Stomach

Motility Disease of the Esophagus

Dr. Smoot

1/12/05 9:00

These notes correspond to the ppt entitled “Smoot acid peptic esoph.” My notes are

italicized and if there are no notes for a slide then he did not add any additional info.

Gastroesophageal Reflux (slide 18)

Causes of reflux

-Relaxation of the LES

-transient relaxation with meals

-foods stimulate relaxation

fatty foods, mints, alcohol, chocolate

-medications (nitrates, calcium and beta - blockers)

-Cigarette smoke

-Drinking through a straw

-Increased abdominal pressure

What causes reflux? The LES relaxes too often- people may have a low pressure

sphincter meaning that it doesn’t take much fluid for it to open up but most people with

reflux have a normal sphincter pressure but the sphincter just relaxes when it should not;

this is transient relaxation

Foods that stimulate: chocolate, fatty foods (cause more acid secretion), mints, alcohol,

caffeine is included but it is variable, not as absolute. Restaurants give mints because

they cause relaxation of the intestines and relaxation of the sphincter so you don’t feel as

full; relaxed sphincter may give you a warm feeling or you may feel pain if you have

reflux.

Meds: Ca channel blockers reduce esophageal spasm by reducing smooth muscle so they

are good for hypertensive LES but the problem is that patients may develop reflux

following the use of the drug since it may cause the sphincter to be too relaxed.

Drinking through a straw reduces pressure in chest and that helps contents of stomach

come into the esophagus

Abdominal pressure is associated with weight gain; weight gain does not have to be very

significant. If reflux sx occurred following the weight gain you can probably tell the

patient that if they lose weight they will get rid of the reflux but if patient has been

overweight for a while and the sx just recently occurred, weight loss will not get rid of

symptoms. Reflux is associated with pressure and tightness of the stomach. If the

stomach is hard then this increases pressure more than a soft stomach

Gastroesophageal Reflux (slide 19)

Normal acid reflux occurs with meals and infrequently at night (< 4% of time over 24 hrs)

Symptoms occur with

-Increased number of reflux episodes

-Prolonged duration of reflux episodes

-Decrease in mucosal protection

-Mucosal hypersensitivity

-loss of esophago-salivary reflex Eating before bed causes acid secretion for 1-2 hours after meal time

There is a normal amount of acid that gets into the esophagus around meal time but if

you lie down and do not have good sphincter pressure this can lead to reflux. Sound

sleepers may not feel reflux until they get ulcers. <4% acid in esophagus is normal >6%

acid in esophagus is abnormal.

Mucosal hypersensitivity implies that the nerves may be closer to the surface leading to

lower pain threshold.

Good indicator of reflux: if after lie down you get lots of saliva (to buffer) in mouth you

are refluxing; normally when acid gets into the esophagus, salivary glands are stimulated;

people with reflux may have loss of this esophageal-salivary reflex that normally occurs

with reflux

Gastroesophageal Reflux (slide 20)

Diagnosis

-Primarily through typical history

pain may be burning, sharp or dull

-24 hour pH testing is the gold standard

the percent time that the pH is < 4 is the most important measure

-Therapeutic trial with a proton-pump inhibitor

-Endoscopy only helpful to identify esophageal erosions and ulcers, not good at

diagnosing acid reflux.

Main treatment is a good hx and meds. 24 hours pH testing is the gold standard. This is

done by inserting a capsule into the esophagus which will catch onto the tissue and put a

pin through it and after four days it will slough and pass in the stool. This allows the

identification and time of reflux.

It is impt to be specific when asking questions about the type of pain in the hx; muscle

spasm is more gripping pain and reflux pain is more of an irritation. Is feeling moving up

the chest? This is more consistent with reflux

*Esophagitis can cause muscle spasmchest pain although we generally don’t associate

esophagitis with chest pain. Realize that motility problems can occur as a result of

esophagitis. Only 1/100 patients will have esophagitis however, so most are treated for

reflux and if there is not significant improvement after 3-5 days of meds then that patient

is tested for esophagitis.

People with longstanding reflux disease need endoscopy

Gastroesophageal Reflux (slide 22)

Extraesophageal Disease

-Pulmonary complications