greatest risk factor for Barrett's changes -adenocarcinoma is more common with middle aged white men -adenocarcinoma is associated with obesity
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Surviving esophageal cancer
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-Prognosis most closely correlates at this stage of the disease at the time of diagnosis -surgical esophagectomy remains the only cure for the disease; not offered to patients with advanced disease states
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Staging esophageal cancer
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Step 1: thorough physical exam, keying in on sites prone to metastases including supraclavicular nodes, liver, lung step 2: PET/CT scan of chest and abdomen to evaluate for metastases step 3: endoscopic ultrasonography with possible fine needle aspiration biopsy -management is generally palliative -one discovered by symptoms (dysphagia, bleeding, weight loss) treatment is generally palliative
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Goal of palliation in esophageal cancer
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to allow the patient to stay at home, allow oral intake, and control pain
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Treatment of early disease stage
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Treated and cured with surgery only -endoscopic resection may be tried for stages 0, 1
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Treatment of advanced esophageal cancer
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-Radiation, chemotherapy and surgery in combination
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Treatment of metastatic disease
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-Endoscopic stenting or tumor ablation with photodynamic therapy, radiation and chemo palliation. -Surgery should be avoided
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Photodynamic therapy
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-systemic injection of light-sensitive drug porfimer sodium. -local activation of low-power, red light laser -patients may remain light-sensitive for up to 8 weeks and must avoid the sun
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Relief of dysphagia
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-Balloon dilation: effective but only last for a few days -stenting: ;15% risk of acute complications and 20-40% chance of late complications
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Late complications of stenting
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Migrations, bleeding, fistula
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Acute complications of stenting
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Perforation, bleeding
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Specific treatment of esophageal cancer
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-Surgery -radiation -chemotherapy -palliation -thermal -chemical
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Standard chemotherapy for esophageal cancer
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Cisplatin and 5 fluorouracil -response is 20-40% -there is no improved survival
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things that aggravate heartburn
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alcohol caffeine chocolate citrus products fat peppermint spicy foods tomato products bending lifting meals before bed some medications obesity? pregnancy running smoking tight clothing
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alarm symptoms of reflux
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Dysphagia Odynophagia GI bleeding and anemia Weight loss Chest pain Choking Recurrent pneumonia New onset...Age ; 45 yrs
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LA grade A esophageal reflux
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One or more mucosal breaks no longer than 5 mm
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LA grade B Esophageal reflux
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One or more mucosal breaks longer than 5 mm
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LA grade C esophageal reflux
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Bridging of the tops of mucosal folds involving ;75% of the circumference
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LA grade D esophageal reflux
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Involving ;75% of the circumference
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GERD complications
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1. Esophageal reflux 2. Refractory erosive esophagitis -Persistent heartburn and chest pain 3. esophageal rings -Intermittent dysphagia 4. peptic strictures -Persistent dysphagia 5. Barrett's esophagus 6. esophageal adenocarcinoma -Progressive dysphagia
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schatzki ring
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superficial mucosal scar
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Strictures
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mucosal and submucosal scarring -most common complication of GERD -May occur in up to 25% *Decreasing severity due to PPI
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acid clearance mechanisms
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-salivation -peristalsis -gravity -esophageal bicarb secretion
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resting pressures
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intrathoracic = -5mmHg intraabdominal = +5mmHg LES = +25mmHg
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progression to hypotensive LES
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TLESRs ? reflux and inflammation ? weak LES
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Role Of Endoscopy In GERD
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-Rule out complications -Grade disease severity -Influence management? 50% with heartburn have no findings (NERD) severity of heartburn does not predict esophagitis lack of esophagitis does not predict an easier-to-treat subset of patients
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when to perform an Esophageal 24 hr pH-Impedance Test
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Symptoms NOT responding to PPI: -Heartburn -Atypical chest pain -Extraesophageal manifestationsof GERD (e.g. laryngitis, chroniccough, adult-onset asthma) -Considering non-acid reflux
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GERD treatment goals
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-Relieve symptoms -Heal esophageal injury -Prevent complications (eg, esophagitis,peptic strictures, Barrett's esophagus) -Maintain remission
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GERD Pathophysiology-based Pharmacologic Treatment
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1. enhance esophageal clearance and salivation -cholinergic and prokinetic drugs 2. enhance mucosal defense -prostaglandins and sucralfate 3. decrease acid and pepsin -antacids and alginates 4. improve gastric emptying -prokinetic drugs 5. strengthen the antireflux barrier -motility stimulating drugs
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principles of anti-reflux surgery
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restore intra-abdominal esophagus approximate diaphragmatic crurae reduce hiatal hernia perform fundoplication
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most effective treatment in the management of GERD
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PPIs
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Barrett's histopathology
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Metaplastic changes of esophagus from GERD Specialized columnar epithelium Abundant goblet cells
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Barrett's Esophagus
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Change from squamous to columnar epithelium with goblet cell metaplasia is a risk factor for dysplasia and development of adenocarcinoma
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Barrett's w/ LG Dysplasia
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-Nuclear atypia, <50%, are large and have dark markings -Increased mitosis -Normal gland pattern (cells are grow in even rows).
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Barrett's with HG Dysplasia
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-Nuclear atypia with ;50% with dark nuclear spots -Abnormal glandular growth not beyond the lamina propria -Glands are branching, budding, and distorted -Increased mitosis -Cytoplasm may appear abnormal staining
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Treating Barrett's ...(Preventing Adenocarcinoma)
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1. No clear evidence of reversal back to squamous 2. To prevent reflux-related inflammation: -PPI's - minimal effect -Antireflux surgery - some literature supports 3. Surveillence: every 2 years endoscopy + biopsies 4. Ablation for Barretts with dysplasia: -Radiofrequency Ablation Therapy -Photo Dynamic Therapy - more complications with a stricture rate 30%
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Radiofrequency Ablation for Barretts
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-Bipolar array -Devices are available in circumferential and focal configurations -Bipolar array technology, controlled ablation depth -Frictional heating of cellular water
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adenocarcinoma risks
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1. Reflux-Barretts 2. Reflux risk factors: Obesity High fat diets Bile reflux
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Esophageal Cancer - presenting symptoms occur late:
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Dysphagia to solids +/- liquids Weight loss Anemia/hemetemesis Chest pain Back pain Late presentation: -Esophagus is very distensible -Tumor must be large to cause dysphagia. -No adventitia layer thus CA spreads readily to surroundings.
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Staging Esophageal Cancer
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1. Location: proximal vs. lower 2. Lymph nodes: regional vs. distant 3. Metastases: local vs. distant 4. Staging tests: CT scan of chest, abdomen, pelvis Endoscopic ultrasound PET scan
