A 26-year-old business executive complained of a dull pain (heartburn) behind th

Question

A 26-year-old business executive complained of a dull pain (heartburn) behind the sternum. The pain was postprandial 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 pectoralis. X-rays revealed a small portion of the stomach above the diaphragm, and an endoscopic biopsy revealed mucosal inflammation. Esophageal manometry 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 (e.g., fats, chocolates), and smoking, all of which reduce LES competence. Elevation of the head of the bed by about 6 inches is also recommended. Suggested treatments also include use of cholinergic agonists (e.g., bethanechol) to increase LES pressure and use of histamine (H2) antagonists (e.g., cimetidine) to reduce gastric activity. 1. Define postprandial. 2. Define manometry. 3. What mechanisms normally prevent gastric reflux into the esophagous when lying down or bending over? 4. Why are anticholinergic agents avoided and cholinergic agonists recommended in the treatment of gastroesophageal reflux? 5. Why is elevation of the head of the bed recommended? To help stimulate gravity pull toward 6. What is the normal pH of the esophagus? Of the stomach? Predict values for the gastroesophageal patient in this case for lower esophageal and stomach pH. 7. Does this person have a hiatal hernia? Explain.

Explanation / Answer

1. Postprandial: Postprandial defined as after the meal.

2. Manometry: This defined as the measurement of pressure of the various part of the Gastro-Intestinal Tract.

3. There is three normal mechanism which prevents gastro-esophageal reflux:

a) Lower esophageal sphincter: This is a muscle ridge at the lower end of the esophagus and controlled by neural input, which prevents the reflux.

b) The pinchcock like action of the diaphragm, where esophagus crosses the diaphragm to enter the abdominal cavity.

c) The gastroesophageal flap valve: this is formed by the oblique angle at which the esophagus enters into and integrates with the stomach.

4. In CNS and PNS, acetylcholine is the main neurotransmitter which causes lower esophageal sphincter to contract and thereby increases the lower esophageal tome and prevent gastroesophageal reflux. Anticholinergic agents blocks the action of acetyl choline--> so anticholinergic agents will lower the tone of the lower esophageal sphincter and thereby will be unable to prevent the gastroesophageal reflux.

5. The likely mechanism behind head elevation is the gravitational force. As the head is elevated gravitation force is exerted on the food particle that is in the esophagus. Due to gravitational force the food particles, promptly moves from esophagus to stomach and also acid mixed food from the stomach cannot go back to the esophagus.

6. Normal esophageal pH is near to 7.0 ( reference range is 4.0 to 7.0 )

Normal Gastric pH is 1.3 to 3.5

In this patient the lower esophageal pH will be bellow 4 as a esophageal pH bellow 4 indicates gastroesophageal reflux disease . The gastric pH will remain wiht their normal range between 1.5 to 3.5

7. Yes the person has hiatal hernia. Hiatus is an opening in the diaphragm through whch esophagus enters the abdominal cavity and joins with the stomach. But when part of stomach pops above into the mediastinal cavity through this opening of the diaphragm, it is known as the hiatal hernia. In this question, The X-ray report is showing that some part of the stomach is above the diaphragm, whic concludes the diagnosis of hiatal hernia.

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