348.2 🩺 國考版

348.2.1 高頻考點

348.2.1.1 GERD

  • TLESRs main mechanism
  • Typical: heartburn + regurgitation
  • Atypical: cough, asthma, hoarseness, dental erosion
  • Complications: esophagitis, stricture, Barrett’s, adenocarcinoma

348.2.1.2 LA Grade Esophagitis

  • A ≀ 5 mm, B > 5 mm, C < 75% circumferential, D > 75%

348.2.1.3 GERD Diagnosis

  • Clinical + PPI trial
  • EGD for alarm features
  • 24-hour pH monitoring for refractory / atypical

348.2.1.4 Treatment

  • PPI first-line (omeprazole et al.)
  • Famotidine for nighttime breakthrough
  • Vonoprazan (PCAB) newer
  • Surgery: Nissen fundoplication, LINX device

348.2.1.5 Barrett’s Esophagus

  • Specialized intestinal metaplasia
  • GERD long-standing, obesity, male, white, smoking
  • Surveillance: EGD with biopsies every 3-5 yr (no dysplasia), 6 mo or RFA (LGD), RFA + EMR (HGD)
  • Lifelong PPI

348.2.1.6 EoE

  • ≥ 15 eos/HPF
  • Symptoms: dysphagia, food impaction
  • Atopic comorbidities
  • Linear furrows, rings (“trachealization”)
  • Treatment: PPI, STC (fluticasone, budesonide), 6-food elimination
  • Dupilumab (LIBERTY-EoE-TREET 2022, FDA 2022) for refractory
  • Endoscopic dilation for strictures

348.2.1.7 Achalasia

  • LES failure to relax + absent peristalsis
  • Manometry (Chicago Classification I-III)
  • Bird beak on esophagram
  • Treatment: pneumatic dilation, POEM, Heller myotomy, botox (elderly)
  • Type III: POEM preferred

348.2.1.8 Esophageal Cancer Risk Factors

  • Squamous: smoking + alcohol (synergistic), HPV, hot beverages, achalasia, lye, tylosis, Plummer-Vinson
  • Adenocarcinoma: GERD + Barrett’s + obesity + smoking + male

348.2.1.9 Esophageal Cancer Treatment

  • Early: EMR / ESD
  • Locally advanced: neoadjuvant chemoradiation + esophagectomy
  • Metastatic: chemotherapy + IO:
    • Pembrolizumab + chemo (KEYNOTE-590) for both SCC + adeno
    • Nivolumab + ipilimumab + chemo (CheckMate 648)
    • Adjuvant nivolumab (CheckMate 577) post-chemoradiation

348.2.1.10 Vonoprazan

  • Potassium-competitive acid blocker (PCAB)
  • Faster + more sustained acid suppression
  • FDA 2022 H. pylori; 2024 erosive esophagitis

348.2.1.11 Key Trials

  • LIBERTY-EoE-TREET (2022): dupilumab for EoE
  • KEYNOTE-590: pembrolizumab + chemo first-line esophageal cancer
  • CheckMate 577 (2021): adjuvant nivolumab esophageal cancer
  • CheckMate 648: nivolumab + ipilimumab + chemo

348.2.2 易混淆比范

Condition Symptoms Diagnosis Treatment
GERD Heartburn + regurgitation Clinical + PPI trial; EGD if alarm PPI + lifestyle
Barrett’s Often asymptomatic EGD + biopsy Surveillance + RFA dysplasia
EoE Dysphagia + food impaction ≥ 15 eos/HPF PPI/STC, dupilumab
Achalasia Progressive dysphagia + weight loss Manometry, bird beak POEM/Heller/dilation
DES Chest pain + dysphagia Manometry: premature contractions CCB/nitrate/POEM
Scleroderma esophagus Heartburn + dysphagia Manometry: absent peristalsis High-dose PPI

348.2.3 Special Topics

348.2.3.1 Functional Heartburn (Rome IV)

  • Symptoms + normal pH studies + no esophagitis
  • Antidepressants (TCA, SSRI)
  • CBT
  • Acupuncture (some evidence)

348.2.3.2 Reflux Hypersensitivity

  • Symptoms + reflux without pathologic acid exposure
  • Multidisciplinary

348.2.3.3 LPR (Laryngopharyngeal Reflux)

  • Atypical GERD with laryngeal symptoms
  • Hoarseness, throat clearing
  • Higher PPI doses often needed

348.2.3.4 Pediatric EoE

  • Failure to thrive, feeding difficulties
  • Similar evaluation + treatment