Esophageal D/Os and Nausea

Question 1

What are the proposed pathophysiological mechanisms for DIS (dilated intercellular spaces)?

Answer 1

Repeated mucosal exposure to:
refluxed acid
digestive enzymes
bile acids

Question 2

What percentage of GERD patients have DIS?

Answer 2

essentially all GERD patients have DIS on Bx

Question 3

What three mechanisms have been proposed to explain the occurrence of heartburn in endoscopy-negative patients?

Answer 3

• esophageal visceral hypersensitivity
• sustained esophageal contractions – too strong à pain
• abnormal tissue resistance – example, not enough prostglandins, lactoferrin in saliva or other protective factors

Question 4

What are the key symptoms of laryngopharyngeal reflux (LPR)?

Answer 4

• Chronic throat clearing
• Chronic cough
• Chronic sore throat
• Halitosis
• Globus sensation
• Recurrent aspiration pneumonia
• Dysphagia (Esophageal webs)
• Hoarseness – dysphonia
• Airway obstruction - glottic stenosis, laryngospasm

Question 5

What is the evidence for a relationship between asthma and GERD?

Answer 5

• GERD can trigger asthma symptoms:
- vagal reflex, by the presence of acid in the esophagus
- microaspiration of gastric contents into the trachea.
• Conversely, asthma may cause GERD :
- asthma alters intrathoracic pressure, thereby triggering the vagal reflex;
- asthma drugs may change the LES pressure (relax)

Question 6

What are the three phases of vomiting?

Answer 6

• Nausea: Inhibition of gastric tone, Antiperistalsis begins in jejunum, Reflux of duodenal contents into stomach
• Retching: Upward thrusting and extrusion of stomach into thorax? (by contraction of diaphragm and abd. Mm, LES closed
• Vomiting: Propulsion of food by abd. mm contractions through opened esophageal sphincters

Question 7

What happens during nausea?

Answer 7

Inhibition of gastric tone
Antiperistalsis begins in jejunum
Reflux of duodenal contents into stomach

Question 8

What happens during Retching?

Answer 8

Upward thrusting and extrusion of stomach into thorax by contraction of diaphragm and abd. Mm
–> The LES is closed

Question 9

What happens during Vomiting?

Answer 9

Propulsion of food by abd. mm contractions through opened esophageal sphincters

Question 10

How can you help improve parasympathetic tone in your patients?

Answer 10

Generally:
• Grace before meals
• Taking time to smell food being prepared
• Thorough chewing
• A relaxed atmosphere for meals
• Resolve upsetting (mealtime) memories

Question 11

What are the ND treatments for functional reflux?

Answer 11

• Treat hiatal hernia syndrome or hypochlorhydria if present
• Release diaphragm if needed
• Massage Chapman esophageal points
• Assess and correct T2 dysarticulation if present
• Use GERD treatments if needed
• Remove offending food intolerances
• Breath training

Question 12

Is rumination syndrome a form of vomiting? If not, why not?

Answer 12

No.
Often mistaken for chronic vomiting.
Sx Picture: No nausea, no retching, no vomiting – reverse peristalsis just brings it back up. Often no sign of reflux, but we don’t know if it stays in esophagus or goes to stomach.

Question 13

What are the 6 key issues in chronic nausea?
(Assume that the nausea is not due to pancreatitis, cholecystitis, kidney disease, etc. but is in a patient who has had a full workup to rule out known pathologies)

Answer 13

• Liver issues
• Yeast overgrowth
• SIBO
• Gastroparesis
• Hypochlorhydria
• Gluten intolerance