L12: Esophageal Diseases Flashcards
Def of GERD
- A condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.
Incidence of GERD
- It is one of the most common conditions affecting the gastrointestinal system.
- Anywhere from 36-77% of people have symptoms of GERD (heartburn, regurgitation of acid etc.)
- Spread equally between men and women.
Normally, esophageal reflux is prevented by the following mechanisms …..
Etiology & Pathogenesis of GERD
Contributing Factors to GERD
Factors that Decrease LES Pressure
Factors that directly irritate gastric mucosa
Other Conditions Associated with GERD
CP of Classic GERD
Heartburn sensation
- Mainly Epigastric & may radiate retro-sternal even to the lower jaw
- It occurs 30 - 60 m after meals
what increases symptoms of GERD?
bending, straining, lying down & pregnancy
what Decreases symptoms of GERD?
Standing, oral intake of water or alkali
Extra esophageal Manifestations of GERD
Barret’s Esophagus is thought to be caused by ……
Ongoing injury.
Inflammation.
Damage to the lining of the esophagus.
Symptoms of complicated GERD
Def of Barret’s Esophagus
a change from the normal (squamous) mucosa to a specialized intestinal type (columnar metaplasia).
Barret’s Esophagus is associated with ……..
increased risk of esophageal adenocarcinoma.
(Risk of cancer per year in Barrett’s esophagus 0.5% )
Are Investigations needed for GERD?
Usually not needed (clinical diagnosis) but may be indicated in:
- Red-flags (bleeding, weight loss, dysphagia etc.)
- Persistent symptoms after therapeutic trial of 4-8 weeks of PPI twice daily.
- High risk for Barrett’s (male, age >50, obese, white, tobacco use, long history of symptoms).
Investigations of GERD
- Barium swallow
- Endoscopy
- 24-hr pH Monitoring
- Esophageal Manometry
Barium Swallow in GERD
Endoscope in GERD
24-Hr pH Monitoring in GERD
DDx in GERD
Esophageal Manometry in GERD
TTT of GERD
- Lifestyle Modification
- Drugs
- Surgery
Indications of Pharmacologic Therapy in GERD
if no response to lifestyle modifications
Lifestyle modification in GERD
cornerstone
Diet control
Weight reduction
Raising head during sleep
Take dinner 2-4 h before sleeping
Avoid Tight corset
Categories of drugs in GERD
- Antacids
- Prokinetic
- Acid Suppression Therapy
- Baclofen
Examples of antacids in GERD
Aluminum hydroxide & Magnesium hydroxide (help symptoms, not the disease).
Prokinetic Drugs in GERD
Itopride, metoclopramide & Domperidone
Acid suppression therapy in GERD
MOA of baclofen in GERD
GABA B agonist, reduces the transient LES relaxations that enable reflux episodes.
SE of Baclofen
Usage is limited by side effects of dizziness, somnolence, and constipation
Pharmacokinetics of H2 antagonist
Absorbtion of H2 antagonist
Well absorbed → oral and IV doses similar.
Peak of H2 antagonist
Peak 1-3 hours.
Metabolism & Elimination of H2 antagonist
- Hepatic metabolism (cimetidine and ranitidine).
- Renal elimination → famotidine and nizatidine.
SE of H2 antagonist
- Most common side effects→ diarrhea, constipation, CNS (mental confusion, headaches, dizziness).
- Especially at risk → elderly, high doses, renal dis.
Pharmacokinetics of Proton Pump Inhibitors
Effect of PPI
Inhibit > 90% of gastric acid secretion within 24 hours.
Preparations of PPI
Unstable in acid media so they are enteric coated.
Absorbtion & Peak of PPI
Rapidly absorbed and peak 2-4 hours.
Elimination & Metabolism of PPI
Eliminated hepatically and plasma T½ ~ 1-2 hours, antisecretory effect is 1 ½ to 3 days.
SE of PPI
- GI (nausea, diarrhea), CNS (dizziness, headache) skin rash, gynecomastia, increase liver enzymes.
Def of Refractory Esophagitis
persistent heartburn and/or regurgitation despite 8 weeks of double-dose PPI therapy
Types of Surgery in GERD
- Laparoscopic Nissen fundoplication gold standard surgical treatment
- Laparoscopic anterior 180° fundoplication (180° LAF)
- Bariatric surgery in obese patients Roux-en-Y gastric bypass
Indications of Surgery in GERD
Incidence of Achalasia
Affects all ages and both genders.
what ia another name for Achalasia?
Cardiospasm
Def of Achalasia
Rare, chronic disorder.
Pathophysiology of Achalasia
Failure of relaxation of LES & loss of peristalsis in the distal esophagus
Etiology of Achalasia
Degeneration of the Auerbach’s plexus
1) Idiopathic
2) pseudo-achalasia: e.g. malignancy,
3) Chagas disease (Trypanosoma cruzi)
CP of Achalasia
Typical Patient with Achalasia
adults aged 25-60 years, equally in both males & females.
Dysphagia in Achalasia
- Early intermittent then progressive
- Early liquids > solids then both solids & liquids
Globus Sensation in Achalasia
Substernal chest pain —> during / after a meal
Investigation for Achalasia
- Barium swallow
- Esophageal manometry: definitive diagnosis.
Barium Swallow in Achalasia
esophagus terminates in narrowing at LES (Bird’s beak - parrot peak)
Manometry in Achalasia
Absent or incomplete LES relaxation.
Loss peristalsis.
Endoscopic pneumatic dilation in Achalasia
LES disrupted using balloons of progressively larger diameters.
Repeat dilations are often required.
Goals of TTT of Achalasia
- Relieve symptoms & improve esophageal emptying.
- Prevent development of mega esophagus.
Surgery in Achalasia
Heller myotomy:
Done laparoscopically.
LES surgically disrupted.
Often has antireflux surgery at same time.
1 to 2 weeks for recovery
Drug Therapy in Achalasia
Smooth muscle relaxants.
- Botulinum toxin injection 1 to 2 years relief.
Drugs:
- nifedipine, Nitrates or sildenafil (relax LES)
Symptomatic TTT in Achalasia
Semisoft diet.
Eating slowly.
Drinking with meals.
Sleeping with HOB elevated
Def of Hiatus Hernia
- Protrusion of the upper part of the stomach upward through diaphragmatic esophageal hiatus
Types of Hiatus Hernia
- Type I ( Sliding)
- Type II ( Para-esophageal or rolling hernia )
- Type III ( Mixed )
Def of Sliding Hiatus Hernia
Herniation of the GEJ through the esophageal hiatus into the thorax
CP of Sliding Hiatus Hernia
asymptomatic or heart burn
Investigations in Sliding Hiatus Hernia
Barium swallow & Upper endoscopy
TTT of Sliding Hiatus Hernia
Weight reduction, small meals, sleeping in semi-sitting position, PPI & Prokinetics.
Fundoplication indicated in resistant cases
Def of Para-esophageal or rolling hernia
small part of the fundus of the stomach rolls up alongside the esophagus
CP of Para-esophageal or rolling hernia
asymptomatic, No GERD symptoms
Investigations of Para-esophageal or rolling hernia
Barium swallow & Upper endoscopy
Complications of Para-esophageal or rolling hernia
Mediastinal compression, Volvulus of the stomach can occur
Stages of Swallowing
Def of Dysphagia
- Sensation that food is hindered in its passage from the mouth to the stomach.
- Most patients complain that food “sticks” “hangs up” “stops”
Def of Odynophagia
painful swallowing
Intaluminal Causes of oropharyngeal dysphagia
Extraluminal Causes of oropharyngeal dysphagia
Neuromuscular Causes of oropharyngeal dysphagia
CNS Causes of oropharyngeal dysphagia
PNS Causes of oropharyngeal dysphagia
MEP Causes of oropharyngeal dysphagia
Muscle Causes of oropharyngeal dysphagia
Metabolic Causes of oropharyngeal dysphagia
intraluminal Causes of Esophageal dysphagia
Extraluminal Causes of Esophageal dysphagia
Neuromuscular Causes of Esophageal dysphagia
Primary Causes of neuromuscular Esophageal dysphagia
Secondary Causes of Neuromuscular Esophageal dysphagia
Algorithm for dysphagia
Done
..
