GERD & Barrett's Esophagus for USMLE Step 2 Exam

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Gastroesophageal Reflux Disease (GERD) and Barrett’s Esophagus for USMLE Step 2

Definition

Gastroesophageal Reflux Disease (GERD): A chronic condition caused by the reflux of gastric contents into the esophagus due to lower esophageal sphincter (LES) dysfunction, resulting in symptoms like heartburn, regurgitation, and potential complications like esophagitis.

Barrett’s Esophagus: A premalignant condition where chronic GERD leads to metaplasia of the esophageal squamous epithelium into columnar epithelium with goblet cells (intestinal metaplasia). This increases the risk of esophageal adenocarcinoma.

Pathophysiology

GERD

LES Dysfunction: The primary defect is transient relaxations or weakening of the LES, allowing gastric contents to flow back into the esophagus.
Hiatal Hernia: A structural abnormality where part of the stomach herniates into the thoracic cavity, weakening the LES and promoting reflux.
Mucosal Damage: Recurrent exposure of the esophagus to acidic gastric contents causes inflammation (esophagitis), erosions, and can lead to complications like strictures and Barrett’s esophagus.

Barrett’s Esophagus

Chronic Acid Exposure: Repeated acid reflux from GERD damages the esophageal lining, causing metaplasia where normal squamous cells are replaced by columnar cells, which are more resistant to acid.
Progression: Barrett’s esophagus can progress from intestinal metaplasia to low-grade dysplasia, high-grade dysplasia, and eventually esophageal adenocarcinoma.

Risk Factors

GERD

Obesity: Increases intra-abdominal pressure, promoting reflux.
Smoking: Lowers LES tone and increases acid production.
Dietary Triggers: Fatty foods, caffeine, alcohol, chocolate, and spicy foods lower LES tone and worsen reflux.
Pregnancy: Hormonal changes and increased intra-abdominal pressure contribute to GERD.

Barrett’s Esophagus

Chronic GERD: The most significant risk factor for developing Barrett’s esophagus.
Age and Gender: More common in older adults and males.
Smoking and Obesity: Both increase the risk of Barrett’s esophagus and progression to adenocarcinoma.

Clinical Features

GERD

Heartburn: A burning sensation in the chest, typically after meals or when lying down.
Regurgitation: Acid or food moving back into the throat or mouth.
Dysphagia: Difficulty swallowing due to inflammation or esophageal strictures.
Atypical Symptoms: Chronic cough, hoarseness, asthma, and non-cardiac chest pain.

Barrett’s Esophagus

Often Asymptomatic: Usually found during evaluation for GERD.
Persistent GERD Symptoms: Some patients may experience worsening or chronic GERD symptoms.
Alarm Symptoms: Dysphagia, odynophagia (painful swallowing), weight loss, or gastrointestinal bleeding (hematemesis or melena), which suggest complications like strictures or malignancy.

Diagnosis

GERD

Clinical Diagnosis: Based on typical symptoms like heartburn and regurgitation, often confirmed by response to proton pump inhibitor (PPI) therapy.
Endoscopy: Indicated for alarm symptoms or to evaluate for complications like Barrett’s esophagus or esophagitis.
24-hour pH Monitoring: Measures acid exposure and is used when GERD diagnosis is uncertain or for atypical symptoms.

Barrett’s Esophagus

Endoscopy with Biopsy: The gold standard for diagnosing Barrett’s esophagus. Intestinal metaplasia is confirmed by the presence of goblet cells on biopsy.
Surveillance: Regular endoscopic surveillance is recommended for patients with confirmed Barrett’s esophagus to monitor for dysplasia or cancer.

Treatment

GERD

Lifestyle Modifications: Weight loss, avoidance of trigger foods (e.g., caffeine, alcohol, fatty foods), and elevating the head of the bed to reduce nighttime reflux.
Proton Pump Inhibitors (PPIs): First-line therapy for GERD. PPIs suppress gastric acid production and promote healing of esophagitis.
H2-Receptor Antagonists: Used for mild or intermittent symptoms.
Surgical Management (Fundoplication): Indicated for refractory GERD or in patients with large hiatal hernias.

Barrett’s Esophagus

PPI Therapy: Chronic PPI use helps reduce acid exposure and may prevent progression of Barrett’s esophagus.
Endoscopic Surveillance: Regular endoscopy with biopsies to monitor for dysplasia.
Endoscopic Ablation: For dysplastic Barrett’s esophagus, radiofrequency ablation (RFA) or endoscopic mucosal resection (EMR) is performed to remove or destroy abnormal tissue and prevent cancer.

Complications

GERD

Erosive Esophagitis: Severe inflammation leading to erosions or ulcers in the esophagus.
Esophageal Strictures: Chronic inflammation and scarring cause narrowing, resulting in dysphagia.
Aspiration Pneumonia: Refluxed gastric contents can be aspirated, causing pneumonia.

Barrett’s Esophagus

Esophageal Adenocarcinoma: The most serious complication of Barrett’s esophagus, especially in patients with dysplasia.

Prevention

GERD Control: Long-term management of GERD with lifestyle changes and PPIs can help prevent Barrett’s esophagus.
Surveillance in Barrett’s Esophagus: Regular endoscopy to detect dysplasia or early adenocarcinoma.

Key Points

GERD is caused by LES dysfunction, leading to reflux of gastric contents and symptoms such as heartburn and regurgitation.
Barrett’s esophagus is a complication of chronic GERD characterized by intestinal metaplasia, increasing the risk of esophageal adenocarcinoma.
GERD is managed with lifestyle modifications and PPIs, while Barrett’s esophagus requires surveillance and possibly ablation for dysplasia.
Complications of GERD include erosive esophagitis, strictures, and aspiration pneumonia. Barrett’s esophagus increases the risk of esophageal adenocarcinoma.