Esophagitis esp. GERD

00:01 Let’s move on to esophagitis.

00:03 In general, a nice little overview of the different things we’ll take a look at with esophagitis.

00:08 GERD - we’ll take a look at symptoms, diagnosis, treatment.

00:11 Pill induced - for example if it’s NSAIDs and such, and aspirin over a long period of time you decrease the lining of the esophagus.

00:18 Caustic ingestion - And by that we mean that the patient is now taking up some type of chemical.

00:23 Infectious to you should mean immunocompromised.

00:28 Viral - maybe Herpes, Cytomegalovirus, HIV.

00:33 Immunocompromised.

00:35 Maybe bacterial, fungal, definitely, definitely immunocompromised.

00:39 You’ve heard of candidiasis, you’ve heard of oral thrush.

00:44 If you have a Candida infection of esophagus, you’ll have the same type of cottage cheese appearance.

00:50 Let’s begin.

00:52 Reflux esophagitis is what we are, GERD is my topic.

00:57 Reflux disease.

00:59 Gastroesophageal Reflux Disease, we had talked about this and discussed as to how a patient as an adult may then have hiatal hernia, at the level of T10.

01:08 This reflux over a long period of time, with this acid coming back into the esophagus, may then bring about a metaplastic change.

01:17 Mean to say that the squamous cells of the esophagus may then turn into or undergo metaplasia into columnar cells.

01:27 If it continues from… this is then referred to as Barrett’s esophagus.

01:31 If this continues, and the patient is either non-compliant, and we’ll talk more about this later in steps of management.

01:38 For example, lifestyle modification is huge.

01:41 Don’t eat late at night.

01:42 When you go to sleep, angle yourself so that you do not… you prevent the reflux from taking place.

01:49 And try not to smoke, and so on and so forth.

01:53 But if the reflux continues to Barrett’s esophagus, which is not a cancer, but its metaplasia, is at risk for dysplasia and adenocarcinoma.

02:02 Common.

02:03 Associated with hiatal hernia as we talked about.

02:06 Or what if a patient has diabetes mellitus, and there’s something called gastroparesis and you don’t have proper emptying of your stomach? And then you might then result in reflux.

02:18 Transient relaxation of the lower esophageal sphincter, that’s my problem.

02:22 Excessive relaxation of the LES.

02:25 GERD has a more frequent transient relaxation and longer periods of that reflux.

02:31 See relaxation is a good thing.

02:33 It’s called your receptive relaxation.

02:36 Remember, there’s a test that you’ve seen in physio which is called manometry.

02:41 If you were to put a bolus into the mouth and get into esophagus, the pressure within esophagus rises.

02:50 As soon as you have a rise, physiologically, of pressure in the esophagus, this then triggers automatically relaxation of the lower esophageal sphincter because obviously peristalsis.

03:03 You want to get the food into the stomach.

03:06 However in GERD, there’s excessive relaxation.

03:09 Underlying cause remains unknown, potentially maybe perhaps one of you will end up finding it and go on to great praise.

03:20 The symptoms of GERD: If there’s reflux taking place, heartburn, “chest pain”, often times could be… well in your head as a differential you should be thinking about things such as myocardial infarction.

03:37 Dyspepsia, water-brash and dysphagia.

03:41 Dysphagia here reflux, difficult because of that chest pain.

03:45 And also, with all this acid reflux, there might be with enough reflux in the esophagus, may actually irritate the respiratory system.

03:53 And so therefore, your patient may complain of breathing issues, similar to that of asthma.

03:59 “Doc, for whatever reason, I feel like I’ve just developed asthma.

04:04 I’m having a hard time breathing at times." “Hmm." Along with this you go on to do a barium swallow and you end up finding issues with reflux.

04:16 Chronic cough.

04:18 Atypical symptoms.

04:20 The diagnostic evaluation of GERD: dysphagia; Testing not necessary for typical symptoms.

04:27 Weight loss, anemia, refractory symptoms, prolonged symptoms, atypical symptoms are extremely alarming.

04:35 So testing not necessarily for typical symptoms but recommended for “alarm” features.

04:41 The reason for this is because you’re worried about your patient going on to developing cancer of the esophagus.

04:48 What kind would this be most likely with GERD? You go from Barrett’s esophagus to metaplasia, into dysplasia and into your adenocarcinoma, most likely located in your lower esophagus.

05:05 May present as progressive dysphagia.

05:10 You start losing blood and such, you’re worried about iron deficiency.

05:13 The diagnostic evaluation’s important for you.

05:18 Quite a bit of a problem is GERD in the US, but because of proper diagnostic evaluation and screening methods, and hopefully the patient is compliant.

05:28 The incidence of adenocarcinoma in the US, thank goodness is dropping.

05:35 You’ll want to do a 24 to 48 hour pH monitoring; now we do this wirelessly.

05:41 Presence of esophageal damage, this you’re going to check out on endoscopic examination.

05:47 And the damage that you’re looking for here, we call Barrett’s tongue.

05:51 The Barrett’s tongues represents the metaplastic changes taking place of your squamous into columnar cells.

05:59 Symptoms correlation with reflux; for example, with something called the Bernstein test - the perfusion of esophagus with acid to induce the symptoms of GERD.

06:11 Such as, your coughing we talked about, the burning sensation in the chest, so on and so forth.

06:19 The complications of reflux: The barium swallow.

06:21 Well, what does damage that’s taking place with the esophagus due to the reflux, remember there’s strictures, means what to you? Increased repair process of the esophagus upon injury.

06:38 Of course reflux is injury.

06:40 So things that you’re looking for with the GERD as very common associated diagnoses include stricture formation.

06:51 And also I’d mention that hiatal hernia is also accompanying, accompanying issue with in fact reflux.