Esophageal Disorders Flashcards
- Functions to deliver food and fluid to stomach; no role in direct digestion
- squamous epithelium
- UES: striated muscle valve
- LES: smooth muscle valve
- esophageal muscle: starts as triated and then transitions to smooth muscle
The esophagus
reflux of gastric contents other than air in to the esophagus. Normal post-prandial condition
Physiologic reflux
a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications
Pathologic gastroesophageal reflux
Classic features
- Heartburn (pyrosis): restrosternal burning ascending toward chest and neck
- regurgitation: unpleasant return of sour gastic contents to the pharynx
Atypical symptoms
- chest pain, globus sensation, nausea
- laryngopharyngeal reflux (LPR): cough, hoarse voice, sore throat
- dental enamel erosions
GERD
What is the pathophysiology of GERD?
Imbalance of protective versus offending agents
Offending agents
- Acidic gastric contents (pH 1.5-3.5)
- bile, pepsinogen, pancreatic enzymes, mucus, contents
- overwhelms mucosal resistance and stimulates sensory nerves
Defects
- Impaired barrier to function of the LES (transient relaxtion of LED to hypotensive LES; Hiatal hernia, increased intragastric pressure)
- esophageal motility disorders (impaired esophageal acid clearance; hypo or hypercontractile)
- gastric motility disorders: gastroparesis
- reduced salivation
Diagnosis of GERD
- Pyrosis and regurgitation: can be treated with a PPI trial if no alarm symptoms
- Endoscopy- gold standard for diagnosing esophagitis and investigating possible comoplications
what are considered alarming symptoms?
- dysphagia or odynophagia
- GI bleeding or anemia
- weight loss
- symptoms > 5 years
- don’t respond to PPI trial or relapse after discontinuing therapy
When and who should you screen for Baretts’s eshophagus?
Chronic (> 5 years) and or frequent (weekly or more) symptoms of GERD and two or more risk factors
* age >50
* presence of central obesity
* current or past history of smoking
* confirmed family history or esophageal adenocarcinoma?
when should you refer to gastroenterology?
- Refractory GERD
- atypical GERD manifestations (non cardiac chest pain, extra-esophageal symptoms)
- considering referral for anti-reflux surgery
- alarm symptoms (dysphagia)
- abnormal findings on imaging (esophagram) or endoscopy
- Quantifies reflux
- helpful in patients unresponsive to empiric therapy and may have non-acid reflux
- disadvantages: time consuming, availability, difficult to tolerate
Ambulatory pH-impedence testing
lifestyle modifications that can be done with esophageal disorders
- Weight loss for obese patients
- elevation of the head of the bed
- avoid late meals (3 hours before bed)
- avoid specific foods: coffee, alcohol, chocolate, fatty foods, colas, red wine, orange juice
- rapidly acting (should be taken immediately after eating)
- only temporarily alleviate symptoms of episodic GERD
- should not be used for healing esophageal damage (poor compliance & high dose requirements)
antacids
ranitidine, famotidine
- inhibits histamine stimulation of the parietal cell
- can use sporadically or regularly
not as good for healing severe esophagitis
- compared to PPI
Adverse effects
- changes in bowel habits
- frequent drug interactions (warfarin, phenytoin, propranolol)
H2 receptor blockers
- Irreversibly inhibit the H+-K + ATPase of the parietal cell
- work better when taken regularly (30 minutes prior to a meal)
- provide better symptom control, esophageal healing and maintenence of remission than either H2 receptor blockers or prokinetic agens
- low side effect profile
Proton pump inhibitors
safety concerns of proton pump inhibitors?
- Achlorhydria (calcium malabsorption/risk fracture)
- hypomagnesemia
- infection (increased risk for C.diff infections in people treated with chronic PPIs)
