Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Pathophysiology 2 > Feb 23 - GERD > Flashcards

Feb 23 - GERD Flashcards

1
Q

Describe the normal physiological response to acid reflux

A
  1. Acid and food reflux into the esophagus
  2. Peristalsis returns most acid reflux to the stomach
  3. After peristalsis, a small amount of acid remains in the esophagus
  4. Saliva, which contains bicarbonate, neutralizes the remaining acid in the esophagus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the lower esophageal sphincter?

A

3-4 cm of tonically contracted smooth muscle situated at the gastroesophageal junction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the main function of the lower esophageal sphincter?

A

Main function is to protect the esophagus from noxious stomach contents. It is dynamic to protect against reflux in a variety of situations such as swallowing, recumbency, and abdominal straining (it’s not going to spontaneously burst open; even with a variety of activities, it will remain closed)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How is the tone of the LES maintained?

A

By acetylcholine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the pressure of the LES? Does it vary? How is it affected?

A

The pressure is 15-30 mmHg above intragastric pressure and varies from person to person. It exhibits diurnal variation as well; it is highest at night and lowest in the daytime and postprandially. It is affected by various drugs, foods and hormones

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the role of the pyloric sphincter?

A

It controls emptying of stomach contents into the duodenum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the role of the duodenum? What is the pH of the duodenum

A

It continues digestion of chyme (food mixed with stomach contents). Its pH is around 6.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Name the different parts of the stomach

A

Fundus, body, antrum, pyloric sphincter, stomach lining

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Name the different contents of the stomach

A

Gastric juice (with a pH of 1, normally), and contains HCl, electrolytes (sodium, potassium, sulfates, phosphates, calcium, bicarbonate), water, enzymes (pepsin), and organic substances (mucus and proteins)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What protects the stomach from the stomach acid?

A

Lipoprotein rich membrane protects the stomach walls from acid (age and nutritional status influence the ability of the mucosa to withstand injury)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe gastric acid production

A

Done by gastric glands deep within the stomach lining. Mucous cells/superficial epithelial cells produce mucous. Parietal cells secrete HCl and intrinsic factor (B12). G cells in the antrum secrete gastrin. Enterochromaffin-like cells secrete histamine. Chief cells secrete pepsinogen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How is gastric acid production controlled?

A

It is controlled by 3 regulatory pathways that overlap and are stimulated via the vagus nerve (10th cranial) by food: acetylcholine, gastin and histamine (H2)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What stimulates acetylcholine in gastric acid production?

A

The sight, smell and taste of food, and stomach distension stimulate acetylcholine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What stimulates gastrin secretion?

A

Dietary amino acids stimulate G cells
Acetylcholine via stomach distension
Elevated pH (a lower pH is inhibitory via the release of somatostatin from antral D cells)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What stimulates histamine (H2) secretion?

A

Stimulation via acetylcholine and gastrin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Describe the pumps in parietal cells

A

They are known as H/K-ATPase proton pumps; they exchange hydrogen ions from the cytosol for potassium in the canaliculi using energy from ATP. There is passive movement of potassium and chloride ions into the canaliculus. When hydrogen ions are transported out, they meet up with chloride ions to form HCl

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is GERD?

A

A chronic disorder related to the retrograde flow of gastro-duodenal contents into the esophagus and/or adjacent organs, resulting in a spectrum of symptoms, with or without tissue damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Why is it important to include the symptoms and pathophysiological changes in the definition of GERD?

A

Because most people experience reflux every hour without symptoms or changes. Pathologic reflux results in the true definition of GERD vs heartburn, which is and unpleasant or burning sensation below the sternum. These changes can lead to a host of other issues. Pathologic reflux is more frequent and in longer duration occurring both day and night disrupting the patient’s life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the most common type of symptoms? What other type of symptoms exist?

A

Chest symptoms are the most common. Other atypical/extra-esophageal symptoms include pulmonary symptoms, oral symptoms, throat symptoms and ear symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Describe the chest symptoms of GERD

A

Heartburn, regurgitation, chest pain, dysphagia/odynophagia, belching

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Describe the pulmonary symptoms of GERD

A

Non-allergic asthma, cough, aspiration, hoarsness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Describe the oral symptoms of GERD

A

Tooth decay, gingivitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Describe the throat symptoms of GERD?

A

Globus sensation, hoarseness, laryngitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Describe the ear symptoms of GERD

A

Earache

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is the hallmark sign of GERD? Describe it

A

Heartburn. It usually occurs after a meal. It is aggravated by bending over. When it happens more than twice a week, this suggests GERD. If it occurs with regurgitation, there is a 90% certainty of GERD diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

How can you distinguish between acid reflux and MI chest pain?

A

Does the pain get worse after meals?
When did it start? (has it been two months? probably not an MI)
Does it get worse with exertion? (GERD doesn’t get worse with exertion, chest pain from an MI does)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is dysphagia?

A

The perception of impaired movement of swallowing material from the pharynx to the stomach (hard to swallow)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is odynophagia?

A

Sharp substernal pain that occurs during swallowing usually indicative of an esophageal ulceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is heartburn?

A

Burning pain that can move up from the stomach to the middle of the chest and maybe into the throat (it can include regurgitation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is regurgitation?

A

A symptom of acid reflux. Contents of the stomach move into the esophagus and maybe into the throat (sour taste in mouth)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is dyspepsia?

A

AKA indigestion

Mostly discomfort and can include: burping, nausea, bloating, upper abdominal pain

32
Q

What is included in the contents of acid reflux?

A

Acid, pepsin, bile, pancreatic enzymes

33
Q

Why is the volume of the reflux is important

A

It is important as it determines how hard the body will have to work to clear the reflux from the esophagus

34
Q

What type of things go wrong in GERD?

A 
Decreased salivation
Impaired esophageal acid clearance
Transient tissue resistance
Decreased resting tone of the LES
Delayed gastric emptying
35
Q

What causes dysfunction of the lower esophageal sphincter pressure (LESP)?

A

Spontaneous LES relaxation not associated with swallowing = transient LES relaxation (TLESR; most common causative mechanism and it is unrelated to swallowing or peristalsis)
Increases in intra-abdominal pressure (coughing, bending over, straining, eating, pregnancy)
Sphincter is atonic (factors that can lower LES tone include endogenous hormones, medications, and food)

36
Q

What is the occurrence rate of TLESRs in normal vs GERD patients?

A

Normal patients: 94%

GERD patients: 65%

37
Q

What is the occurrence rate of transient increase in intra-abdominal pressure in normal vs GERD patients?

A

Normal patients: 5%

GERD patients: 17%

38
Q

What is the occurrence rate of atonic sphincter in normal vs GERD patients?

A

Normal patients: 1%

GERD patients: 18%

39
Q

What types of foods increase LESP? Decrease LESP?

A

Proteins increase LESP

Fat, chocolate, ethanol, peppermint, garlic, onions decrease LESP

40
Q

What hormones increase LESP? Decrease LESP?

A

Gastrin, motilin, susbtance P increases LESP

Glucagon, progesterone, estrogen decreases LESP

41
Q

What are the two main ways the esophagus is cleared?

A

Primary peristalsis due to swallowing (secondary peristalsis due to esophageal distension or gravity)
Swallowing increases salivary flow (contains bicarbonate that buffers acidic contents

42
Q

What causes impaired acid clearance?

A

Decreased peristalsis, decreased salivation, and increases frequency of reflux leads to increased time the mucosa is exposed to gastric contents

43
Q

What determines the severity of the symptoms and the length of recovery?

A

The duration of acid exposure
The composition of the reflux
Delayed gastric emptying

44
Q

How does duration of stay affect the severity of symptoms and the duration of recovery

A

The time exposed to reflux under pH of 4 leads to more severe symptoms and longer recovery. There is only so many defence mechanisms including mucous that can hold off an attack of an acid environment. More pain is felt at lower pH levels than at higher ones and eventually weans off at pH 4

45
Q

How does a composition of the reflux affect the severity of symptoms and the length of recovery?

A

The composition is most notably are a pH 2, and contain pepsin, bile and/or alkaline pancreatic secretions

46
Q

How is GERD diagnosed? What is the most important tool?

A

There is no gold standard, however tests include: endoscopy, 24-hour pH monitoring, proton-pump administering, manometry. The most important tool is a thorough clinical history

47
Q

What is 24-hour pH monitoring?

A

It involves having the patient write a diary of symptoms and at the same time a pH probe is placed 5cm above the LES and measurements are compared tot he diary. In addition, the probe monitors the percentage of time the pH was low, the frequency and severity of reflux

48
Q

What is manometry?

A

Manometry looks at motility issues by measuring the pressure differences across the stomach, LES, esophagus and pharynx

49
Q

How is heartburn different from cardiac chest pain?

A

Heartburn is a substernal pain. It may spread to the neck or throat. Pain does not change upon exertion (except bending). There is regurgitation. Increasing symptoms when lying down or eating

50
Q

How is cardiac chest pain different from heartburn?

A

Cardiac chest pain is a crushing chest pain (feels like an elephant sitting on you). There is radiating pain into the left arm, neck, back and shoulders. Pain increases with exertion. There may be sweating, nausea, vomiting. Symptoms increase until treatment or death

51
Q

What are complications of GERD?

A 
Esophagitis
Bleeding
Esophageal erosions and ulcerations
Stricture formation (fibrous tissue build up that closes off the esophagus)
Barrett's esophagus
Adenocarcinoma of the esophagus
52
Q

Is weight loss commonly associated with GERD?

A

No. Most patients will change their diet to suite their needs or avoid pain (weight loss greater than 5% is a red flag)

53
Q

What are factors that trigger GERD?

A 
Food
Obesity
Pregnancy
Medications
Smoking
Hiatial hernia
54
Q

How does food trigger GERD?

A

Large meals induce TLESRs
Meals within 2-3 hours of bedtime or with alcohol increase acid production and increase nocturnal GERD
High fatty meals impairs gastric emptying
Aggravating foods include: raw onions, caffeine, chocolate, alcohol, tomato products, spicy foods, citrus, peppermint, carbonated beverages, coffee, and tea

55
Q

How does obesity trigger GERD?

A

There are conflicting results, but generally recognized that exercise and weight loss will decrease symptoms

56
Q

How does pregnancy trigger/affect GERD?

A

Most typically have heartburn symptoms and usually subside after delivery

57
Q

How does smoking trigger GERD?

A

Decreases LESP (nicotine)

58
Q

How does hiatial hernia trigger GERD?

A

The proximal stomach is dislocated through the hiatus of the diaphragm into the chest of the crural diaphragm becomes separated from the LES

59
Q

When should a patient be referred?

A

When any red flags appear
When there is a presence of unexplained cough, hoarseness, or dyspnea
When the patient is under 18 or over 50 years old
When the patient requires further evaluation as symptoms described do not offer a clear self-diagnosis
When the GERD is drug-induced, contact the doctor to change

60
Q

What are red flags?

A 
Chest pain typical of cardiac events
Recurring vomiting
Blood loss in vomit or stool
Dysphagia, especially with solids
Odynophagia
Unexplained weight loss >5%
Family history of gastric ulcers
61
Q

What are things patients should avoid?

A 
Foods that trigger symptoms
Lying down right after meals
Smoking
Excessive bending
Tight fitting clothing
62
Q

What are things that should be done to treat GERD?

A 
Exercise
Maintain a healthy body weight
Reduce alcohol intake
Reduce caffeine intake
Eat smaller, more frequent meals
Reduce stress
Sleep with the head elevated hight than the pelvis
63
Q

What are pharmacological treatments available?

A 
Antacids
Alginic acids
H2-Receptor antangonists
Proton-pump inhibitors
Prokinetics
Mucosal protectants
64
Q

Describe antacids as treatment options for GERD

A

They lack efficacy data over placebo
They provide symptomatic relief by raising pH over 4 which decreases conversion of pepsinogen to pepsin
They neutralize acidic contents

65
Q

Describe alginic acid as treatment options for GERD

A

They create a viscous barrier at the top of the stomach contents
They decrease reflux episodes
Efficacy evidence is lacking on healing

66
Q

Describe H2-receptor antagonists as treatment options for GERD

A

The provide immediate relief of symptoms
12-week therapy at BID dosing helps for 60% of patients with mild to moderate GERD
All have similar efficacy. The choice should be based on kinetic profile and side effects

67
Q

What are common adverse reactions of H2-Receptor antagonists

A

Common adverse reactions include diarrhea, headache, dizziness, rash and tiredness

68
Q

What are examples of H2-receptor antagonists?

A

Cimetidine (prescription drug in Canada)
-lots of drug interactions (warfarin, phenytoin, theophylline) as it inhibits CYP450,1A2, 2C19, 2D6
-can cause gynecomastia and impotence (anti-adrenergic effect)
Nizatidine (prescription drug in Canada)
Famotidine (OTC)
-both Niz/Fam have very little effect on CYP450
Ranitidine (OTC)
-minor inhibitor of CYP450

69
Q

Describe proton-pump inhibitors as treatment options for GERD?

A

Superior to all other pharmacological treatments for all types of patients (mild to severe) especially for daytime symptoms.
They are newer agents, esomeprazole, pantoprazole, and rabeprazole have fewer drug interactions.
They maintain pH above 4 for a greater period of time allowing healing
Differences between them are minimal
Best to take 30 minutes before breakfast because they only work on actively secreting pumps (as a pharmacist it is your job to check for compliance)

70
Q

What are adverse reactions of proton-pump inhibitors?

A

Side effects are mild and reversible including headache, diarrhea, nausea, abdominal pain, constipation, dizziness and rash

71
Q

What are examples of proton-pump inhibitors?

A 
Esomeprazole
Lansoprazole
Omeprazole
Pantoprazole
Rabeprazole
72
Q

Describe prokinetics as treatment options for GERD?

A

Side effect profile makes them less desirable
They help move contents of stomach faster
Significant drug interactions

73
Q

What are examples of prokinetics?

A

Cisapride
Metaclopromide
Domeperidone

74
Q

Describe mucosal protectants as treatment options for GERD

A

Includes: Sucralfate
Not used very often
Only used for mild GERD

75
Q

What are some unique therapies for the treatment of GERD?

A

Baclofen (reduces TLESRs and increases gastric emptying)
Trazodone and SSRIs (improve esophageal pain)
Surgical laparoscopic sphincter augmentation (a device comprised of a string of magnetized beads)
Cholestyramine (for patients who fail PPI therapy and have bile reflux; evidence is lacking)
Acupuncture (more study is needed, but when compared to doubling the dose of PPI, acupuncture was significantly better in controlling regurgitation and heartburn)

Pathophysiology 2 (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions