Questions and Answers

Esophageal Reflux Disease and Its
Missale Solomon and James C. Reynolds
Questions and Answers
1. Which of the following statements regarding gastroesophageal reflux disease (GERD) is correct?
A.Acid exposure is caused by gastric acid hypersecretion.
B.Hiatal hernia is a necessary initial event in the
pathophysiology of GERD.
C.The incidence of heartburn is decreased in the elderly.
D.The incidence of reflux-induced esophageal cancer has
increased by more than eightfold in the past 3 decades.
Answer: D.
Esophageal adenocarcinoma (EAC) has emerged as one of
the fastest rising cancers in the western hemisphere. Since
the mid 1970s, the incidence of EAC has risen by more than
eightfolds [62]. Barrett’s esophagus, the most important risk
for developing EAC is caused by chronic gastroesophageal
reflux (GER). There is no increase in gastric acid production
in patients with GERD, but rather failure in the antireflux
mechanism leading to increased and prolonged exposure of
the distal esophagus to gastric contents. The presence of
hiatal hernia predisposes to GERD by compromising the
competence of the lower esophageal sphincter (LES), but is
not necessary for the development of GERD. Until recently,
it was widely believed that the incidence of GERD increases
with age; however, several studies have demonstrated that
the incidence remains the same across all ages.
2. An 82-year-old White woman is referred to you by her
primary care physician for consideration of upper endoscopy. She describes symptoms of acid regurgitation and
classic heartburn occurring once or twice weekly.
Endoscopy is performed and reveals Los Angeles class C
erosive esophagitis. Which of the following represents the
best approach to treatment?
A.Advise appropriate changes in lifestyle and diet to
control her symptoms prior to starting antisecretory
therapy to minimize unnecessary sideffects.
B.Start histamine-2-receptor antagonists (H2RA) therapy
twice daily for 12 weeks, then taper off if symptoms
are controlled.
C.Start proton pump inhibitor (PPI) therapy twice daily
for 12 weeks, then step down to once-daily PPI and
maintain at this level to avoid recurrence.
D.Antireflux surgery will provide superior benefit in this
patient as compared to long-term acid-suppressive
Answer: C.
Erosive esophagitis is a chronic disease and relapse is
common in the elderly with a relapse rate as high as 90%
annually. Lifestyle modifications, while reasonable
adjuncts, are inadequate treatments by themselves. H2RA
therapy is inferior to PPI therapy with a high failure rate
as maintenance. While antireflux surgery provides similar
clinical efficacy as medical acid-suppressive therapy, it is
associated with significant complications and cost and is
not the best initial approach in managing this patient. The
recommended approach for treatment of erosive esophagitis is PPI therapy twice daily for 12 weeks followed by a
step down to once-daily PPI for long-term maintenance
which has a safe side effect profile even in the elderly.
3. A 71-year-old business man with longstanding diabetes
returns to the emergency department 2 days after discharge with midsternal chest pain that awakened him
from sleep. He had been hospitalized previously for similar symptoms of episodic chest pain and underwent extensive evaluation including stress test, echocardiography,
and CT angiogram of the chest which were all negative.
Empiric use of sublingual nitroglycerine has not been
successful due to severe headaches. He denies heartburn
or dysphagia. What would be the most cost-effective next
step in this patient?
A.Trial of PPI
B.Prokinetic medications like metoclorpramide
C.Esophageal pH monitoring
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_31, © Springer Science+Business Media, LLC 2012
D. Referral to psychiatry
E.Esophageal manometry
Answer: A.
Noncardiac chest pain (NCCP) is a diagnosis used to
describe retrosternal pain or discomfort that is not attributed to myocardial ischemia. GERD is a common cause
of NCCP and a therapeutic trial of antisecretory therapy
with proton pump inhibitors is the most efficient initial
approach to diagnosis and therapy. Metoclorpramide is
useful in patients with documented delayed gastric
­emptying and has no role in the treatment of NCCP.
Esophageal pH monitoring and manometry can be helpful
in evaluating for acid reflux and esophageal dysmotility,
respectively, in these patients, but are not cost-effective as
an initial approach. While psychological stress can lead to
somatic gastrointestinal symptoms, several organic entities first need to be ruled out prior to psychiatric consideration in this patient.
4. What statement is true regarding Barrett’s esophagus?
A.PPI therapy reduces the extent of metaplastic
B. Surveillance is reasonable in the elderly because costeffective ablative techniques are available for advanced
dysplasia and early cancer.
M. Solomon and J.C. Reynolds
C.Antireflux surgery decreases risk of esophageal cancer.
D.The most common cause of death in patients with
Barrett’s esophagus is adenocarcinoma.
Answer: B.
Elderly patients with established Barrett’s esophagus
should be placed on endoscopic surveillance program
since there is no treatment that significantly decreases the
length or cancer risk. Endoscopic ablation is a cost-effective and preferred strategy for managing patients with
high-grade dysplasia and early cancer. While experimental studies suggest that adequate acid suppression results
in a decrease in cellular proliferation in Barrett’s esophagus, there are no data as yet that acid suppression reduces
in cancer risk. Similarly, antireflux surgery does not
decrease the subsequent risk of developing esophageal
cancer. Studies indicate that when patients with Barrett’s
esophagus (with or without dysplasia) are followed prospectively, the rate of progression to EAC is only 0.5%
per patient per year and most of these patients die of diseases other than EAC.