Gastroesophageal reflux disease (GERD)

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Gastroesophageal reflux disease (GERD)

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Questions

USMLE® Step 1 style questions USMLE

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A 69-year-old man presents to the primary care physician with dysphagia. The patient reports progressive difficulty swallowing, now to the point where he has trouble tolerating liquids and sometimes vomits after eating. The patient has a significant history of alcohol abuse, 50-pack-year smoking history, as well as hypertension and hyperlipidemia. Temperature is 37°C (98.6°F), pulse is 68/min, respirations are 14/min and blood pressure is 130/82 mmHg. Physical exam shows a thin male with bitemporal wasting and non-tender anterior cervical lymphadenopathy. Oral and neck examination is unremarkable aside from poor dentition. Laboratory results are as follows:  
 
Laboratory value  Result 
CBC, Serum 
 Hemoglobin  11.2  g/dL 
 Hematocrit  33.6% 
 Leukocyte count  10,100 /mm3 
 Platelet count  149,000/mm3 
 MCV                        72 fL 
 RDW                    11.5-14.5% 
 Iron Studies, Serum  
          Serum Iron                     90 μg/dL  
             Ferritin            Ferritin 170 ng/mL  
 Total iron binding capacity                               220 μg/dL 
A barium swallow study reveals an esophageal mass that significantly narrows the lumen in the middle of the esophagus. Which of the following pathologic features is most likely to be found on upper endoscopy?  

External References

First Aid

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Acid reflux

esophageal pathology and p. 384

H2 blockers for p. 405

proton pump inhibitors for p. 406

Asthma p. 692

gastroesophageal reflux disease p. 384

Cough p. 148, 567

gastroesophageal reflux disease p. 384

Gastroesophageal reflux disease (GERD)

esophageal cancer and p. 385

presentation p. 384

Hoarseness

gastroesophageal reflux disease p. 384

Transcript

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Gastro- refers to the stomach, esophageal stands for esophagus, and reflux means “to flow back”.

So gastroesophageal reflux disease, or GERD, is when stomach acid flows back into the esophagus.

The presence of acid in the esophagus can lead to Barrett’s esophagus, a serious complication of GERD where the normal mucosa of the esophagus is replaced by one that’s similar to that of the intestines.

Barrett’s esophagus poses a higher risk of developing esophageal adenocarcinoma.

Normally, the wall of the entire gastrointestinal tract is made of 4 layers: the inner mucosa, the submucosa, a muscular layer, and an outer layer called the adventitia.

The mucosa is further divided into three layers - an innermost epithelial layer, a middle layer called the lamina propria, and an outermost layer, in contact with the submucosa, called the muscularis mucosae, which is made up of smooth muscle that contracts and helps with the breakdown of food.

Now, the stomach mucosa is different from the esophageal mucosa.

Inside the stomach, the epithelial layer is made up of cylindrical cells, which dive into the lamina propria, forming pits.

These pits are the gastric glands, and there are many of them scattered throughout the stomach.

Distributed among the cylindrical gland cells, there’s different types of secretory cells.

First, there’s G cells, which are a type of neuroendocrine cells that secrete a hormone called gastrin in response to food entering the stomach.

Gastrin stimulates another type of cells, the parietal cells, to release hydrochloric acid.

And then, there’s chief cells, which secrete an enzyme called pepsinogen.

Hydrochloric acid and pepsinogen are useful for digestion, but they can be quite aggressive for the delicate mucosa.

Luckily though, the stomach also has some defense mechanism in place.

First, the gastric glands also have foveolar cells, also called surface mucus cells, because they are closer to the surface of the stomach, and they secrete mucus.

Mucus is mostly made up of water and glycoproteins, and also bicarbonate ions which are also secreted by foveolar cells.

This bicarbonate-rich mucus protects the gastric mucosa from our own gastric acid, so it won’t get digested along with food.

Lastly the gastric mucosa is highly vascularized, which helps deliver oxygen and bicarbonate and carry away acid that makes it through into the lamina propria.

The esophagus, on the other hand, is better adapted for the passage of food. So its mucosa is made up of stratified squamous epithelium, which is better equipped to resist abrasion from food going down.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Objective Documentation of the Link between Gastroesophageal Reflux Disease and Obesity" American Journal of Gastroenterology (2007)
  6. "Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease" American Journal of Gastroenterology (2013)
  7. "Overprescribing proton pump inhibitors" BMJ (2008)
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