Esophageal Reﬂux Disease and Its Complications 31 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 . 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 therapy. 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 329 330 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 epithelium. 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.