Question

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.
1. 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?

3. Why are anticholinergic agents avoided and cholinergic agonists recommended in the treatment of gastroesophageal reflux?

4. Why are histamine (H2) antagonists recommended?

5. Why is elevation of the head of the bed recommended?

6. Predict values for the gastroesohageal patient in this case for lower esophageal and stomach pH?

Answer 1

Answer:

1) Hiatal hernia is the disorder of this 26 year old business executive. Hiatal hernia occurs when upper part of stomach pushes through an opening in the diaphragm, and up into the chest. THis opening is called a esophageal hiatus or diaphragmatic hiatus. It is basically a protrusion of the upper part of stomach into the chest through a tear on the chest through a tear or weakness in the diaphragm. The patient presents with :

• Chest pain
• Severe hurtburn
• Abdominal pain
• Frequent burping
• Difficulty in swallowing
• Throat soreness

• Belching
• Nausea

2) Adequate lower esophageal pressure at the lower esophageal sphincter normally prevent gastric reflux into the esophagus when lying down or bending over.

3) As M3 receptors (parasympathetic) are distributed at the lower esophageal sphincter, cholinergic agonist activates these receptors and increases contraction thus rsulting in a decrease in contraction and preventing Gastroesophageal reflux. Similarly the anticholinergic are avoided because they will relax the LES and thus GERD will increase.

4) H2 antagonists are recommended because they decrease the acid secretion especially at night by blocking H2 receptors.

5) Elevation of the head of the bed recommended in order to encourage the gravitational flows of the contents in stomach toward the pyloric end.

6) Normal Stomach pH = 3-5

   Normal esophageal pH = 6-7

   pH at Lower esophagus  in gastroesophageal patient = 3-5

   pH of stomach in patient of GERD = 3-5 (same as that in normal)

Answer 2

( 1 ) The 26years old business executive is suffering from a disorder known as HIATAL HERNIA which is a structural defect in which a weakened diaphram allows a portion of the stomach to pass through the esophageal opening into the chest thus causing an increase in pressure.

( 2 ) The mechanisms that normally prevent gastric reflux into the esophagus when lying down or bending over is adequate lower esophageal pressure at the lower esophageal sphincter.

( 3 ) The parasympathetic stimulation (PS) of the autonomic nervous system innervates the lower esophageal sphincter,so cholinergic agonists will then increase lower esophageal sphincter (LES) contractions preventing gastric reflux. Anticholinergic agents will decrease lower esophageal sphincter pressure.

( 4 ) histamine (H2) antagonists are recommended because they reduce gastric acidity by selectively blocking H2 receptors (which are mediators for gastric secretion).

( 5 ) Elevation of the head of the bead is recommended because it encourages gravitational flow of the gastric contents towards the pyloric end of the stomach.

( 6 ) The normal PH of the esophagus is 6-7,and the normal PH of the stomach is 3-5.

For this patient,the lower esophageal PH will be 3-5 while the stomach PH will not change.