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Diseases of the Esophagus (GASTROESOPHAGEAL REFLUX DISEASE (GERD) (DDx:…

- - - - (1) transient LES relaxations (a vagovagal reflex: gastric distention-->LES relaxation): 90% of refluxes in normal or GERD w/o hiatus hernia
      - (2) LES hypotension
      - (3) anatomic distortion of EG junction inclusive of hiatus hernia (significant unto itself + also bc it interacts w/ first two mechanisms)
    - - impaired peristalsis (attributable to: disrupted peristalsis or superimposed reflux a. w/ a hiatal hernia (superimposed reflux: fluid retained within a sliding hiatal hernia refluxes back into esophagus during swallow-related LES relaxation, an abnormal phenomenon))
      - reduced salivation (decr titration of residual acid w/ HCO3 from saliva)
    - - Bile : important bc it persists in refluxate despite acid-suppressing medications + can transverse cell membrane--> severe cellular injury in a weakly acidic environment; also a cofactor in pathogenesis of Barrett’s metaplasia and adenocarcinoma. Hence, the causticity of gastric refluxate extends beyond hydrochloric acid
  - - - incidence of these lesions has incr, not decreased
      - endoscopically recognized by tongues of reddish mucosa extending proximally from GE junction or histopathologically by finding of specialized columnar metaplasia
      - a. w/ incr risk of esophageal adenocarcinoma
        
        Barrett’s metaplasia--> low- and high-grade dysplasia--> adenocarcinoma; high prevalence of unrecognized coexisting cancer w/ high-grade dysplasia; Esophagectomy, intensive endoscopic surveillance, and mucosal ablation all advocated. Currently, esophagectomy is gold standard treatment for high-grade dysplasia
        
        areas of Barrett’s and esp any included areas of mucosal irregularity: extensively biopsied
        
        group at greatest risk: obese white males in their 60s
        
        no high-level evidence: aggressive antisecretory therapy or antireflux surgery causes regression of Barrett’s or prevents adenocarcinoma
  - - - (1) avoidance of foods that reduce LES pressure, making them “refluxogenic” (fatty foods, alcohol, spearmint, peppermint, tomato-based foods, and possibly coffee and tea)
      - (2) avoidance of acidic foods that are inherently irritating
      - (3) adoption of behaviors to minimize reflux and/or heartburn
        
        most broadly applicable recommendation: weight reduction. (strong epidemiologic relationship between BMI and GERD beyond dispute)
        
        sleep disturbance from nighttime heartburn: elevation of head of bed and avoidance of eating before retiring