Read the Patient’s Clinical Presentation and answer the questions below. You will be graded on the accuracy and thoroughness of the information that you provide, the quality of the sources that you use, and your attention to details and instructions.
Patient’s Clinical Presentation
Chief Complaint:
A 26-year-old business executive complained of a dull pain (heartburn) behind the sternum. The pain was postprandial (occurred after meals) and disappeared within a few minutes to an hour. It was often associated with belching and often was worse on lying down or on exertion after heavy meals. Sometimes it radiated to the back, jaws, shoulders, and down the inner aspects of the arms, simulating angina pectoris. X-rays revealed a small portion of the stomach above the diaphragm, and an endoscopic biopsy revealed mucosal inflammation. Esophageal manometry (determining pressures at the lower esophageal sphincter, LES) revealed decreased LES pressure. Esophageal pH monitoring showed reflux of gastric contents into the esophagus and provided direct evidence of gastroesophageal reflux. Recommended treatment for this individual is avoidance of strong stimulants of gastric acid secretion (e.g., coffee, alcohol) and avoidance of certain drugs (e.g., anticholinergics), and specific foods (fats, chocolates, whole milk, and orange juice), and smoking, all of which reduce LES competence. Elevation of the head of the bed by about six inches is also recommended. Suggested treatments also include the use of cholinergic agonists (e.g., bethanechol) and the use of histamine (H2) antagonists (cimetidine).
Answer the following questions.
- What is the disorder of this 26-year-old business executive? Explain.
- 2. What mechanisms normally prevent gastric reflux into the esophagus when lying down or bending over?
- Why are anticholinergic agents avoided and cholinergic agonists recommended in the treatment of gastroesophageal reflux?
- Why are histamine (H2) antagonists recommended?
- Why is elevation of the head of the bed recommended?
- What is the normal pH of the esophagus? Of the stomach?
Full Answer Section
- Regurgitation (belching): Acidic stomach contents backing up into the esophagus.
- Symptoms worsened by lying down or exertion: Increased pressure in the abdomen pushing stomach contents upwards.
- Esophageal manometry: Decreased pressure in the Lower Esophageal Sphincter (LES), the muscular valve between the esophagus and stomach, allowing backflow of stomach acid.
- Esophageal pH monitoring: Confirmation of reflux of acidic stomach contents into the esophagus.
- Mechanisms Preventing Reflux:
Several mechanisms normally prevent gastric reflux:
- Lower Esophageal Sphincter (LES): This muscular valve tightens to prevent stomach contents from flowing back into the esophagus.
- Anatomy: The angle between the esophagus and stomach (known as the esophagogastric junction) helps keep stomach contents down.
- Diaphragm: The diaphragm muscle supporting the esophagus also helps prevent reflux.
- Esophageal peristalsis: Wave-like muscle contractions in the esophagus push food downwards.
- Anticholinergics vs. Cholinergic Agonists:
- Anticholinergics: These drugs block the action of acetylcholine, a neurotransmitter that stimulates muscle contractions. While they might seem helpful for tightening the LES, they can actually worsen GERD by slowing down stomach emptying and increasing pressure within the stomach.
- Cholinergic agonists: These drugs mimic the effects of acetylcholine, promoting muscle contraction. In the context of GERD, they might be considered to improve esophageal peristalsis, helping to clear stomach contents more efficiently. However, their use in GERD treatment is not common.
- Histamine (H2) Antagonists:
These medications work by blocking histamine receptors in the stomach, which
reduce stomach acid production. This helps to reduce the amount of acid refluxing into the esophagus and alleviate heartburn symptoms.
- Elevation of the Head of the Bed:
Sleeping with the head of the bed elevated by 6 inches allows gravity to assist in keeping stomach contents down and reducing the likelihood of reflux during sleep.
- Normal pH:
- Esophagus: The normal pH of the esophagus is around 3.5-5.5, which is acidic but less acidic than the stomach.
- Stomach: The normal pH of the stomach is highly acidic, ranging between 1.5-3.5. This acidity helps with digestion and destroys bacteria.