GERD and esophagogastric motility Flashcards
The proximal 5% of the esophageal body is made of _____ muscle; the proximal third is a _______; the distal 2/3 is _____
striated muscle
transition mix of smooth and striated muscle
smooth muscle
The two muscle layers of the esophagus are:
inner circular
outer longitudinal
What is the excitatory neurotransmitter of the ENS?
ACh
causes contraction of muscle layers
What is the inhibitory neurotransmitter of the ENS?
NO, VIP
causes relaxation of muscle layers
List three considerations when classifying pathologic GERD
- Typical or Classic (heartburn/regurgitation) vs. Atypical reflux
- Mucosal disruption description: Erosive/Ulcerative vs. Non Erosive
- Extent of reflux: Esophageal vs. Laryngopharyngeal Reflux
List classic symptoms of GERD
heartburn/ pyrosis
regurgitation
water brash
When _____ and _____ occur together, it is 90% predictive of GERD
regurgitation and heartburn
What are some atypical symptoms of GERD
asthma chronic cough chronic hoarseness non-cardiac chest pain loss of dental enamel
_____ results from a multifactorial failure of the reflux barrier
GERD
Progression of _______ over time leads to chronic LES changes
Transient lower esophageal sphincter relaxations
______ disrupts diaphragmatic positioning at the LES and leads to loss of sphincter integrity
hiatal hernia
Poor ____ of the esophagus leads to inadequate clearing of refluxed material
peristalsis
Reduced epithelial resistance is caused by
decreased bicarbonate from saliva and mucosa
List caustic substances (other than HCl) that can be present in refluxate from the stomach
deconjugated bile salts pancreatic enzymes pepsin medications ingested food
presumptive diagnosis of ____ can be made based on symptoms alone
GERD
When is further testing for GERD warranted?
if the patient has dysphagia or other “red
flag” symptoms, or who’s GERD symptoms have not responded to typical treatment regimen.
_______ is the most sensitive test for viewing esophagitis, strictures, and findings of Barrett’s esophagus
upper endoscopy with biopsy
_______ is a test that can give information about motility and amount of reflux
esophogram or GI x ray
In ______, an acid sensor is used to quantify the amount of reflux and correlate to reported symptoms
24 hour pH monitoring
List lifestyle changes that can be used in treatment of GERD
elevate head of bed
stop smoking, decrease alcohol
reduce fat intake
decrease size of meals
avoid meals before bed
avoid tea, coffee, citrus, chocolate, mint, tomato juice, cola
avoid anticholinergics, diazepam, theophylline, CCBs, narcotics
List drug therapy for GERD
Antacids (OTC)
H2 antagonists (OTC and prescription)
PPIs (OTC and prescription, more potent acid suppression)
What surgical procedure can be used electively by GERD patients?
Nissen fundoplication is an elective surgical procedure that can be performed either laparoscopically or as an open surgery. The fundoplication functions to correct any hiatal hernia and to re-establish the anti-reflux barrier by wrapping the stomach around the GEJ to recreate a high pressure barrier from gastric content reflux
List complications of GERD
strictures
Barrett’s esophagus
bleedign
esophageal cancer
______ are formed when chronic inflammation leads to scarring of the esophageal wall, compromising its diameter and function.
Strictures
most commonly found near GEJ
will lead to dysphagia more with solids than liquids
How are strictures treated?
Will resolve with acid suppression if mild
More prominent strictures need balloon dilation
Barrett’s esophagus is metaplastic change from ____ to ____ epithelium and is a step on the way to developing adenocarcinoma of the esophagus
squamous to columnar
What are symptoms of esophageal motility disorders?
dysphagia to BOTH solids and liquids
chest pain (atypical)
heartburn
regurgitation
How are esophageal motility disorders diagnosed?
Esophagram (barium study)
Endoscopy
Esophageal manometry following imaging study
In _____, the LES cannot relax due to loss of neurons
achalasia
What are the typical symptoms of achalasia?
Dysphagia vomiting undigested food chest pain weight loss regurgitation and aspiration at night pyrosis
Achalasia involves a gradual loss of ____ neurons from the lower esophageal sphincter, which moves proximally. The LES loses the capability to relax, followed by a loss of esophageal body peristalsis
enteric
How is achalasia treated?
Medications: CCBs, nitrates, anticholinergics used to relax the spastic LES
Botulinum toxin
Endoscopic balloon dilation of LES
Surgical myotomy- most long lasting intervention
The gastric pacemaker cells are the ________
interstitial cells of Cajal
The _____ nervous system is responsible for the general motility pattern of the stomach. The ______ nervous system functions to modulate the automatic motility
Enteric
Central
In addition to the circular and longitudinal layers of muscle, the stomach also has a 3rd layer of _______ muscle, which facilitates the forceful contractions needed for mixing and churning food.
oblique
Describe the two motility patterns of the stomach
Fed pattern: accommodation and more random contraction of ingested food.
Fasting pattern: increasing frequency and strength of sequential muscle contractions (peristaltic-like). Maximum cycling of this sequence is 3 cycles per minute. This phase functions to grind, mix, and ultimately empty stomach contents.
Diabetes mellitus is the most common cause of ______, a disorder of “too slow” gastric motility
gastroparesis
What is the pathophysiology of gastroparesis related to DM?
Hyperglycemia leads to abnormal nerve conduction
List non-DM causes of gastroparesis
Medications: antidepressants, anticholinergics, nitrates, CCBs, phosphodiesterase inhibitors
Iatrogenic: surgical vagotomy
Because the signs/symptoms of gastroparesis can mimic __________, this must be ruled out first.
mechanical obstruction
________ is the most useful study for diagnosing gastroparesis
gastric emptying study
How is gatroparesis treated
glycemic control in DM
adjusted gastroparetic diet- low in roughage and fatty foods, small meals
medications: motilin analogues erythromycin and meoclopramide
gastric pacemakers
surgical options: partial gastrectomy, feeding tube
The smooth muscle of the lower esophageal sphincter is tonically ______ at rest
contracted
What are hypothesized causes of achalasia?
Virus, other infectious agents, autoimmune
List other conditions on the differential diagnosis for achalasia
Malignancy: especially gastric cardia
Chaga’s disease: trypanasomi cruzi
Amyloidosis
Chronic idiopathic intestinal pseudo-obstruction
Post-radiotherapy
Severe esophageal stricture/end-stage GERD
What are dietary recommendations for a person with achalsia?
Liquid or semi-liquid foods only
Small infrequent meals
Increased time after meal prior to reclining
What are causes for acute delayed gastric emptying
Opioids
Viral illness, hyperglycemia
Describe the dietary recommendations for a person with gastroparesis
Small, frequent meals
Reduced fiber to avoid bezoar
Liquid and simple starch foods
Liquid caloric supplementation if necessary
