348.4 📋 章末速記 Summary

348.4.1 🔑 一句話總結

GERD (gastroesophageal reflux disease) = symptoms or complications from gastric content reflux；typical：heartburn + regurgitation；atypical：cough + asthma + hoarseness + dental erosion；complications：esophagitis (LA grade A-D), strictures, Barrett’s esophagus (specialized intestinal metaplasia → adenocarcinoma), adenocarcinoma；diagnosis：clinical + PPI trial → EGD for alarm features (≥ 50-60 yo, weight loss, dysphagia, GI bleeding, vomiting) → 24-h ambulatory pH monitoring for refractory / atypical；treatment：lifestyle (weight loss, elevation, trigger avoidance) + PPI first-line foundation + H2 RA for nighttime breakthrough + vonoprazan (potassium-competitive acid blocker, PCAB, FDA 2024 erosive esophagitis) newer; surgery for refractory (Nissen fundoplication, LINX magnetic ring, TIF endoscopic); endoscopic RFA / EMR for Barrett’s dysplasia；Barrett’s surveillance：EGD every 3-5 yr (no dysplasia), 6 mo or RFA (LGD), RFA + EMR (HGD)；other esophageal disorders：(1) eosinophilic esophagitis (EoE) — chronic immune-mediated + dysphagia + food impaction + ≥ 15 eos/HPF + linear furrows + concentric rings “trachealization”; atopic comorbidities; PPI/swallowed topical corticosteroids (fluticasone, budesonide) + 6-food elimination diet + dupilumab (LIBERTY-EoE-TREET 2022, FDA 2022) for refractory; (2) achalasia — LES failure to relax + absent peristalsis; bird beak on esophagram; Chicago Classification I-III on manometry (Type III spastic, POEM preferred); treatment pneumatic dilation / POEM / Heller myotomy / botox (elderly); (3) diffuse esophageal spasm; (4) scleroderma esophagus; (5) esophageal cancer — adenocarcinoma (GERD + Barrett’s + obesity + smoking + male, distal) vs squamous cell (smoking + alcohol synergy + HPV + hot beverages + achalasia + lye + tylosis + Plummer-Vinson, mid-upper); treatment EMR/ESD (early), neoadjuvant chemoradiation + esophagectomy (locally advanced), pembrolizumab + chemo (KEYNOTE-590) + nivolumab/ipilimumab + chemo (CheckMate 648) for metastatic, adjuvant nivolumab (CheckMate 577) post-chemoradiation if residual disease。

348.4.2 💊 治療精要

• GERD：lifestyle + PPI (omeprazole, esomeprazole, pantoprazole) 30-60 min before meals once daily (BID for severe); famotidine for nighttime breakthrough; vonoprazan PCAB newer; surgery for refractory
• Barrett’s：lifelong PPI + EGD surveillance (3-5 yr no dysplasia, 6 mo / RFA LGD, RFA + EMR HGD); esophagectomy for invasive
• EoE：PPI first-line (30-40% respond) + swallowed topical corticosteroids (fluticasone, budesonide) + 6-food elimination diet + dupilumab (FDA 2022) for refractory + endoscopic dilation for strictures
• achalasia：pneumatic dilation (endoscopic) OR POEM (peroral endoscopic myotomy) OR Heller myotomy (surgical) + botox (elderly); POEM preferred for type III; CCBs/nitrates limited efficacy
• esophageal cancer early (T1a)：EMR or ESD curative
• locally advanced：neoadjuvant chemoradiation + esophagectomy
• metastatic：pembrolizumab + chemo (KEYNOTE-590) first-line for SCC + adeno + nivolumab + ipilimumab + chemo (CheckMate 648) + adjuvant nivolumab (CheckMate 577) post-chemoradiation if residual disease
• stenting for palliative dysphagia; PEG for nutrition

348.4.3 🎯 盧醫師的考前提醒

1. GERD diagnosis flow：typical symptoms + PPI empiric trial is sufficient; EGD for alarm features (≥ 50-60 yo, weight loss, dysphagia, GI bleeding, vomiting persistent); 24-hour ambulatory pH monitoring for atypical or refractory
2. LA grading esophagitis (A-D)：A ≤ 5 mm, B > 5 mm, C < 75% circumferential, D > 75%
3. vonoprazan (PCAB) FDA 2022 H. pylori + 2024 erosive esophagitis：faster + more sustained acid suppression; alternative to PPI for severe; emerging
4. Barrett’s esophagus：salmon-colored mucosa + specialized intestinal metaplasia (goblet cells) on biopsy; high-risk for adenocarcinoma (LGD ~ 0.5%/yr, HGD higher); RFA for dysplasia
5. EoE classical features：young adult/teen + atopic comorbidities + dysphagia + food impaction; EGD linear furrows + concentric rings “trachealization” + white exudates; biopsy ≥ 15 eos/HPF in 4-6 samples from multiple levels
6. dupilumab (LIBERTY-EoE-TREET 2022) FDA 2022：anti-IL-4Rα for refractory EoE ≥ 12 yo; reduces eos count + improves symptoms
7. achalasia treatment hierarchy：young/fit → pneumatic dilation OR POEM OR Heller myotomy; POEM preferred for type III (spastic) per Chicago Classification; elderly/poor surgical candidate → botox (temporary)
8. achalasia Chicago Classification on manometry：Type I (classic — no contractility), Type II (with panesophageal pressurization — most amenable to dilation), Type III (spastic — POEM preferred)
9. esophageal cancer epidemiology shift：US/Europe adenocarcinoma increasing (distal, GERD/Barrett’s, obesity, smoking); squamous decreasing (smoking + alcohol synergy still major; hot beverages, achalasia, Plummer-Vinson, tylosis)
10. esophageal cancer treatment：KEYNOTE-590 (pembrolizumab + chemo first-line both SCC + adeno) + CheckMate 648 (nivolumab + ipilimumab + chemo) + CheckMate 577 (adjuvant nivolumab post-chemoradiation if residual disease, ↑ DFS)