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52 Cards in this Set
- Front
- Back
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normal defence mechanisms for acid reflux (steps 1-4) |
1. there will be acid and food reflux into the esophagus (at this time, the lower esophageal sphincter will be relaxed) 2. as a result, peristalsis will occur to return most of the acid reflux into the stomach 3. there will be some remaining acid in the esophagus after peristalsis 4. Saliva (containing bicarb) in the esophagus will neutralize the acid in the esophagus |
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where is the lower esophageal sphincter located? what is its main function? |
at the gastroesophageal junction (between the stomach and esophagus
-main function is to protect esophagus from acidic stomach contents |
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what maintains the tone of the LES |
-acetylcholine |
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what is the pressure of the LES in relation to the pressure in the stomach? Is that a set range? |
LES pressure is 15-30 mmHg above the intragastric pressure -it varies from person to person |
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LES exhibits diurnal variation in pressure, what does that mean? |
-pressure in the LES varies during the day - it is highest at night and lowest in the daytime and postprandially (after eating) |
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what 3 things can affect the LES pressure? |
drugs food hormones |
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how can the pyloric sphincter cause GERD |
-it is responsible for gastric emptying into the duodenum -if pyloric sphincter delays gastric emptying, food will build up in the stomach --> higher intraabdominal pressure - intra-abdominal pressure > LES pressure = GERD bc food/acids from stomach will push up and enter esophagus |
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role of duodenum, pH? |
- continues digestion of chyme -pH 6.5 |
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would an anti-muscarinic (anti- ACh) drug be a good idea for GERD to reduce acid production? |
-not a good drug choice -bc ACh is also responsible for LES tone, therefore it would block acid production but also would block LES tone |
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which stomach cells secrete both HCl and intrinsic factor (B12) |
parietal cells |
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what 3 regulatory pathways control gastric acid production in the stomach? |
1. Acetylcholine 2. Gastrin 3. Histamine all of these bind to receptors on parietal cells to increase acid production |
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roughly how many proton pumps does each parietal cell have? |
1 million |
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how does the proton pump (H+K+-ATPase pump) work? |
-exchanges H+ ions from cytosol for K+ ions in the canaliculi using energy from ATP - passive movement of K+ and Cl- ions into the canaliculus -when H+ is pumped out of cytosol, it forms HCl with the Cl- ions |
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what is GERD |
-chronic disorder related to retrograde flow of gastro-duodenal contents into the esophagus and/or adjacent organs -may or may not cause tissue damage |
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GERD vs heartburn |
-GERD: can actually lead to tissue damage, is more frequent, and has longer duration, occurs at all times of the day -heartburn: short term, less frequent, mainly after eating |
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how many people suffer from GERD monthly? weekly? and what age? where in the world is prevalence for GERD higher? |
1 in 2 suffer monthly 1 in 5 suffer weekly people over 40yo higher prevalence in western country |
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hallmark / most common sign of GERD |
- heartburn |
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chest symptoms of GERD (BODVCH) |
-Belching -Odynophagia (sharp substernal pain during swallowing) -Dysphagia (perception of impaired movement of swallowing material from pharynx to stomach) -Vomiting -Chest pain -HEARTBURN |
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Pulmonary symptoms of GERD (CAHA) |
-Cough -Asthma (non-allergic) -Hoarseness - Aspiration |
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Oral symptoms of GERD |
-tooth decay -gingivitis |
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Throat symptoms of GERD |
-globus sensation (lump in throat) -hoarseness -laryngitis
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extraesophageal symptoms |
-laryngitis -chronic cough -chronic sinusitis -dental erosion -pharyngitis -asthma |
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how often would heartburn occuring be indicative of GERD? if it occurs with ____________ then there is a 90% certainty of GERD |
2 times per week -if occurs with regurgitation = 90% certainty of GERD |
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define heartburn |
-burning pain that can move up from stomach into chest area, and maybe into chest -can include regurgitation |
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define regurgitation |
-symptom of acid reflux -contents of stomach move up into esophagus and maybe into throat (sour taste in mouth) |
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define dyspepsia |
-INDIGESTION (think problem with digestive enzyme pepsin) -mostly stomach discomfort (can include burping, nausea, bloating, upper abdominal pain) |
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explain slide 18 |
refer to ppt |
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3 dysfunctions in LES pressure |
1. spontaneous LES relaxation that is not associated with swallowing is transient LES relaxation (TLESR) --> most common causative mechanism 2. increased intra-abdominal pressure (tight clothes, obesity, pregnancy, bending over, eating, coughing) 3. Atonic Sphincter (no muscle tone) allows contents to move between stomach and esophagus easily |
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which food increase LESP, decrease? |
proteins increase fats, chocolate, alcohol, peppermint, garlic, onions decrease |
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hormones that increase or decrease LESP |
INCREASE: gastrin, motilin, substance P DECREASE: glucagon, progesteron, estrogen |
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medications that increase or decrease LESP |
INCREASE: metoclopramide, domperidone, cisapride DECREASE: nitrates, nicotine (think smoking), anticholinergics, caffeine, dopamine (released from smoking), narcotics (morphine), theophyline |
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the esophagus is cleared mainly by: |
1. primary peristalsis (swallowing) secondary peristalsis is due to gravity or esophageal distention 2. salivary flow (increased by peristalsis) - contains bicarb |
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what is the pH threshold that the esophagus can withstand in regards to reflux? |
pH of 4 -anything lower is severe damage to esoph |
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what pH is pepsinogen activated at and what does that cause? |
-activated at pH of 2 -activates pepsinogen into pepsin which denature proteins --> esophagitis |
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out of: composition of reflux, duration of acid exposure, or delayed gastric emptying, which is the primary cause of symptoms and tissue damage? |
duration of acid exposure |
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what tests have been used to try to diagnose GERD |
-24 hour pH monitoring (pH probe inserted above LES, patient writes diary of symptoms, those two are then compared) - manometry - measure intra-abdominal pressure - proton-pump administering - endoscopy (can actually see the condition of the mucosa) |
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when trying to diagnose GERD, what is most important indicator? |
take thorough clinical history |
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differences between heartburn pain and cardiac chest pain |
HEARTBURN pain -burning substernal -can spread into throat and neck -does not change upon exertion - regurgitation -symptoms increase when lying down or eating CARDIAC CHEST pain -crushing feeling in chest -can radiate into left arm, neck, shoulders, back -pain increase with exertion -sweating, nausea, vomiting -increasing symptoms till treatment or death |
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stricture formations |
- formation of scar tissue in the esophagus as a defence mechanism against ulcerations -can lead to dysphagia |
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barrett's esophagus |
-when the tissue lining of the esophagus changes to be like that of the intestine |
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how does food trigger GERD? |
- large meals induce TLESR - meals within 2-3 hours of bedtime or with alcohol increase acid production and increase nocturnal GERD - high fatty meals |
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hiatial hernia |
when a portion of your proximal stomach is pushed up past your diaphragm (through the hiatus in the diaphragm) -this can build up the stomach contents in can cause the LES to open --> esophagitis, GERD |
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Hallmark Clinical characteristics of GERD (VBAD) |
- vomiting - bleeding - Abdominal weight loss -Dysphagia (problems with swallowing) -family history of gastric cancer - cough, hoarsness, dyspnea |
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age most common for GERD |
between 18 and 50 yo |
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lifestyle modifications for GERD |
-eat smaller, less fatty meals, not before bed -lower caffeine -less stress -less smoking -avoid excessive bending -exercise - less alcohol |
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OTC treatment options which is more recommended |
Anatacids (Tums) -raise pH over 4 which decreases the conversion of pepsinogen into pepsin Alginic Acid (Gaviscon) -creates viscous barrier at top of stomach -decrease reflux episodes - neutralize acid and coat stomach -BETTER THAN TUMS |
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H2 Blockers as prescription treatment options, what is the common therapy regime? |
H2 Blockers -reduce acid production -provide immediate relief of symptoms -common adverse reactions: diarrhea, headache, dizziness, rash, tiredness -12 weeks, take BID |
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Proton Pump inhibitors as prescription treatment options. When is it best to take them |
-reduce acid production (maintains pH above 4 for longer) -superior to all other treatments -best to take them 30 mins before breakfast -same side effects as H2 blockers (+constipation, abdominal pain) |
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how often does need to get refluxes in a week in order to have proton pump inhibitors as the first line choice of drug? |
2 times per week |
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prokinetics |
-help move contents of stomach faster to avoid reflux -less desirable because of their side effects -significant drug interactions |
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mucosal protectants, what kind of people are they used for? |
- used for more sedentary people |
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look at alternative off-label treatment options |
slide 37 |
