Lecture 7 Flashcards

Question

Contributing Mechanisms to GORD

Answer 1

1. Hypotensive LOS - not contracting tight enough (too lax/excessive relaxation) - can be born with - Caffeine, alcohol, chocolate, fats (can get reflux after alcohol) - certain medications e.g. beta-blockers, nitrates, calcium channel blockers 2. Hiatus Hernia - Note: not all people with hiatus hernia have reflux - common contributor - relevant, but not main part of the pathophysiology 3. Impaired Oesophageal Peristalsis - reduced clearance (of acid via secondary peristalsis of oesophagus)

Answer 2

The hiatus is an opening in the diaphragm, where oesophagus passes through to joint the stomach The diaphragm acts as additional support, like a sphincter, constricting around the GO junction A hernia is when part of an organ protrudes through an opening in the muscle/tissue that is meant to hold it in place Hatius hernia: top stomach passes through hiatus, into the chest (herniates through weak part of diaphragm and sits above). 1. now have section acting as chamber for food to sit in. Gastric Acid Can now reflux freely into distal oesophagus. 2. LOS Lower Oesophageal SPhincter/The GO junction has lost support from diaphragm. Weakens sphincter, precipitating to reflux

Answer 3

Symptoms occur due to: Gastric acid coming in contact with oesophagus -Oesophageal mucosa sensitive to acidic pH -Normal pH in oesophagus 6-7 -pH of gastric contents 1-2 (unless buffered by food) -Nerve fibres in oesophagus are sensitive to acidic pH, give sensation of "burning" Eventual complications of chronic acid exposure -Heartburn/chest discomfort: burning sensation or discomfort over the (bottom) chest -Regurgitation: Food or liquid coming back up into mouth -Sour or bitter taste in mouth -May be worse soon after eating or lying down (e.g. bed time)

Answer 4

GORD can be viewed as a disease due to abnormal motility of oesophagus (and stomach) But it can also cause structural complications: 1. Reflux Oesophagitis -damage to oesophagus mucosa by reflux leading to inflammation, ulceration and bleeding 2. Peptic Stricture -Prolonged inflammation of oesophageal mucosa by reflux can lead to fibrosis and scarring (tightening) -Barrett's Oesophagus -Cancer

Answer 5

damage to oesophagus mucosa by reflux leading to inflammation, ulceration and bleeding Pain/discomfort in chest 1. Bleeding- haematemesis (vommiting blood) 2. Dysphagia- difficulty swallowing -Linear ares of ulceration- red and inflamed- due to chronic exposure -over time, if inflammation untreated, can cause Narrowing=Peptic Stricture (significant tightening of lower Oesophagus)

Answer 6

Damage to oesophageal epithelium by chronic acid exposure from GORD can lead to Barrett's oesophagus Intestinal Metaplasia= Oesophageal epithelium (squamous epithelium) transforms --> to become like Gastric epithelium (columnar epithelium w. goblet cells) - trying to adapt for protection -but increased risk of dyspalsia and cancer Males, over 50, increased BMI, smoker with chronic GORD Increased risk of Oesophageal Adenocarcinoma -no regular circular line around transformation zone - squamous=lighter columnar=darker

Answer 7

Squamous oesophagus -->(injury:acid and bile reflux nitrous oxide) Chronic Inflammation --> (genetics:, gender, race , 7x other factors (cox-2)) ---Accumulate genetic changes continue to increase over remaining development--- Barrets Metaplasia --> Low-grade Dysplasia (if not treated, increases risk of abnormal cells forming) --> High-grade Dysplasia (low grade abdormal cells become high grade abnormal cells) --> Invasive Adenocarcenoma -main driver of this transformation is ongoing acid reflux

Answer 8

2x types: Adenocarcinoma (adenoCa) (GORD, Barrett's), squamous cell carinoma (SqCC) GORD- risk of Barrett's - risk of oesophageal adenoCa Smoking, alcohol, diet - risk of SqCC "lifetsyle cancer" In Western countries, oesophageal adenoCa more common. seeing less as reflux is better treated Presents similarily except: -adenCa more likely to be in distal oesophagus/GO junction -SqCC more likely higher up in oesophagus

Answer 9

The terms oeosphageal web and ring are often used interchangeably Thin mucosal membrane -can sometimes obstruct passage of food (therefore some people complain of dysphagia (difficulting swallowing)) Schatzki ring- found distally, typically associated with hiatus hernia, aetiology/cause uncertain

Answer 10

Pharyngeal pouch (at back) Excessive pressure causes the weakest portion of the pharynx to balloon out Conditions such as poor swallowing(dysphacia), impair relaxation of cricopharyngeus(prior to swallowing) -presure in pharynx becomes excessive, and weakest part of pharynx (At back where diverticulum occurs) will balloon out and form a pocket More common in elderly

Answer 11

Peptic: i.e. Reflux relates Caustic i.e. Caustic injury (swallow acid/bleach) Post-radiotherapy Post-surgical i.e. anastomotic (joining together where surgery has occured) Malignant (cancer) Present/Results in: Dysphagia

Answer 12

GORD can result in severe oesophagitis or stricture

Answer 13

White plaque coating oesophagus - candida/thrush - usually occurs in people who are immuno supressed

Answer 14

``` Herpes simplex virus Cytomegalovirus Pill-induced: -Doxycycline- sit up + large galss of water. otherwise can get stuck in oesophagus and result in erosion and ulcer formation -Bisphosphonates ```

Answer 15

Eosinphils infiltrate the epithelium of oesophagus Allergy-mediated Patient may have history of atopy: asthma, hayfever, eczema -circular lines up and down oeosphagus + fissures running up and down

Answer 16

Structure, mucosa of oesophagus is normal- appears to be visibly normal Present with difficulty swallowing-dysphagia More likely to be intermittent/variable symptoms May affect liquids as much as solids - in contrast to structural narrowing (e.g. cancer or stricture), which tend to affect solids only Problem with 1. innervation to smooth muscle (loss of function or co-ordination) 2. or direct muscle damage Achalasia most common moltility disorder

Answer 17

Most common Motility disorder of oesophagus Degeneration of nerves in oesophagus (Neurodegenerative condition) -Myenteric plexus -LOS inhibitory nerves -cause uncertain 1. Loss of peristalsis in distal oesophagus 2. failure of LOS to relax with swallow(contracted all of the time/wont relax when swallow) Symptoms: -oeosphagus dilate: pressure increase + retains food (as sphincter too tight and wont relax) - characteristic Barrium swallow/ xray appearance of "birds beak"

Answer 18

"Corkscrew Oesophagus" Non-peristaltic or simultaneous onset of contraction in oesophagus -Peristalsis is occuring but not in right order/ randomly occuring at different segements (spasming) In addition to dysphagia, can cause chest pain (intermittent spasms)

Answer 19

Normal peristalsis, but contractions very high amplitude | -i.e. wave of contractions propagate down oesophagus normally, but just too strong

Answer 20

systemic condition (Manifestation of a more general disease) CT connective Tissue Disease (effects organs including oesophagus) Hardening (fibrosis) of skin and CT connective tissue (Rubbery hose-pipehollow tube) When oesophagus is affect, damage occurs to submucosa, muscle layers, nerves -oesophagus turns into rubbery hose-pipe Peristalsis is absent, contractions weak, LOS is no tone 1. Dysphagia- as food cannot be propelled 2. Severe reflux - acid comes up and not shifted down into stomach

Answer 21

Can be useful to differentiate between conditions - Normal: good amplitude of propagations from left to right in co-ordinated fashion. LOS pressurenormally dips down - Achalasia : Weak peristalsis at bottom=small peaks. LOS consistently high pressure - Diffuse Oesophageal Spasm-degree of peristalsis. 2x contractions instead of one