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Pathophysiology of Gastro Esophageal Reflux Disease Commonly known as GERD Vicki Orzel RN/BSN MSN Student Alverno College Spring 2006 Clip Art derived from Microsoft Office [email protected]

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vicki orzel rn bsn msn student alverno college spring 2006

Pathophysiology of Gastro Esophageal Reflux Disease Commonly known as GERD

Vicki Orzel RN/BSN

MSN Student

Alverno College

Spring 2006

Clip Art derived from

Microsoft Office

[email protected]

slide2
** Click on the arrow at the bottom

right to move forward **

** The arrow at the bottom left will

take you back only one slide **

** Click on the gold button

in the center, to take you

back to the sequence page, which

similar to a table of contents**

slide3

Taking a Closer

Look into

GERD.

Clip Art derived from

Microsoft Office

slide4

Sequence of learning tutorial,

Click on one of the shapes for shortcut.

STRESS RESPONSE

BASIC

ANATOMY

WHAT GERD

IS

PHARMOCOGENOMICS

GENETICS

CELL GROWTH

AND DEATH

INFLAMMATION

ACKNOWLEDGEMENTS

SUMMARY

slide5
“Population based survey revealed that 44 % of the population reported monthly heartburn and 19.8 % suffered from heartburn or acid regurgitation at least once a week”.

(Zuckschwerdt, W. 2001)

Clip Art derived from

Microsoft Office

slide6
“ GERD is more common in whites compared with other ethnic groups. However, the prevalence is increasing in Asians”.(Fennerty, 2003)

It is also more common in women, however men & people over the age of 60 develop more complications.

(Fennerty, 2003)

Clip Art derived from

Microsoft Office

basic anatomy
BASIC ANATOMY

“The upper GI or gastro-intestinal

tract consists of the:

Mouth

Pharynx

Esophagus

Stomach

The small & large intestines form

the lower GI tract”.

(Porth, 1998 )

slide8
The upper GI Tract is sometimes

referred to as the Alimentary canal.

(wikipedia)

Clip Art derived from

Microsoft Office

slide9
Once any food enters the mouth, it

moves into the pharynx, which

is the back of the throat.

(Porth,1998)

slide10
Food is passed from the

pharynx into the esophagus by a

mechanism called peristalsis. This

propelling motion is carried out

by the muscles and the central nervous system. (Porth, 1998)

peristalsis continues in the esophagus
The food is carried

from the esophagus

to the stomach

where acid

production is formed.

(Porth,1998)

Image with permission from MDA

Peristalsis continues in the esophagus.
slide12

“The esophagus is very muscular and collapses when empty. It is 10 inches or 25cm in length” (Porth, 1998)

slide13
The esophagus is sometimes referred to as the “food tube” or the gullet. It extends from the pharynx, which is the back of the throat and goes through the diaphram to the stomach.

Clip Art derived from

Microsoft Office

the esophagus is posterior to behind the trachea
The esophagus is posterior to (behind) the trachea

Image with permission from Bristol-Meyers Squibb

the esophagus produces bicarbonate and mucus kahrilas 2003
“The esophagus produces bicarbonate and mucus”.(Kahrilas, 2003)

“The bicarbonate buffers the acid

and mucus forming a protective

barrier”.(Kahrilas, 2003)

Clip Art derived from

Microsoft Office

slide16

This creates an environment in the esophagus of a higher pH than that of the stomach. The pH in the esophagus is normally about 7-8, whereas the pH in the stomach is generally 2-4. (Kahrilas, 2003)

ph stands for potential of hydrogen
pH stands for potential of hydrogen.

Hydrogen is what causes materials to become acidic. 7 is considered neutral; anything under 7 is considered acidic. (Porth, 1998)

slide18
There are specialized cells deep in the stomach lining that affect the rate of acid production. The primary cells which contribute to acid production are known as parietal cells. (Kahrilas, 2003)

Clip Art derived from

Microsoft Office

slide19

The binding of these 3 receptors in the parietal cells initiates the process of acid production. (Kahrilas, 2003)

the primary function of the activated pumps are to
“The primary function of the activated pumps are to :

Each gastric parietal cell contains about 1 million acid pumps.

Exchange hydrogen ions from the parietal cells to potassium using energy derived from splitting ATP.”

(Kahrilas, 2003)

Clip Art derived from

Microsoft Office

slide21
Ions exchange at different rates based

on the permeability of the parietal

cells. The rate influences the

intracellular pH, resulting in

an environment of acidity or alkalinity

of the cells of the stomach. (Kahrilas, 2003)

slide22
“The stomach produces an average of 2 liters of HCL a day, which in combination with the protein-splitting enzyme pepsin, breaks down chemicals in food”. (Kahrilas 2003)

Clip Art derived from

Microsoft Office

slide23
There is a rare disorder, called

Zollinger-Ellison syndrome:

With this, the body produces an

excessive amount of acid, this

can increase the risk of

GERD. (CNN.com)

the esophagus is divided into
Upper

It has a sphincter to prevent air from entering the esophagus during respirations. The sphincter generally only opens for food to pass.

Lower

It has a sphincter that opens while food is being passed into the stomach. It is known as the LES, lower esophageal sphincter.

The esophagus is divided into:

( Porth, 1998)

click on true or false
Click onTrue or False

The gullet is part of the

stomach.

slide26

Sorry, You are incorrect.

The gullet is another name for

the esophagus.

Clip Art derived from

Microsoft Office

slide27

Yes, you are correct !

The gullet is another name for

the esophagus.

Clip Art derived from

Microsoft Office

click on true or false28
Click onTrueor False

The esophagus is in front

of the trachea.

slide29

Sorry, you are incorrect.

The esophagus

is behind (posterior)

the trachea.

Image with permission from

Bristol-Meyers Squibb.

Clip Art derived from

Microsoft Office

slide30

Yes, you are correct !

The esophagus

is behind (posterior)

the trachea

Image with permission from

Bristol-Meyers Squib.

Clip Art derived from

Microsoft Office

click on true or false31
Click onTrue or False

The upper sphincter of the esophagus is in the upper GI & the lower sphincter is the lower GI.

slide32

Sorry, you are incorrect.

The entire esophagus is in the upper

GI. The upper GI tract consists of

the: mouth

pharynx

esophagus

stomach

The small & large intestines form the

lower GI tract.

Clip Art derived from

Microsoft Office

slide33

Yes, you are correct!

The entire esophagus is in the upper GI. The upper GI tract consists of the: mouth

pharynx

esophagus

stomach

The small & large intestines form the

lower GI tract.

Clip Art derived from

Microsoft Office

click on true or false34
Click onTrue or False

There are a million acid pumps in

each gastric parietal cell.

slide35

Sorry, you are incorrect.

There are 1 million acid pumps in

each gastric parietal cell.

Clip Art derived from

Microsoft Office

slide36

Yes, you are correct!

There are 1 million acid pumps in

each gastric parietal cell.

Clip Art derived from

Microsoft Office

what gerd is
What GERD is

It is quite a complex process, my goal is to simplify it for you. First, let’s break it down to the words it is made up of: gastro = stomach

esophogeal = food tube

reflux = back flow

disease = abnormal condition

of physiologic functioning.

slide38
The Lower

Esophageal

Sphincter is

The primary

focus relating

to GERD.

Image with permission from Dr. Scott Tenner

slide39
If the Lower Esophageal Sphincter (LES) is not working properly creating a dysfunction – the acid from the stomach can backflow into the esophagus. (Porth, 1998)
slide40
Images with

permission from

Life Enhancement

in addition to a dysfunction of the lower esophageal sphincter les another factor is
In addition to a dysfunction of the lower esophageal sphincter (LES) Another factor is:

Percentage of time the esophagus is exposed to a low pH. Clearance of the acid depends on peristalsis & exposure to the saliva. (Porth, 1998)

slide42
Image with permission from

Healthy Living

This uncomfortable feeling can sometimes be confused with other conditions, even a heart attack.

People with this dysfunction, often experience an uncomfortable feeling in the chest, neck, and throat area due to acid exposure.

slide43
Sometimes, just drinking water may

help relieve the symptoms, by

washing the irritating acids back

into the stomach. (Porth, 1998)

slide44

This discomfort can be precipitated by lifestyle, diet, and even certain medications. (Kaynard,, Flora, 2001)

lifestyle
Lifestyle
  • “Smoking – Inhibits saliva, may also increase acid production & weaken the LES”.
  • Certain exercising & bending – that may increase the abdominal pressure.
  • “Wearing of tight clothing – increases the abdominal pressure”.
  • Lying flat after a meal – relaxes the muscles making susceptibility for reflux.

(Kaynard, A., Flora, A., 2001)

Clip Art derived from

Microsoft Office

slide46
Diet
  • “Fatty, greasy foods - take longer to digest keeping food in the stomach longer”.
  • “Peppermint, spearmint, and chocolate weaken the LES”.
  • “Carbonated and alcoholic beverages increase the acidity in the stomach”.
  • Large meal portions – produce large acid levels.
  • Citrus, onions, and acid from tomatoes can be irritating to the esophagus. (Howard, B., 2004)

Clip Art derived from

Microsoft Office

medications that relax the les
Benzodiazepines

Theophylline

Narcotics containing codeine.

Calium channel Blockers

Nitroglycerine

Anticholinergics

Potassium supplements

Iron supplements

NSAIDS

Fosamax

Erythromycin

(CNN)

“Medications that relax the LES”

Clip Art derived from

Microsoft Office

the 3 mechanisms during swallowing that keep acid out of the esophagus include
The 3 mechanisms during swallowing that keep acid out of the esophagus include:
  • “Swallowed saliva which helps neutralize stomach acid”.
  • “Sweeping muscles contractions that act to cleanse the lower esophagus of stomach acid”.
  • Protective contracture of the LES

(Jackson Gastroenterology - 2005)

the 3 mechanisms of the lower esophageal sphincter les which prevent backflow are
The 3 mechanisms of the lower esophageal sphincter (LES) which prevent backflow are:
  • Pressure in the LES is greater than that of the stomach.
  • High levels of Acetylcholine, a neurotransmitter increases constriction of the LES.
  • Gastrin, a hormone also increases constriction of the LES.

(Porth 1998 )

some conditions that can interfere with the 3 mechanisms of the lower esophageal sphincter les
Some conditions that can interfere with the 3 mechanisms of the Lower Esophageal Sphincter (LES):
  • OBESITY - “excess weight puts extra pressure on the stomach & diaphragm”. (CNN.com)
  • Pregnancy – “results in greater pressure on the stomach & also has a higher level of progesterone. This hormone relaxes many muscles, including the LES”. (CNN.com)
  • ASTHMA – it is unsure why, but, is believed that the coughing leads to pressure changes on the diaphragm. (CNN.com)
  • HIATAL HERNIA – which is the following topic.
slide51

In addition to the 3 swallowing mechanisms & the 3 mechanisms of the LES – anatomical structures certainly play a role in the development of GERD.

a hiatal hernia is an anatomical abnormality
A hiatal hernia is an anatomical abnormality

“In individuals with hiatal hernia, the opening of the esophageal hiatus is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest.”(Kahrilas, 2003)

slide53
“The diaphragm supports and puts pressure on the sphincter to keep it closed when you’re swallowing”.

“But a hiatal hernia raises the sphincter above the diaphragm, reducing pressure on the valve. This causes the sphincter muscle to open at the wrong time”. (MayoClinic.com)

Clip Art derived from

Microsoft Office

do you think genetics is a factor
Do you think Genetics is a factor?

There is evidence that genetics is a factor in pediatric patients. This is reported in the Journal of the American Medical Association from the July issue in 2000. (Spice, B., 2000)

Clip Art derived from

Microsoft Office

slide55
“The specific gene has not been

identified as of yet, however research

has narrowed it to a portion of

chromosome 13”

(Hu, Fen Ze MS; et al 2000)

Clip Art derived from

Microsoft Office

slide56
As far as adults, studies have been

performed on identical twins who

share the same genes & it has been

identified that there is a 43%

chance of genetic influence.

( MedicineNet.com)

Clip Art derived from

Microsoft Office

click on true or false57
Click on True or False

GERD can sometimes cause a discomfort in the chest, confusing it

with a heart attack.

image with permission from healthy living
People with GERD can experience an uncomfortable feeling in the neck, chest, & throat area. This can be confused with other diseases, even a heart attack. Image with permission from Healthy Living

Sorry, you are incorrect.

Clip Art derived from

Microsoft Office

image with permission from healthy living59
Image with permission from Healthy Living

Yes, You are correct!

People with GERD can experience an uncomfortable feeling in the neck, chest, & throat area. This can be confused with other diseases, even a heart attack.

Clip Art derived from

Microsoft Office

click on true or false60
Click on True or False

Taking codeine for the pain, will help

relieve the discomfort

experienced with GERD.

slide61

Sorry, you are incorrect

Narcotics such as codeine relax the

LES, making it more likely for acid

to reflux back into

the esophagus.

Clip Art derived from

Microsoft Office

slide62

Yes, You are correct!

Narcotics such as codeine relax the

LES, making it more likely for acid

to reflux back into

the esophagus.

Clip Art derived from

Microsoft Office

click on true or false63
Click on True or False

The diaphragm helps to open

the esophagus.

slide64

Sorry, you are incorrect.

The diaphragm supports and puts

pressure on the sphincter to keep

it closed while swallowing.

Clip Art derived from

Microsoft Office

slide65

Yes, You are correct!

The diaphragm supports and puts

pressure on the sphincter to keep

it closed while swallowing.

Clip Art derived from

Microsoft Office

click on true or false66
Click on True or False

Saliva produces more acid,

creating a potential

for increased reflux.

slide67

Sorry, you are incorrect

Swallowed saliva helps neutralize

acid. It is one of the 3 mechanisms

that keeps acid out of the esophagus.

Clip Art derived from

Microsoft Office

slide68

Yes, You are correct!

Swallowed saliva helps neutralize

acid. It is one of the 3 mechanisms

that keeps acid out of the esophagus.

Clip Art derived from

Microsoft Office

inflammation and its impact
Inflammation and its impact

Often the suffix of “itis” leads the reader

to know there is inflammation.

Therefore, inflammation caused by

GERD is called, “esophagitis”.

Clip Art derived from

Microsoft Office

slide70
Inflammation is the body’s response, as

a protective measure against

infection and injury.

Repeated exposure to acid in the

esophagus will cause inflammation

and injury to the mucosa.

slide71
“Inflammation as a result of GERD can cause epithelial changes, marked by polymorphonuclear or mixed polymorphonuclear and round cell infiltration”.(Fennerty, 2003)

Clip Art derived from

Microsoft Office

there are 3 inflammatory processes that can occur with esophagitis
There are 3 inflammatory processes that can occur with esophagitis:
  • Erosive Esophagitis
  • Esophageal Strictures
  • Barrett’s Esophagus – (Fennerty, 2003)
erosive esophagitis
Erosive Esophagitis

“Erosions appear in esophageal

mucosa as eroded endothelium”.

(Fennerty, 2003)

contributing factors of erosive esophagitis
Hiatal Hernia

Decreased pressure in the lower esophageal sphincter (LES)

Impaired ability of the tissue to resist injury

Impaired esophageal clearance

Increased volume of acid

(Fennerty, 2003)

Contributing factors of Erosive Esophagitis:
slide75
People with erosive esophagitis

may have mild to severe

symptoms of pain. (Fennerty, 2003)

Clip Art derived from

Microsoft Office

strictures
Strictures

A stricture is a narrowing If

esophagitis is left untreated, scarring

can occur resulting in a

stricture that is irreversible .(Fennerty, 2003)

contributing factors of esophageal strictures
Contributing Factors of Esophageal Strictures
  • Decreased pressure in the lower esophageal sphincter (LES)
  • Hiatal Hernia
  • Ineffective peristalsis

(Fennerty, 2003)

slide78
People with strictures often feel like there is something stuck in their throat. Severe strictures result in difficulty swallowing (dysphagia).

(Fennerty,2003)

Clip Art derived from

Microsoft Office

slide79
Those with severe strictures usually have less symptoms of heartburn, acid is not able to reflux due to the narrowing of the esophagus.(Fennerty, 2003)
slide80
Those with strictures may also have weight loss, due to a change in their diet to accommodate the strictures.

(Fennerty, 2003)

stress response
Stress Response

Stress is a complex physiological

response to changes in

the environment.

slide82
Prolonged stress has the

ability to decrease the immune system, making the body susceptible

to inflammation and infection. (Porth, 1998)

slide83
In an effort to cope with the

disruption in routine, caused by

stress, unhealthy lifestyles

become evident.

Clip Art derived from

Microsoft Office

pharmocogenomics
There are 3 categories of medications that can help alleviate or prevent symptoms from occurring.

(Kaynard, Flora, 2001)

Antacids

H-2 receptor blockers

Proton pump inhibitors

Pharmocogenomics

Clip Art derived from

Microsoft Office

antacids
Maalox

Mylanta

Tums

Rolaids

These medications help to neutralize stomach acid. They usually provide quick relief, however, will not heal any inflammation.

(CNN.Com)

Antacids
h 2 receptor blockers
Tagamet

Zantac

Pepcid AC

“These medications reduce the acid production. They do not act as quickly as antacids, but provide longer relief”. (CNN.Com) They start working in about 30 minutes.

H-2 Receptor Blockers
proton pump inhibitors
Prevacid

Prilosec

Aciphex

Protonix

Nexium

These medications are long acting and block acid production. “Because of this, they have the ability to allow time for damaged tissue to heal from inflammation”.

(CNN.Com)

Proton Pump Inhibitors
cell growth and death
Cell Growth and Death

As mentioned earlier, as a result of

inflammation:

cellular changes can occur.

slide89
These cellular changes can be

a precursor to cancer. (Fennerty, 2003)

Clip Art derived from

Microsoft Office

slide90
Some articles may refer to these changes as “metaplasia”. This is the actual transformation of cells or tissue from normal to abnormal; whereas, “dysplasia” is the growth of abnormal

cells or tissue. (Porth, 1998)

barrett s esophagus is the outcome of these cellular changes
Barrett’s Esophagus is the outcome of these cellular changes.

Cells in the lining of the esophagus are actually replaced with abnormal cells similar to those in the stomach.

(Fennerty, 2003)

slide92
This would be, “metaplasia”. As

the cells replicate to multiply,

dysplasia is occurring. (Porth, 1998)

slide93
The exact mechanism is not known.

However, these cellular changes

are believed to be a protective

response to adapt to the repeated

inflammation of exposure to

stomach acid. (MedicineNet.com)

.

slide94
Ulcers, although not a common symptom, can be found with Barrett’s Esophagus. The ulcers can lead to Gastrointestinal bleeding. (Fennerty, 2003)
click on true or false95
Click on True or False

Some people with strictures have

decreased symptoms of reflux.

slide96

Sorry, you are incorrect.

A stricture is a narrowing, as a

result, the acid is sometimes

unable to reflux.

slide97

Yes, You are correct!

A stricture is a narrowing, as a

result, the acid is sometimes

unable to reflux.

click on true or false98
Click onTrue or False

If esophagitis is left untreated,

scarring can occur resulting in a

stricture, which eventually

heals itself.

slide99

Sorry, you are incorrect.

Once scarring is present, the

stricture is irreversible.

slide100

Yes, You are correct!

Once scarring is present, the

stricture is irreversible.

click on true or false101
Click on True or False

GI bleeding is one of the symptoms

of Barrett’s Esophagus.

slide102

Sorry, you are incorrect.

GI bleeding can be a symptom

of an ulcer, which can be

present in someone with Barrett’s

Esophagus, although not common.

slide103

Yes, You are correct!

Gi bleeding can be a symptom

of an ulcer, which can be

present in someone with Barrett’s

Esophagus, although not common.

click on true or false104
Click on True or False

Maalox or mylanta will help

prevent episodes of

acid reflux.

slide105

Sorry, you are incorrect.

Maalox and mylanta are anatacids,

which provide quick relief, but will

not prevent acid reflux.

slide106

Yes, You are correct!

Maalox and mylanta are antacids,

which provide quick relief, but will

not prevent acid reflux.

click on true or false107
Click on True or False

Proton Pump Inhibitors allow time

for damaged tissue to heal by

blocking acid production.

slide108

Sorry, you are incorrect.

Proton Pump Inhibitors allow time

for damaged tissue to heal by

blocking acid production.

slide109

Yes, You are correct!

Proton Pump Inhibitors allow time

for damaged tissue to heal by

blocking acid production.

click on the flowers below for a summarized outline
Click on the flowers below for a summarized outline

Clip Art derived from

Microsoft Office

slide111

Acknowledgements

Cnn.com (nd) Retrieved March of 2006.

Fennerty, B. The Continuum of GERD Complications. Cleveland Clinic Journal of Medicine. Nov. 2003. Vol. 70, Suppl. 5, p. 33-48. Retrieved March, 2006 from http://www.ccjm.org/PDFILES/GERD/Fennerty.pH

HeartburnAlliance Retrieved March 2006 from http://www.HeartburnAlliance.com.

Howard, B. Gut Reactions. Newsweek June 2004, Vol.143, Iss. 24.

Clip Art derived from

Microsoft Office

slide112
Hu, F. , Prestson, R., Post,J. et al. Mapping of a Gene for Severe Pediatric Gastroesophogeal Reflux to Chromosone 13q14. Journal of American Medical Association. Vol 284 (3), July 2000, p. 325-334. Retrieved Feb. 2006 from Ovid database.

Jackson Gastroenterology (2005) Retrived Feb. 2006, from http://www.gicare.com/pated/ecdgs.39.htm

Kahrilas, P. GERD: Pathogenesis, Pathophysiology, and Clinical Manifestations. Cleveland Clinic Journal of Medicine. Nov. 2003. Vol. 70, Suppl 5, p. 4-18. Retrieved Feb. 2006, from http://www.ccjm/org/PDFILES/GERD/Kahrilas.pdf.

Kaynard, A., Flora, K. Gastroesophageal Reflux Disease: Control of Symptoms, Prevention of Complications. Post Graduate Medicine. Sept. 2001. Vol. 110, Iss. 3.

MayoClinic (n.d.) Retrieved Feb. 2006, from MayoClinic.com.

slide113
MedicineNet (n.d.). Retrieved Feb. 2006, from http://www.medicinenet.com

Porth, C. M.(1998). Pathophysiology: Concetps of Altered Health States (5th ed.). Philadelphis, PA. Lippincott.

Spice, B. July, 2000, Retrieved March, 2006 from Post-Gazette PG NEWS Retrieved March, 2006, from http://www.post-gazette.com/healthsciende/20000729gerdstudy.1.asp

Wilkopedia (n.d.) Retrieved March, 2006, from http://en.wikipedia.org/wiki/Alimentary_tract.

Zuckschwerdt, W. Definition, Epidemiology, and Pathogenesis of GERD. (2001) Surgical Treatment: Evidence Based Problem Oriented. Retrieved March, 2006, from http://www.ncbi.nih.gov/books/bv.fegi?rid=surg.section310.

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