1. GROUP D

2.  narrowing of the esophagus(distal) near the junction with the stomach (squamocolumnar jxn).  sequelae of gastroesophageal reflux– induced esophagitis. (GERD) ~10%

3.  “Chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus”

4.  Decreased basal lower esophageal sphincter (LES) pressure and LES relaxations allow refluxate to enter esophagus  Decreased acid clearance allows acidic refluxate to remain in the esophagus  Refluxate of acid and pepsin injures the esophageal mucosa  Decreased basal lower esophageal sphincter (LES) pressure and LES relaxations allow refluxate to enter esophagus  Decreased acid clearance allows acidic refluxate to remain in the esophagus  Refluxate of acid and pepsin injures the esophageal mucosa

5.  Heartburn  Regurgitation of sour materials  Heartburn  Regurgitation of sour materials

6. DEFENSE MECHANISM DISRUPTIONS LES pressuredrugs Diaphragm augmentationHiatal hernia Esophageal peristalsisScleroderma Salivary neutralizationSicca synd, Sjogren’s dse Mucosal resistanceNSAIDs Normal acid secretionGastrinoma Normal gastric emptyingDysmotility Normal abdominal pressurePregnancy, obesity Soll AH. Clin Cornerstone 2003

7.  Calcium Antagonists  Anticholinergics  Beta-blockers  Alpha-Adrenergic blockers  Progesterone  Doxycycline  Potassium tablets  NSAID’s  Bisphosphonates

8. Diet  Alcohol  Coffee  Chocolate  Citrus and tomato products  Fatty and spicy foods  Peppermint Diet  Alcohol  Coffee  Chocolate  Citrus and tomato products  Fatty and spicy foods  Peppermint Exercise  Bending  Lifting  Running Other  Tight clothing  Pregnancy

10.  Persistent Dysphagia  Signs and Symptoms of GERD  Regurgitation of sour food material  Heartburn  Signs and symptoms of Respiratory tract irritation and inflammation (if with pulmonary aspiration)  Pulmonary aspiration complications

11.  Barium esophagram  Endoscopy  Esophageal manometry  24 hour pH monitoring

12.  Goals:  Relieve dysphagia and restore swallowing  Treat the underlying GERD  promote healing of esophagitis  prevent stricture recurrence

13.  Stricture Dilatation  Initial means of relieving dysphagia.  Dysphagia resolves when the stricture can be dilated to 14 mm  Esophageal resection  Patients with undilatable strictures Kahrilas P J. Gastroesophageal reflux disease. JAMA. (1996); 276: 983–988. [PubMed]PubMed

14.  Antacids  Widely used to self-medicate for heartburn  Useful in treating mild GERD

15.  Anti secretory Agents  PPI (Proton Pump Inhibitors)  Specifically inhibit the H + /K + -ATPase enzyme system at the secretory surface of the gastric parietal cell, resulting in a potent antisecretory effect  Promotes healing of erosive esophagitis in chronic GERD  omeprazol (20mg/d)  lansoprazole(30 mg/d)  pantoprazole (40 mg/d)  esomeprazole (40 mg/d)  rabeprazole (20 mg/d)

16.  Anti secretory Agents  H 2 -receptor antagonists  competitive antagonists of histamine at the parietal cells H 2 receptor, suppressing the normal secretion of acid by parietal cells and the meal-stimulated secretion of acid.  cimetidine, 300 mg  ranitidine, 150 mg bid  famotidine, 20 mg bid  nizatidine, 150 mg bid

17.  Antireflux Surgery  Fundoplication (laparoscopic; open surgery)  gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place  Increases LES pressure  alleviates chronic heartburn in people whose condition cannot be controlled by either lifestyle changes or medication

18.  Weight reduction  Head elevation during sleep  elimination of factors that increase abdominal pressure.  Abstinence from smoking and alcohol  Avoid fatty foods, coffee, chocolate, mint, orange juice

19. PATEINTBENIGN PEPTIC STRICTURE Difficulty of SwallowingYES Regurgitation of Sour materialsYES Chest pain after eatingYES Copious sputum upon waking upYES Relieved by omeprazoleYES Weight lossYES