Question

1.  Explain to Mrs. Rinaldi the meaning of her diagnoses reflux esophagitis and esophageal stricture. Pretend that Mrs. Rinaldi knows very little about her body so your explanation should be very clear.

2.  From the brief history provided, explain the factors and behaviors that increase her risk of gastroesophageal reflux disease (GERD).

3. What recommendations will you make to help her change these behaviors?  Relate your advice to each of the factors listed in the history.

4. What medications might the physician prescribe, and why?

5. If untreated what are some of the complications of GERD?

6. What would be your advice to Mrs. Rinaldi as an alternative medicine student?

Answer 1

1) Reflux esophagitis :- Is an esophageal mucosal injury that occurs secondary to retrograde flux of gastric contents into the esophagus. Clinically, this is referred to as gastroesophageal reflux
disease(GERD). Typically, the reflux disease involves the distal 8-10 cm of the esophagus and the gastroesophageal junction.

Pathophysiology of Reflux esophagitis :- Abnormal amount and frequent reflux of gastric content into the esophagus lead to mucosal injury. Several mechanisms take place in the pathophysiology of
reflux.
Reflux esophagitis is usually due to a condition known as gastroesophageal reflux disease (GERD). GERD occurs when stomach contents like acids, frequently back up into the esophagus. This causes chronic inflammation and irritation of the esophagus.
SYMPTOMS :- Heartburn, the most common symptom of reflux esophagitis, is usually described as a substernal burning pain or discomfort.
Treatment for Esophagitis :-
Medications that block acid production such as heart burn drugs.
Antibiotics, anti-fungals, or antivirals to treat an infection.
Pain medications that can be gargled or swallowed.
Corticosteroid medication to reduce inflammation.
An esophageal stricture refers to the abnormal narrowing of the esophageal lumen; it often presents as dysphagia commonly described by patients as difficulty swallowing. It is a serious sequela to many different disease processes and underlying etiologies. Its recognition and management should be prompt.
Symptoms of an esophageal stricture :- Pain while swallowing (odynophagia),Inability to swallow.Sensation of food sticking in the throat or chest,drooling,regurgitation (bringing food back up),frequent heartburn,food or stomach acid backs up into the throat,unexpected weight loss.
Causes:-
The most common cause of an esophageal stricture is long-standing gastroesophageal reflux disease (GERD), where stomach acid backs up from the stomach into the esophagus and causes esophageal inflammation, which can lead to scarring and narrowing over time.

Disease processes that can produce esophageal strictures can be grouped into three general categories: (1) intrinsic diseases that narrow the esophageal lumen through inflammation, fibrosis, or neoplasia; (2) extrinsic diseases that compromise the esophageal lumen by direct invasion or lymph node enlargement; and (3) diseases that disrupt esophageal peristalsis and/or lower esophageal sphincter (LES) function by their effects on esophageal smooth muscle and its innervation.Many diseases can cause esophageal stricture formation. These include acid peptic, autoimmune, infectious, caustic, congenital, iatrogenic, medication-induced, radiation-induced, malignant, and idiopathic disease processes.

The main symptom of an esophageal stricture is dysphagia, meaning difficulty in swallowing. This may manifest as a sensation of food sticking or feeling of delay in food passage in the throat, chest or upper abdomen.

Esophageal stricture can be caused by :-
Gastroesophageal reflux (GERD),eosinophilic esophagitis,injuries caused by an endoscope,Long-term use of a nasogastric (NG) tube (tube through the nose into the stomach).Swallowing substances that harm the lining of the esophagus.Treatment of esophageal varices.

If a stricture is present, the barium may become stuck or slows down. Endoscopy - if the doctor suspects that a structural abnormality is present. A narrow tube called an endoscope is inserted into the esophagus. The endoscope has a light and tiny camera at one end so the doctor can observe the inside of the esophagus.
Treatment :-
Dilation(stretching) of the esophagus using a thin cylinder or balloon that is inserted through an endoscope is the main treatment for acid reflux related strictures.You may need to have this treatment repeated after a period of time to prevent the stricture from narrowing again.

2) Recently, the number of patients diagnosed with gastroesophageal reflux disease (GERD) has increased in Korea. Risk factors of GERD include age, sex, medication use, lack of physical exercise, increased psychological stress, low or high body mass index (BMI), unhealthy eating habits, increased alcohol consumption, and cigarette smoking. However, few studies examined the major factors affecting GERD in women of childbearing age. Therefore, this study assessed the risk factors of GERD among 20,613 female nurses of reproductive age using data from the Korea Nurses’ Health Study.

Methods
Participants were recruited from July 2013 to November 2014. They provided their history of GERD 1 year prior to data collection, along with information on their demographic characteristics, health-related behaviors, diet, medical history, and physical and psychological factors. Of the total sample, 1184 individuals with GERD diagnosed in the year prior to the study were identified. Propensity score matching was used for analysis.

Results
Cigarette smoking, increased alcohol consumption, low or high BMI, depression, and increased psychosocial stress were associated with the prevalence of GERD among Korean young women. Multivariate ordinal logistic regression analysis revealed significant positive relationships between GERD and being a former smoker; having a low (< 18.5 kg/m2) or high BMI (> 23 kg/m2); and having mild, moderate, moderately severe, and severe depression.

Conclusions
Smoking, BMI, and depression were associated with GERD. To reduce this risk among female nurses, intervention strategies are required to help nurses maintain a normal weight and manage their depression.

3) By taking over the counter medications such as antacids, H2-receptor antagonists or PPIs, also known as proton pump inhibitors. If these medications do not offer relief for your symptoms, surgery is the another option.Esophagitis caused by GERD may be prevented by changes in lifestyle and diet.Proper oral hygiene can aid in prevention of esophagitis caused by the Candida yeast.Take all pills with plenty of water, and in an upright position.Avoid foods that may increase reflux.Use good pill-taking habits,lose weight.If you smoke, quit.Avoid certain medications.Avoid stooping or bending, especially soon after eating.Avoid lying down after eating.Raise the head of your bed.

Esophageal Stricture can changed by include the use of dilators, stent placement, surgical resection, and medical management.The technique most utilized for benign stricture management is endoscopic dilation using a bougie or a balloon dilator.The main objective is to improve symptoms, mainly in relieving patients of dysphagia.Taking medications to reduce stomach acid, which can help prevent the stricture from recurring.Dilating, or stretching, the esophagus.Using a small tube called a stent to reopen the esophagus.

4) These include antacids (Maalox, Mylanta, others); medications that reduce acid production, called H-2-receptor blockers, such as cimetidine (Tagamet HB); and medications that block acid production and heal the esophagus, called proton pump inhibitors, such as lansoprazole (Prevacid) and omeprazole (Prilosec).
Antisecretory medications are generally used for the treatment of acid-peptic stricture of the esophagus. PPIs are the most efficacious drugs, and this class is usually used routinely. Long-term PPI therapy (almost indefinitely) is extremely important in patients with esophageal stricture.

5) If untreated, GERD (or acid reflux) can lead to complications, including:

Adult onset asthma
Esophagitis (Inflammation, irritation, or swelling of the esophagus)
Stricture (Narrowing of the esophagus)
Barrett’s Esophagus (Pre-cancerous changes to the esophagus)
Regurgitation of acid into the lungs
Sinusitis
Ulcerations/bleeding

6) Advice:
Maintain a healthy weight.
Stop smoking.
Elevate the head of your bed.
Don't lie down after a meal.
Eat food slowly and chew thoroughly.
Avoid foods and drinks that trigger reflux.
Avoid tight-fitting clothing.