UNIT 8: DIGESTIVE SYSTEM (PATHOPHYSIOLOGY)

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GERD PATHOPHYSIOLOGY
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GERD PATHOPHYSIOLOGY
GASTROESOPHAGEAL REFLUX DISEASE
The Esophageal sphincter is weak and does not close completely after food enters the stomach, which allows the backflow of gastric juices from the stomach to enter the esophagus. Throat tissue is not protected from the acidity like stomach tissue is.
Many patients develop this condition as they get older after a lifetime of "bearing down" to have bowel movements because of the internal pressure pushing against the closed sphincter. Also, weight lifters who hold their breath when training will have the same problem.
HEARTBURN
Heartburn is caused as chyme and gastric acid regurgitates into the esophagus about 30-60 minutes after meals causing inflammation of esophageal mucosa and tissue erosion (causing ESOPHAGITIS). When this tissue heals it causes fibrosis (scar tissue) that does not stretch as well as the original esophageal tissue.
*Many patients will self-medicate with over-the-counter antacid medications. These are temporary and do not prevent the release of acid that is aggravating the problem. Also, taking too many of these antacids (Tums/ Rolaids) can cause an electrolyte imbalance because they are high in sodium and calcium or magnesium.
GERD S/S
*Pain is worse when laying down or bending over. Patients will complain of having to sleep in a recliner or with the head of the bed elevated to relieve the pain. (NOTE: This pain can mimic a heart attack because the stomach is so close to the heart-or-patients with heart problems tell themselves they are just having heartburn and delay going to the ER for a cardiac workup- teach patients not to assume their chest pain is heartburn!) Could also develop respiratory s/s due to gastric reflux entering larynx.
GERD RISK FACTORS
Obesity
Pregnancy
SMOKING
Hiatal hernia
Fatty foods
ALCOHOL
Chocolate
GERD TX
Take acid-suppressing medications (a proton-pump inhibitor like omeprazole) Stop smoking and avoid 2nd hand smoke (increases gastric irritation and causes vasoconstriction which decreases healing); stop caffeine/ alcohol (increases gastrin); check for gluten intolerance.
*Maintain a high-protein, low-fat diet
*Sleep with the head of the bed elevated
*Stay upright for 2-3 hours after eating
*Decrease snacking
*If reflux is severe enough, a surgery can be done: Nissen Wrap (Fundoplication.) This sx wraps the top part of the stomach around the esophagus to make a tighter sphincter. Once this is done, the patient will not be able to vomit or belch air from the stomach.
GERD vs MI
A patient coming to the ER with chest pain may be given a "CARDIAC COCKTAIL" to rule out a MI. This combination of medications contains an acid suppressing liquid (Mylanta) and usually a numbing medication like viscous lidocaine. If the pain goes away after drinking this "cocktail," then the problem can be diagnosed as GI and not cardiac. Also, if the pain gets worse when the pt lies down, it is caused by GERD and not a cardiac problem.
CHRONIC GERD RISKS
Over time, GERD causes the tissue of the throat to develop precancerous dysplasia (Barrett's Esophagitis) and could develop into esophageal cancer. Advise patients NOT to ignore heartburn- it can lead to throat cancer (dysplasia.)
GERD>Barrett's>Low-grade dysplasia>High-grade dysplasia>cancer
HIATAL HERNIA PATHOPHYSIOLOGY
*Diaphragm weakness
Protrusion of the upper part of the stomach through the diaphragm into the thorax causing congestion of blood flow and ischemia. This pressure weakens the opening that the esophagus enters through the diaphragm at the "hiatus" of the stomach- which gives the name "hiatal" hernia. The exact cause of hiatal hernias is unknown. The condition may be due to a weakening of the supportive tissue, which allows the diaphragm ring to widen and allow stomach tissue to rise up through it.
HIATAL HERNIA RISK FACTORS
Increases with age, pregnancy, obesity, habitual vomiting (as in eating disorders), weight training, and smoking/ alcohol.
HH are very common and occur often in people over 50 years old
HIATAL HERNIA S/S
Rarely cause s/s unless GERD is present also. Just as with GERD, HH pain can mimic a heart attack, so chest pain has to be carefully evaluated to rule out cardiac causes for any chest pain first before treating it as a GI problem.
HIATAL HERNIA TX
Acid suppressing medication, and surgery if severe enough. The presence of a hiatal hernia can be observed during an endoscopic exam (looking at the esophagus and stomach with a scope)
PEPTIC ULCER DISEASE (PUD) PATHOPHYSIOLOGY
Erosion of the stomach lining. The bacteria Helicobacter Pylori (H. PYLORI) are present in more than 90% of duodenal ulcers and about 80% of stomach ulcers. Stress ulcers are common in hospitalized patients:
-Develop due to burn trauma, head injuries, critically ill patients
-Multifactorial cause but shock is a known cause (low blood perfusion to stomach)
-Treated with PPI (proton-pump-inhibitor drugs), i.e., IV pantoprazole (Prevacid)
PUD RISK FACTORS
Smoking (1/2nd hand)
Alcohol (ETOH)
NSAID use (Aspirin, Ibuprofen, Naproxen)
PUD S/S
Epigastric (substernal) or chest pain (dull, achy, or sharp) that starts about 2 hours after eating or in the middle of the night after stomach has emptied. PUD pain is often relieved by eating. Ulcers may self resolve or worsen to the point of causing internal bleeding (UGIB-upper gastrointestinal bleeding) or stomach/ duodenal perforation. Ulcers are a common finding in patients who have unexplained low hematocrit/ hemoglobin. Dangers of peptic ulcers are:
-Anemia
-Profuse bleeding
-Stomach cancer
PUD TESTS
CBC
Hematocrit & Hemoglobin
EGD (Esophagogastroduodenoscopy) to visualize and perhaps stop GI bleed
Biopsy of stomach tissue (to test for H. Pylori) during EGD procedure
H. Pylori bloow test
Occult blood smear