Transcript DYSPHAGIA
GROUP D DYSPHAGIA (BENIGN PEPTIC STRICTURE) BENIGN PEPTIC STRICTURE narrowing of the esophagus(distal) near the junction with the stomach (squamocolumnar jxn). sequelae of gastroesophageal reflux– induced esophagitis. (GERD) ~10% GASTROESOPHAGEAL REFLUX DISEASE (GERD) “Chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus” GERD PATHOPHYSIOLOGY: 3-PART PROCESS 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 CLASSIC SYMPTOMS OF GERD Heartburn Regurgitation materials of sour DEFENCE MECHANISM FOR GERD DEFENSE MECHANISM LES pressure Diaphragm augmentation Esophageal peristalsis Salivary neutralization Mucosal resistance Normal acid secretion Normal gastric emptying Normal abdominal pressure Soll AH. Clin Cornerstone 2003 DISRUPTIONS drugs Hiatal hernia Scleroderma Sicca synd, Sjogren’s dse NSAIDs Gastrinoma Dysmotility Pregnancy, obesity MEDICATIONS PREDISPOSING TO GERD Calcium Antagonists Anticholinergics Beta-blockers Alpha-Adrenergic blockers Progesterone Doxycycline Potassium tablets NSAID’s Bisphosphonates FACTORS THAT CAN AGGRAVATE OR PRECIPITATE GERD Diet Alcohol Coffee Chocolate Citrus and tomato products Fatty and spicy foods Peppermint Exercise Other Bending Lifting Running Tight clothing Pregnancy PATHOPHYSIOLOGY (BPS) CLINICAL FEATURES 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 DIAGNOSIS Barium esophagram Endoscopy Esophageal manometry 24 hour pH monitoring MANAGEMENT Goals: Relieve dysphagia and restore swallowing Treat the underlying GERD promote healing of esophagitis prevent stricture recurrence RELIEVE DYSPHAGIA Stricture Dilatation Initial means of relieving dysphagia. Dysphagia resolves when the stricture can be dilated to 14 mm Kahrilas P J. Gastroesophageal reflux disease. JAMA. (1996); 276: 983–988. [PubMed] Esophageal resection Patients with undilatable strictures TREATMENT FOR GERD (MEDICAL) Antacids Widely used to self-medicate for heartburn Useful in treating mild GERD TREATMENT FOR GERD (MEDICAL) 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) TREATMENT FOR GERD (MEDICAL) Anti secretory Agents H2-receptor antagonists competitive antagonists of histamine at the parietal cells H2 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 TREATMENT FOR GERD (SURGICAL) Antireflux Surgery Fundoplication gastric (laparoscopic; open surgery) 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 TREATMENT FOR GERD (LIFESTYLE) 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 PATIENT CORRELATION PATEINT BENIGN PEPTIC STRICTURE Difficulty of Swallowing YES Regurgitation of Sour materials YES Chest pain after eating YES Copious sputum upon waking up YES Relieved by omeprazole YES Weight loss YES