Pathophysiology Flashcards
Definition of GERD
- condition which develops when reflux of gastric contents causes troublesome symptoms and/or complications
- chronic related to retrograde flow of gastroduodenal contents into esophagus and/or adjacent organs, resulting in a spectrum of symptoms, with or without tissue damage
Disease Burden of GERD
-most common GI outpatient disorder in US
-44% adults have heartburn once/month, 20% weekly
-$12 billion/year
-increasing incidence, postulated causes
H. pylori treatment or obesity???
GERD Imbalance b/w Protective & Causative Factors
Protective: GE reflux barriers, esophageal clearance (back to stomach), mucosal resistance
Causative: gastric acid & pepsin, duodenal contents, inc. gastric volume, inc. abdominal presssure
GERD injury: Gastric Contents
-acid & pepsin: key toxic elements, synergistic
-basis for acid suppression therapy
-worse with hypergastrinemia (ZE syndrome)
-increased GERD incidence with H. pylori eradication (may dec. acid secretion)
-
GERD injury: Duodenal Contents
- conjugated bile acids (worse in acid) & typsin & deconjugated bile acids (neutral environment)
- hard to quantify accuracy
GERD protective factors: Anatomic Antireflux Barrier
- diaphragm forms a pinchcock around the entrance of the esophagus into the stomach
1. costal diaphragm: ventilatory muscle
2. crural diaphragm: muscle & sphincter-like action around the esophagus, inc. lower esophageal pressure, esp during instances when inc. pressure gradient b/w stomach and esophagus favors gastroesophageal reflux - LES is 2-4cm long thickened circular muscle fixed by phreno-esophageal lig to diaphragmatic hiatus, contract to 10-30 mm Hg to prevent reflux
- angulation created at fundus of stomach meets esophagus (angle of His), forms flap valve that anatomically prevents reflux
Healthy LES
- resting pressure (10-30mm Hg) prevents GE reflux (GE pressure gradient: 5-10 mm Hg)
- LES relaxes to allow food bolus to enter the stomach
Hypotensive LES
uncommon: mostly with severe esophagitis
- also occurs with pregnancy (estrogen & progesterone) with systemic disease (scleroderma) and after ablative surgery (Heller myotomy)
Decreased LES pressure with???
- fat
- chocolate
- peppermint
- many meds
Transient LES Relaxation (tLESR)
- accounts for most reflux episodes in healthy patients
- Present in 40-80% GERD patients with normal LES
- Independent of swallowing
- Longer (>10sec) than swallowing-induced LES relaxation
- Accompanied by inhibiting of crural diaphragm
- Mechanism for belching?? stimulated by gastric distention and also stress, fat, pharyngeal stimulation
Hiatal Hernia: Disruption of Cardial Function
- widened diaphragmatic hiatus and relaxed phrenoesophageal ligament allows the proximal stomach to migrate into thorax
- barrier functions are disrupted
1. loss of diaphragmatic and abdominal pressure at this location, LES pressure zone is shortened
2. physical barrier function of GE junction is impaired, as angle of His & valve is lost
3. increase in tLESR frequency in patients
GERD Protective Factors: Esophageal Clearance & Resistance
-peristalsis clears refluxate back into stomach
-bicarb (salivary & esophageal) neutralizes acid
-squamous mucosa resistant to acid injury
Importance of Salivation
-initiates primary peristaisis & neutralizes residual acid
-dec. salvation at night, smoking, anticholinergics
-esophageal dysmotility: both cause and result in GERD
-worse with connective tissue disease
GERD: gravity
-worse reflux when supine
GERD: gastric volume
-worse with delayed gastric emptying (anatomic or functional, diabetic gastroparesis)
GERD: abdominal & intragastric pressure
- increase GE pressure gradient
- GERD worse with obesity (& after gastric banding)
Cardinal Symptoms of GERD
- Heartburn: burning behind sternum radiating up to neck, worse after meals and lying flat, eased by antacid sen: 30-76% spec: 62-96%
- Regurgitation: reflux of gastric content into hypopharynx
- Dysphagia: from esophageal dysmotility (active inflammation) or strictures (scarring or cancer)
- reported by over 30% patients with GERD
Associated Symptoms of GERD
- Belching & Hiccups from esophageal irritation
- “water brash” sudden appearance of sour/salty fluid in mouth increased salivary secretion in response to acid reflux
- reflux laryngitis, due to reflux into hypopharynx (hoarseness and globus)
- cough & bronchospasm from intermittent micro-aspiration into airway
GERD Clinical Diagnosis
-Symptom Questionnaire: complexity & breadth of symptoms & cross-cultural differences (no gold standard) poor specificity
-Therapeutic Trial: anti-reflux lifestyle modifications
acid suppression: 2 weeks high dose PPI
symptomatic response with Rx & recurrence w/o Rx: sufficient to establish diagnosis of GERD
GERD: Radiologic Evaluation
Barium studies: noninvasive, available, cheap
Evidence: GE reflux, specific not sensitive
-esophagitis: mucosal ulvers
Contributory factors for GERD: hiatal hernia-potential for surgical repair
-gastric retention: anatomic & functional
Consequence: obstruction test with 13mm tables, stricture, web, ring
-dysmotility “poor man’s manometry”
-not good for Barrett’s esophagus
GERD: Endoscopic Evaluation
-visualization of GERD
-indicated for dysphagia, odynophagia, weigh loss, bleeding
-find: edema & erythema, friability, granularity, red streaks, erosions, ulcers
Los Angeles Classification A to D
GERD: pH Monitoring
TEST: atypical symptoms to document acid reflux, refractory symptoms to verify poor control of acid reflux, pre-op assessment to predict efficacy of anti-reflux surgery
pH Monitoring Methods
- traditional: transnasal probe tip 5cm above LES, portable recorder & event monitor, 24 hr duration
- wireless: probe stapled to the distal esophagus
GERD pH Monitoring Interpretation
Acid Reflux: Esophageal pH < 4.0 for > 5 sec
Pathologic reflux: pH 5% recorded time
No absolute threshold value for GERD