What DCI value indicates failed peristalsis?
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Values below 100.
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What DCI value indicates failed peristalsis?
Values below 100.
What is the purpose of medical management in achalasia?
To provide temporary, mild relief of dysphagia for patients who cannot tolerate other therapies.
What percentage of patients with new adenocarcinoma diagnoses have no previous Barrett's esophagus?
95%.
What is the effect of achalasia on esophageal motility?
Loss of relaxation results in aperistalsis and abnormal contractions.
What is the most common esophageal cancer in the United States?
Esophageal adenocarcinoma.
What age range is most commonly affected by achalasia?
Usually 20-65 years.
What does the Integrated Relaxation Pressure (IRP) measure?
It measures LES pressure by evaluating a continuous or interrupted 4-second relaxation in a 10-second window.
What objective assessment score is used to assess symptoms of achalasia?
Eckardt score.
Which parasite infection can lead to achalasia?
Trypanosoma Cruzi (Chagas' disease).
Which demographic is more likely to develop esophageal adenocarcinoma?
Whites compared to blacks, and men compared to women.
What causes the high lower esophageal sphincter (LES) pressure in achalasia?
Selective loss of post-ganglionic inhibitory neurons containing nitric oxide and substance P.
What is the most common surgical treatment for GERD?
Laparoscopic fundoplication.
What are the risk factors for esophageal adenocarcinoma?
Barrett's esophagus, GERD, smoking, obesity.
What is the primary method for diagnosing esophageal cancer?
Endoscopy and biopsy.
What is the purpose of pneumatic dilation in achalasia treatment?
To break the muscular fibers of the lower esophageal sphincter.
What is the Stretta procedure?
An FDA approved outpatient procedure for GERD performed in less than an hour.
What is the most common symptom of esophageal cancer?
Dysphagia.
What is considered a large peristaltic break?
A discontinuity of peristalsis of > 5 seconds.
What is the diagnosis if a patient has no prior diagnosis of GERD, normal acid exposure, negative reflux-symptom association, and no major motility disorders?
Functional heartburn.
What does the LINX® Reflux Management System do?
It augments the pressure of the lower esophageal sphincter (LES) to prevent reflux.
What were the findings of the meta-analysis regarding Stretta?
It showed no difference between Stretta and control for certain GERD outcomes, but a more recent analysis found it improves GERD symptoms and quality of life.
Why should EGD be avoided within 5-15 days of corrosive ingestion?
Due to tissue softening and increased risk of perforation.
What is diagnostic of GERD in LA class B esophagitis?
Typical GERD symptoms and PPI response.
What is the role of esophageal manometry in GERD diagnosis?
It is required for accurate placement of the catheter during pH impedance monitoring.
What is the Los Angeles Classification system used for?
It classifies erosive esophagitis based on the length and extent of mucosal breaks.
What are some possible GERD-related syndromes?
Pharyngitis, sinusitis, pulmonary fibrosis, and otitis.
What are the common side effects of baclofen?
Nausea, drowsiness, dizziness, fatigue.
What is the annual incidence rate of adenocarcinoma in patients with low-grade dysplasia?
Approximately 0.7% per year.
What should be documented during an endoscopic examination of Barrett's Esophagus?
Measurements of diaphragmatic pinch, lower esophageal sphincter, circumferential extent of BE, and maximum extent of BE.
What does a DCI value of ≥ 8000 indicate?
A hypercontractile pattern.
What is the FDA approval status of Vonoprazan?
It is FDA approved for the treatment of erosive esophagitis and for use with amoxicillin +/- clarithromycin to treat H. pylori.
What supportive measurements may be included in the HRM protocol?
Solid test meal, multiple rapid swallows, rapid drink challenge, and pharmacologic provocation.
Which type of achalasia has a better overall response to treatment?
Type 2 achalasia.
What is indicated by ≥ 20% swallows with premature/spastic contractions?
Type 3 Achalasia (spastic achalasia).
What is the recommended screening for patients with tylosis?
Screening is recommended starting at age 30, to be repeated every 1-3 years.
What is the indication for endoscopy in GERD patients?
Reflux symptoms unresponsive to medical therapy, dysphagia, odynophagia, weight loss, GI bleeding, abnormal imaging, persistent vomiting, and recurrent symptoms following endoscopic or surgical therapy.
What treatment is recommended for extensive necrosis (Grade 3b) after caustic ingestion?
NPO (nothing by mouth) and consider further management based on the patient's condition.
What are common clinical manifestations of caustic ingestion?
Chest pain, sore throat, odynophagia, dysphagia, stridor, hoarseness, respiratory distress, epigastric pain, hematemesis.
What is the significance of borderline acid exposure time (4-6%)?
Diagnosis of GERD is suggested if there is adjunctive evidence; absence suggests functional heartburn.
What might laryngoscopy reveal in patients with laryngitis?
Nonspecific edema and erythema of the larynx.
What is Dupilumab and its function?
Dupilumab is a human monoclonal IgG4 antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling, approved for treating EoE in adults and children over 12 years.
What is a cricopharyngeal bar (CPB)?
A CPB is a radiologic abnormality appearing as a posterior indentation at the level of the cricoid cartilage on barium swallow.
What is the normal range for Distal Contractile Integral (DCI)?
450-8000.
How does Vonoprazan differ from traditional PPIs?
It is more potent, provides quicker and steadier inhibition of acid secretion, and does not require administration before meals.
What is the treatment for small, early tumors (T1a or T1b) of esophageal cancer?
Endoscopic Mucosal Resection (EMR) if there are no regional lymph nodes involved and no distant metastasis.
What balloon sizes are typically used for pneumatic dilation?
30, 35, and 40 mm diameters.
Why is describing the extent and severity of inflammation more useful than categorizing esophagitis?
It provides more specific information about the condition.
What does a Symptom Sensitivity Index (SSI) greater than 10% indicate?
It indicates an abnormal association between reflux episodes and symptoms.
What is the distensibility index (DI) used for?
To assess the distensibility of the GE junction.
What was the treatment success rate for the surgical group in the randomized trial for reflux-related heartburn?
67%.
What are the types in the Hill classification?
Type 1: Snug fold; Type 2: Less snug; Type 3: No closure; Type 4: Sliding hiatal hernia.
How do PPIs work in treating GERD?
They irreversibly inhibit active hydrogen potassium (H+, K+)-ATPases.
What are common nonspecific symptoms of extraesophageal GERD?
Hoarseness, throat pain, sensation of a lump in the throat, repetitive throat clearing, and excessive phlegm production.
Is EGD without reflux monitoring recommended for diagnosing extraesophageal GERD?
No, it is not recommended.
What histological features are demonstrated in Barrett's esophagus?
Intestinal metaplasia and goblet cells.
What are common symptoms of achalasia?
Dysphagia to solids and liquids, chest pain, regurgitation, heartburn, weight loss, aspiration.
What does TNM staging stand for?
Tumor, Node, Metastasis.
What imaging is recommended if pseudoachalasia is suspected?
Cross-sectional imaging of the chest and abdomen +/- EUS of the distal esophagus and gastric cardia.
What characterizes Type 1 Achalasia?
Elevated IRP with 100% failed peristalsis and no panesophageal pressurization.
When is esophagectomy indicated?
In patients with T2, T3 cancers without lymph node involvement.
Why is it important to exclude cardiac disease in GERD patients?
Because GERD is the most common cause of non-cardiac chest pain, especially in older patients and those with cardiac risk factors.
What is the mechanism of action of botulinum toxin in treating achalasia?
It inhibits excitatory acetylcholine-releasing neurons, resulting in decreased LES pressure.
What does the Hill classification describe?
The integrity of the gastroesophageal flap valve.
What lifestyle modifications are recommended for managing non-acid reflux?
Weight loss and smaller meals.
What is the role of manometry in GERD diagnosis?
It has a limited role but is required prior to surgical fundoplication to rule out motility disorders.
How is acid reflux defined in pH monitoring?
As a decrease in pH to < 4.
What is the recommended treatment for patients with GERD symptoms?
A therapeutic trial of PPI for at least 3 months.
What defines Barrett's esophagus (BE)?
The presence of intestinal metaplasia of ≥ 1cm that replaces the normal stratified squamous epithelium.
What is Vonoprazan?
A potassium-competitive acid blocker (PCAB) that blocks the hydrogen-potassium ATPase.
What are some medical management options for achalasia?
Nifedipine, sublingual isosorbide dinitrate, and sildenafil.
What is the AGA's recommendation for therapy in T1a tumors?
AGA recommends EMR and ablation as a preferred therapy over esophagectomy.
What was the complete endoluminal remission rate for T1b-sm1 tumors in a small retrospective study?
87%, with a higher rate of 97% for small focal neoplasia ≤ 2 cm.
What are the clinical manifestations of GERD?
Esophageal symptoms include heartburn, regurgitation, dysphagia, odynophagia, and chest pain; extra-esophageal manifestations include asthma, cough, and laryngitis.
What are some side effects of pneumatic dilation?
Perforation, GERD, and reflux esophagitis.
What defines refractory GERD?
Persistent bothersome heartburn (>2 times/week for 3 months) despite BID PPI therapy.
What lifestyle modifications are recommended for GERD patients?
Weight loss, stopping smoking, elevating the head of the bed, small meals, and avoiding alcohol/caffeine.
What does LA class A indicate in the Los Angeles Classification?
One or more mucosal breaks < 5 mm in length.
What is another name for laryngitis in the context of GERD?
Laryngopharyngeal reflux.
What is Barrett's Esophagus (BE) a significant risk factor for?
Esophageal adenocarcinoma.
How does the risk of adenocarcinoma change with the length of Barrett's Esophagus?
It is higher in patients with long segment BE (> 3 cm).
What is the recommended biopsy approach for non-dysplastic Barrett's Esophagus?
Four quadrant biopsies every 2 cm.
What does a distal latency (DL) less than 4.5 seconds indicate?
Premature/spastic contraction.
When can EGD be deferred in asymptomatic patients after caustic ingestion?
If there is a history of ingestion of a small amount of weak caustic substance, EGD can be deferred and the patient discharged within 6-12 hours.
What defines abnormal acid exposure time in the context of GERD?
Acid exposure time greater than 6% is considered abnormal.
What does a barium swallow test show in achalasia?
A dilated esophagus and tight LES (bird's beak appearance).
What is the possible etiology of functional heartburn?
Esophageal hypersensitivity.
What are potential mechanisms of action for the Stretta procedure?
Increased LES muscle thickness, decreased transient lower esophageal sphincter relaxation (TLESR), and reduced gastro-esophageal junction compliance.
What is the initial response rate for botulinum toxin injection in achalasia?
70-90%.
What is the mainstay medical therapy for severe GERD?
Proton Pump Inhibitors (PPIs).
What is the mechanism of action of baclofen?
It decreases transient lower esophageal sphincter relaxations.
What do alginic acid derivatives do in the context of GERD?
Create a mechanical barrier between the esophagus and the stomach.
Does asymptomatic GERD contribute to uncontrolled asthma?
No, it does not appear to be a contributing factor.
What is the treatment for Zenker's diverticulum?
Treatment is by surgical or endoscopic cricopharyngeal myotomy.
What is panesophageal pressurization?
It occurs when esophageal content is trapped between two simultaneously contracting esophageal segments.
What are the most common causes of GERD?
A weak lower esophageal sphincter (LES) and increased frequency of transient lower esophageal sphincter relaxations (TLESR).
What are some contributing factors to GERD?
Hiatal hernia, gastric hyperacidity, delayed gastric emptying, and increased intra-abdominal pressure.
What are predictors of therapeutic failure in pneumatic dilation?
Age younger than 40, male gender, pre-dilation LES pressure > 20 mmHg, and type 3 achalasia.
What did the RESPECT trial find about TIF?
It was more effective than PPI in treating regurgitation at 6 months follow-up.
What should patients with severe erosive esophagitis undergo after PPI treatment?
A repeat EGD to evaluate for Barrett's esophagus.
What clinical features suggest a diagnosis of achalasia?
Chronic dysphagia, dilated esophagus, bird beak appearance on barium, delayed barium emptying, tight LES, and failed swallows.
What does pathologic acid exposure time indicate?
It indicates GERD if the acid exposure time is greater than 6%.
What should be done if a patient does not respond to one PPI?
Switching to another PPI is reasonable to try to achieve symptom relief.
When should laparoscopic fundoplication be considered?
In patients with severe symptoms refractory to medical therapy.
What does the Six-Food Elimination Diet (SFED) remove?
The SFED removes the most common food allergens: milk, wheat, soy, eggs, nuts, seafood, and sesame.
What can lead to the development of Zenker's diverticulum?
Increased upper esophageal sphincter pressure and decreased compliance, possibly due to sphincter fibrosis.
What is the significance of the pH monitoring study in diagnosing GERD?
It measures reflux duration and the association between reflux and symptoms.
What findings might be observed during an EGD in a patient with achalasia?
Dilated esophagus, residual secretions, candidal plaques, and a tight LES.
What treatment method is more effective for type 3 achalasia?
Per Oral Endoscopic Myotomy (POEM).
What is the purpose of the Stretta procedure?
To deliver radiofrequency energy to the LES to reduce GERD symptoms.
What type of necrosis is caused by alkaline ingestions?
Liquefactive necrosis.
What is the goal of further investigations in patients with refractory GERD?
To make an accurate diagnosis, suggest effective therapy, and discontinue ineffective medications.
What is the preferred treatment for patients with type 3 achalasia?
POEM (Per Oral Endoscopic Myotomy).
What does LA class D indicate in the Los Angeles Classification?
Mucosal breaks extend between ≥ 1 mucosal fold, involving > 75% of esophageal circumference.
What is the management approach for patients with hoarseness or respiratory distress after caustic ingestion?
They should undergo laryngoscopy and consider endotracheal intubation.
What is the absolute annual risk of adenocarcinoma in patients with BE according to a population-based study?
0.12% (1.2 cases per 1000 person-years).
Who should undergo endoscopic screening for Barrett's Esophagus?
Male patients with >5 years of GERD symptoms and two or more risk factors.
What is the diagnosis for a patient with a history of GERD, normal acid exposure on pH impedance, and negative symptom association?
Functional heartburn overlapping with GERD.
What is the immediate response rate for pneumatic dilation?
70-90%.
What is EsophyX TM Transoral Incisionless Fundoplication (TIF)?
A completely per oral procedure under general anesthesia that creates a full thickness partial circumferential fundoplication.
What is Zargar's endoscopic grading used for?
To classify caustic esophageal injury and provide corresponding management recommendations.
What management is recommended for Grade 1 caustic esophageal injury?
Start a liquid diet and advance within 1-2 days to a full diet.
What should be done for patients with purely functional heartburn regarding PPI?
Discontinue PPI.
What does the AFS Hiatus Grade score range indicate?
It describes the flap valve and degree of hiatal disruption.
Do botulinum toxin injections affect the success rates of future myotomy in achalasia?
No, they do not affect success rates.
What is recommended for patients without GERD symptoms before starting PPI?
Reflux monitoring.
How is Barrett's esophagus recognized endoscopically?
By its salmon-colored mucosa.
What is a rare autosomal dominant disease associated with esophageal squamous cell carcinoma?
Tylosis.
What are the common symptoms of esophageal cancer?
Dysphagia, odynophagia, hematemesis, and weight loss.
What indicates GERD in the presence of erosive esophagitis?
Class C or D esophagitis and/or long segment Barrett’s esophagus.
What does a Symptom Association Probability (SAP) greater than 95% suggest?
It suggests a strong likelihood that the patient's symptoms are related to reflux.
How do untreated achalasia patients' DI values compare to healthy controls?
Untreated achalasia patients have lower DI values.
What should be done if a patient has a normal endoscopy?
Proceed with pH testing, ideally during the same session as EGD.
What is the recommended follow-up for patients with a history of lye or caustic esophageal injury?
Screening for squamous cell carcinoma is recommended 15-20 years after injury, to be repeated every 1-3 years.
What imaging is performed if there is suspicion of perforation in caustic ingestion cases?
Chest X-ray and CT scan.
What is the effectiveness of endoscopic dilation for EoE strictures?
Endoscopic dilation is highly effective, resulting in 90% symptom improvement.
What symptoms do symptomatic patients with Zenker's diverticulum typically experience?
Oropharyngeal dysphagia to solids and/or liquids, cough, choking, and throat pain with swallowing.
What is the recommended time frame for performing EGD after caustic ingestion if the patient is symptomatic?
EGD should be performed within 24-48 hours of caustic ingestion.
What is the purpose of the Symptom Index (SI) in GERD assessment?
It calculates the percentage of symptom episodes occurring at documented pH < 4.
What does the Endoscopic Functional Luminal Imaging Probe (EndoFLIP) measure?
Luminal geometry and mechanical characteristics of the esophagus.
Which surgical therapy is more effective than medical therapy for truly refractory GERD?
Nissen fundoplication.
What is the typical endoscopic finding in most GERD patients?
Most patients will have a normal endoscopy, known as Non-Erosive Reflux Disease (NERD).
What late complication can arise from caustic esophageal injury?
Strictures can be multiple and tortuous.
What should be avoided in the management of caustic ingestion?
Emetics and gastric lavage.
What is specialized intestinal metaplasia of the GE junction associated with?
It is not associated with increased risk of malignancy or dysplasia.
What defines GERD in terms of acid exposure time?
A total acid exposure time of >6% of the duration of the study.
What are the complications associated with endoscopic dilation?
Complications include chest pain (2%), esophageal tears, and perforations (0.3%).
What is the management approach for a patient with dysphagia and a CPB finding?
Consider the patient for endoscopic dilation.
What are some contraindications to performing EGD?
Respiratory distress, severe chest pain, and suspicion or confirmation of esophageal perforation.
What are the manometric features of achalasia?
Absent esophageal peristalsis and EGJ outflow abnormality.
What are the three types of achalasia based on pressure topography?
Type 1: classic achalasia; Type 2: achalasia with esophageal compression; Type 3: spastic achalasia.
What were the remission rates for PPIs compared to surgical therapy in the LOTUS trial?
PPIs had a 92% remission rate, while surgical therapy had an 85% remission rate.
What are established extraesophageal reflux syndromes?
Asthma, cough, laryngitis, and dental erosions.
What should be considered if a hiatal hernia is present in achalasia patients?
Heller myotomy with hernia repair.
What is the purpose of pH monitoring in GERD?
To document abnormal esophageal acid exposure and evaluate persistent symptoms.
Why should the diagnosis of reflux laryngitis not rely solely on laryngoscopic findings?
Many healthy asymptomatic individuals may have abnormal laryngeal findings.
What does abnormal TP53 immunohistochemistry in Barrett’s mucosa indicate?
It can identify patients with a higher risk of progression, including those with non-dysplastic BE.
What is the Prague classification used for in Barrett's Esophagus?
To report the length of BE as C/M.
