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what's up Ninja nerds in this video
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today we're going to be talking about
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gastrosoph agile reflux disease also
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known as gird what I want you guys to do
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before we get started on this video I
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want you guys to take a second go down
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the description box below we got links
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to our website where it'll be a lot of
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awesome notes and illustrations that I
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think will be super critical for you
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guys to follow along with me during this
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lecture also if you guys benefit from
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this lecture please support us by
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hitting that like button commenting down
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in the comment section and please
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subscribe all right let's start talking
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about gastral reflux disease so gird is
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this basic concept it's super super
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basic in which things like nasty stuff
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like hydrochloric acid contents from the
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stomach unfortunately will just decide
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to move its way upwards into the
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esophagus now when that happens what's
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the downside of that what's the actual
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problematic issue with this actual
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hydrochloric acid getting into the
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esophagus well if we zoom in here what
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you'll notice is that this acid
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substance within the actual esophagus
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can cause a lot of problems one of these
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things is it can lead to just common
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sensation such as heartburn and this may
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manifest if you will with this Burning
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retro sternal chest pain that usually
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occurs after meals and it's really bad
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when you lay
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supine sometimes because the esophagus
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is not just here within the chest but it
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can actually come down here just to the
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epigastric level you may even have epep
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gastric pain we call this dyspepsia it's
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that burning pain that you may have
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right here in the epigastrium so two
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very common manifestations is going to
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be heartburn and
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dyspepsia this is super critical and the
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reason why is because this hydrochloric
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acid is going to be coming up into the
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esophagus causing a lot of burning and
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inflammation now the question I have for
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you guys is what are some of the
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complications that are associated with
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gastr Solage or reflux disease so the
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basic concept is hydrochloric acid is
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coming up into the esophagus it's
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ripping it up causing heartburn
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dyspepsia but it can also do a lot of
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other things like what it can really
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inflame the esophagus and start
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ulcerating it and this can lead to
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esophagitis additionally with the
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esophagitis sometimes patients can come
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in presenting with like things like
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oasia like a lot of pain with swallowing
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that's one common thing the other
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problem here is that as you kind of
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cause this constant inflammation over
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time if this esophagus is being inflamed
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and inflamed and inflamed it'll then
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undergo a fibrotic reaction to heal but
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it'll narrow the actual Lumin of the
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esophagus and this can lead to stricture
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formation another potential complication
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associated with this gastro Solage or
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reflux disease is that sometimes this is
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very very interesting with this
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hydrochloric acid not only can It
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inflame the Esopus lead to strictures
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but sometimes the actual contents can
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move its way into the airway
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and this could lead to features of a lot
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of what's called kind of a reflux or an
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aspiration type of event so you want to
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watch out for
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aspiration now the problems with this
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very quickly is if you aspirate some of
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this Hydrochloric contents into the
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larynx it can cause laryngitis what's a
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common manifestation of that voice
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changes if it goes into the bronchos it
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can inflame the bronchos and lead to
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inflammation of the bronchos what could
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that worsen asthma so the other ways
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that I want you to think about gird
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presenting is not just with esophagitis
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or strictures but aspiration that can
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lead to heness larynx and worsening
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Asthma bronchial inflammation boom
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roasted what's another potential
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complication you know if you erode and
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ulcerate the esophagus there's blood
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vessels that are lining that you can
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erode into the actual blood vessel and
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lead to bleeding so you want to watch
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out for GI
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bleeding ways that GI beds can present
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is this can have a patient who presents
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with like a lot of maybe anemia right so
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maybe it's an actual uh a lab finding or
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they can present with a lot of fatigue
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that's another particular thing the last
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and scariest complication of gastrosoph
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reflux disease over chronic and chronic
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and chronic inflammation is you increase
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the risk of what's called esophageal
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cancer with that being said one of the
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very interesting Concepts here that we
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have to dig into just quickly for the
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pathophysiology is whenever you look at
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normal cells of the esophagus it's
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actually stratified squamous so it's
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stratified squamous so here we'll
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actually write on the side here this
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should be squamous
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cells but whenever you expose the actual
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Squam cells over a long period of time
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to a lot of hydrochloric
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acid this will cause the cells to have
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to adapt when the cells have to adapt
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they undergo something called
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metaplasia so whenever they adapt they
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change into a different type of cell and
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this is going to be called columnar
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cells
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this process where they go from squamous
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to columnar you know what that's called
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This is called metaplasia let's actually
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write that here this process here is
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called
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metaplasia all right beautiful so going
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from the Squam cells to the columnar
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cells is called metaplasia but then if
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you continue and continue to cause more
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erosive damage more inflammation you can
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turn these columnar cells into
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neoplastic cells so you can turn these
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into to neoplastic cells let's stick
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with our color here which we did was
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blue so again this is our neoplastic
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cells so this here going from columnar
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cells to neoplastic cells is called
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dysplasia so one of the biggest things
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to understand here is with this
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metaplasia aspect that's really a very
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specific type of intermediate so I want
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you guys to understand kind of the
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progression here is that the progression
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of this disease is you have something
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called
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barrettes and then over time this baret
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will then progress to what's called
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adino
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carcinoma so this is the metaplasia this
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is the dysplasia so this is the concept
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that I want you guys to understand okay
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now let's go and let's talk about the
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different causes of Girt all right my
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friends so gastrosoph reflux disease
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heartburn dyspepsia from the reflux of
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the hydrochloric acid we know the
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complications associated with it
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esophagitis strictures aspiration we
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also know that you can have gi bleeds
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and we know that you can have a Soph
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cancer the question that you have to ask
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yourself is why is the hydrochloric acid
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going up into the esophagus as much it
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is as it is causing these
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complications there's four particular
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reasons one of the reasons is that this
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part here this is a problematic area for
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us this area here is called the lower
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esophagal sphincter it's supposed to be
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nice and tight and prevent things like
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Hydrochloric hydrochloric acid from
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going up into the esophagus what if the
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tone is really low that's one particular
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mechanism so a low lower esophageal
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sphincter
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tone another particular mechanism that
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can cause this is that there is a defect
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somewhere here so you know the esophagus
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is supposed to go up through this little
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area here called the esophageal Hiatus
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but in certain patients they have a
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defect within that Junction and it
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slides upwards and if it slides upwards
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above the actual esophageal Hiatus this
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is a very significant problem for gird
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you know what that's called where parts
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of the esophagus slides up above the
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esophagal hatus this is called a hiatal
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hernia remember that hiatal
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hernia Okay the third particular problem
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here is that the hydrochloric acid that
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you're producing by the stomach is much
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more so if you have hydrochloric acid
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going up into the Esopus it's going to
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burn it but what if you had a lot more
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hydrochloric acid you're likely going to
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cause more symptoms the more
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hydrochloric acid the more severe the
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actual gird can be so another particular
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problem here is that we have cells of
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the stomach that is just banging out
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hydrochloric acid that's another
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particular mechanism is increased
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hydrochloric acid
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production all right let me take you
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through a quick mechanism here of why
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this is a problem and how we can
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actually treat this so here we have a
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couple parietal cells you know parietal
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cells are cells that make hydrochloric
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acid there's a couple ways that they do
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this one way that they do this is they
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use these kind of like proton potassium
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ATP Aces to push out things like
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potassium and pro I'm sorry push out
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things like protons and these protons
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are what make the hydrochloric acid
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contents super super acidic so there's
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one thing that's the proton pumps but
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you also have little receptors here on
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these cells that tell them to actually
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stimulate and increase the production of
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hydrochloric acid you know what these
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are these are histamine 2 receptors so
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what are these particular receptors here
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these guys here are
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called histamine 2
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receptors
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when these receptors are stimulated they
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increase they increase the hydrochloric
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acid production and this is super
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important because you know when we talk
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about pharmacology if we give drugs that
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block this proton pump like proton pump
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inhibitors you would decrease the
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hydrochloric acid production if we give
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drugs that block the histamine from
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binding to the H2 receptors you would
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block hydrochloric acid production
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that'll come into play when we talk
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about the actual pharmacology okay the
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last particular mechanism here is that
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you have a very high inter gastric
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pressure imagine the pressure in your
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stomach is higher than the pressure
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within your esophagus where are things
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going to want to go from high pressure
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to low pressure things will decompress
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into the esophagus so that's the last
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particular problem here is you're going
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to have a patient who has very high
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intragastric
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pressure all right so out of all of this
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these are the four reasons why the
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patient would develop a very nasty G
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gastrosoph reflux disease what I want to
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do is I want to quickly talk about what
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are the things that decrease the lower
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Sagel sphincter tone what are the actual
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basic type of hiatal hernia that is
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really really highly associated with
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gird what increases hydrochloric acid
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production and what increases inter
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gastric pressure so let's come down here
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and let's go through these and let's
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write them all down because again I
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think this will help you with the
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repetition first one decrease the lower
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esophagal sphincter
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tone next one is you have AAL
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Heria
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third one is you have high in gastric
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pressure and the fourth mechanism is you
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have increased hydrochloric acid
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production okay we have to now say what
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is the reasons why you have a low
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esophagal sphincter tone one of these is
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because the patient is smoking drinking
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alcohol or they're just consuming tons
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and tons of caffeine these are very very
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common triggers so I want you to
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remember these particular
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causes all right so again smoking
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alcohol caffeine are triggers that lower
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the esophagal fter tone all right H
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hernias what is the most common type
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associated with gird I want you to
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remember sliding hernas sliding
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hernas the next thing I want you to
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remember is what are the things that can
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increase the intragastric pressure
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causing it to decompress the contents
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into the esophagus pregnancy
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obesity as well as very large meals and
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one other disease called
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gastroparesis so again pregnancy obesity
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very large meals gastroparesis which is
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a disease associated with diabetes it's
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where the nerves of the actual stomach
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aren't actually working properly so the
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stomach can't contract if you can't
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contract can you empty things into the
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actual duodenum no so all the stomach
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does is distend distend distend pressure
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Rises can decompress into the actual
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esophagus the last one here is you
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increase hydrochloric acid production
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the big things are things like ineds
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alcohol smoking and a rare rare disease
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called Zinger Ellison
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syndrome okay again ineds alcohol
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smoking zeling or Ellison syndrome which
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is a rare disorder where you're actually
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have a tumor like a pancreatic tumor
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that pumps out gastrin you know what
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gastrin does a hydrochloric acid
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production cranks it up all right so
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these are the mechanisms behind
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gastrosoph reflux disease now let's dig
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into the diagnostic approach all right
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so gird heartburn we know the particular
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three pathophysiological processes
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intragastric pressure GE AB uh gastral
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Junction abnormality or reduced lower
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solal sphincter tone we know the three
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complications that they can present with
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how do we diagnose this well gir's
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generally a clinical diagnosis but I
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think it's important to remember that
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often times they'll present with
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heartburn and so heartburn kind of
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present sometimes presents like chest
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pain and here's the other thing
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sometimes patients who present with
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heartburn or maybe even a little bit of
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like epigastric abdominal pain dyspepsia
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we don't want to miss an inferior mind
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and so you should always in any
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complaint of chest pain obtain an ECG
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and depending upon the ECG results get
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your opponents if you see any evidence
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of St elevation reciprocal change es and
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positive tronin this is not gird this is
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potentially an acute coronary syndrome
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and you should completely change your
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diagnostic approach here but if it comes
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back normal and there is no evidence of
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any true changes such as troponin
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elevation no ST depression t-wave
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inversions or elevations then I'm
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starting to think it could be more gird
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related so how do I do this it's more of
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just you try a treatment and see if it
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improves it what I do is I would
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initiate an empiric PPI trial I'll give
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them a proton pump inhibitor that'll
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suppress the hydrochloric acid
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production in the stomach and if that
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happens I'll reduce the hydrochloric
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acid moving into the esophagus and
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causing the heartburn sensation and
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complications do they get better if they
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do it's probably gir if they don't then
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you can't completely exclude that it's
00:14:15
not gir so then what else could we do if
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maybe their symptoms are not
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significantly better with the PPI then I
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really want to start asking myself the
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question is there any severe
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complications am I missing something so
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I look for alarm symptoms is there
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dysphasia because that could identify a
00:14:34
strcture is there vomiting that could
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identify a stricture is there anemia
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this could be indicative of a GI bleed
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or sometimes even cancer and is there
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weight loss this could be indicative of
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a stricture or cancer if I have any of
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these alarm symptoms I have to get an
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EGD with a
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biopsy the reason why is gird can lead
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to potential complications and I want to
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see is this just esophagitis from from
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the reflux or does this look really bad
00:15:01
and I got some really bad like reflux
00:15:03
like related structures
00:15:04
here and then worst case scenario is is
00:15:07
there cancer and so sometimes this may
00:15:10
lead you to kind of find potential
00:15:12
complications related to the gird I
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think one of the big things though is if
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a patient has a normal EGD they have not
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improved with the empiric PPI trial then
00:15:22
I think the next thing that you could
00:15:24
potentially do is say let me just rule
00:15:26
out any other type of esophageal dis
00:15:28
order so I'm going to get esophagal
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manometry and if I do that I can rule
00:15:34
out an esophagal motility disorder
00:15:36
because if all they have is their lower
00:15:38
Sagal sphincter tone is reduced but all
00:15:41
the other mid distal kind of tone is
00:15:43
normal it's likely gir and if that's the
00:15:47
case I've ruled out any other Sage Gil
00:15:48
motility
00:15:50
disorder the other thing that I can do
00:15:52
is I can get pH monitoring this is where
00:15:55
I take kind of a little U it's kind of
00:15:58
like a pH sensor goes through the nose
00:16:01
down into the esophagus and it has
00:16:03
different pH sensors at each different
00:16:06
point here of the esophagus what happens
00:16:08
is in a patient who has very bad gird
00:16:10
hydrochloric acid will move up into the
00:16:13
esophagus and it'll trigger this pH
00:16:15
sensor so the amount of times that this
00:16:18
pH sensor picks up that the pH is lower
00:16:21
than it's supposed to be it'll trigger a
00:16:24
triggering of the score activation and
00:16:26
what happens is this will lead to the
00:16:28
act the calculation of something called
00:16:30
a demer score and the demer score
00:16:32
greater than 14.7 how they came up with
00:16:34
that I'm not sure really helps me to
00:16:36
identify that this sensor was picking up
00:16:38
drops and pH pretty frequently and it
00:16:41
really adds to the diagnosis of gird so
00:16:44
that's how I would go about it empiric
00:16:46
PPI trial they improve it's gir if they
00:16:49
have alarm symptoms get an EG with
00:16:51
biopsy if that's normal but they're
00:16:53
still not better with the PPI trial rule
00:16:56
out that it's not an esophagal motility
00:16:57
disorder and then from there try and do
00:17:00
the actual pH monitoring to definitely
00:17:03
see if they have the evidence of
00:17:05
gird now we've identified gird how do we
00:17:09
treat it it's really pretty
00:17:11
straightforward we got to suppress
00:17:12
hydrochloric acid production because
00:17:13
that's the Crux of it all obviously it's
00:17:15
about treating the underlying causes so
00:17:18
in obesity what should you do lose
00:17:20
weight in patients who have some type of
00:17:23
uh maybe trigger such as caffeine reduce
00:17:25
your caffeine if you're smoking stop
00:17:27
smoking if you drink alcohol reduce your
00:17:29
alcohol intake these are things that
00:17:31
potentially can be
00:17:32
reversed but otherwise it should always
00:17:35
start with trying to suppress the
00:17:36
hydrochloric acid production in patients
00:17:38
with severe gird so really bad heartburn
00:17:41
maybe on top of that they have atypical
00:17:43
findings like cough laryngitis worsening
00:17:45
of their asthma and maybe they even have
00:17:47
a gird complication maybe they have
00:17:48
reflux of esophagitis maybe they have
00:17:50
strictures maybe on top of that they've
00:17:52
had GI bleeds or maybe they have some
00:17:53
type of barit esophagus you need to get
00:17:55
them on a PPI right away and keep that
00:17:58
going going for at least 8 weeks and
00:17:59
then reevaluate if I can actually step
00:18:01
down on that PPI ppis work by kind of
00:18:04
suppressing hydrochloric acid production
00:18:06
right so they block these hydrogen
00:18:08
proton ATP channels reduce hydrochloric
00:18:10
acid secretion that reduces a lot of the
00:18:13
gird and complications associated with
00:18:16
gird now if the patient has mild gird
00:18:18
they just have some mild heartburn they
00:18:20
have no evidence of any complications no
00:18:23
esophagitis no strictures no barretts
00:18:26
nothing to that effect I think h 2as are
00:18:29
a little bit more appropriate the reason
00:18:31
why is ppis they can interfere with
00:18:33
other drugs and reduce the actual
00:18:35
bioavailability of those drugs because
00:18:36
they can interact with the cytochrome
00:18:38
p450 complex and on top of that it
00:18:40
actually has been associated with like
00:18:41
electrolyte abnormalities such as
00:18:43
hypomagnesemia and CI so it's important
00:18:45
to remember that and so sometimes h2ras
00:18:47
are just a little bit more safe and not
00:18:49
as having as many complications so this
00:18:52
would be things like foden that's a very
00:18:55
common one renadine whereas pprs are
00:18:57
things like ome prol pentool Lano prasol
00:19:01
so how does an H2 work it's the same
00:19:04
concept it's going to suppress the
00:19:06
actual histamine response at the
00:19:08
receptor site histamine actually helps
00:19:10
to stimulate hydrochloric acid
00:19:12
production so if I give them this it'll
00:19:14
block the actual histamine at that
00:19:16
receptor reduce the hydrochloric acid
00:19:18
secretion and reduce gird and the any
00:19:21
for formation of any complications of
00:19:22
that sense often times when patients
00:19:25
come in if they have severe gird and
00:19:27
gird complic put them on a PPI for 8
00:19:29
weeks review to see if they're getting
00:19:31
any better and see if you can step down
00:19:32
to an
00:19:33
H2 if they can't then maybe you have to
00:19:36
go back to the lowest dose of the PPI
00:19:37
that they were on where they were
00:19:39
completely controlled if they're on an
00:19:41
H2 and they develop any worsening gird
00:19:43
or G complications then you have to upti
00:19:45
trate them to a
00:19:47
PPI let's say that you've had them on
00:19:49
Max PPI and they're still not getting
00:19:52
any better they're still having very bad
00:19:54
gird they're having gird related
00:19:55
complications then you need to go to
00:19:57
What's called a Nance fundoplication so
00:20:00
what that is is you're going to
00:20:01
basically take a part of the fundus and
00:20:03
you're going to you're basically going
00:20:04
to help to reinforce the lower sofel
00:20:06
sphincter so you're going to take the
00:20:07
fundus and literally wrap this sucker
00:20:09
around the lower sofro sphincter and
00:20:11
tighten that area up and so look at this
00:20:14
thing I took the fundus wrapped it
00:20:16
around it and then I sued it tight and
00:20:18
now I have a very very tight lower Sagel
00:20:20
sphincter which will reduce into the
00:20:21
hydrochloric acid leaking back up into
00:20:23
the esophagus reducing the gird related
00:20:26
complications so that'd be a niss
00:20:28
application if they have refractory gird
00:20:30
that's not responsive to Medical therapy
00:20:33
and then also Improvement or at least
00:20:35
treating of their underlying
00:20:37
cause last thing is gird has a very high
00:20:41
risk of cancer especially if it's
00:20:42
chronic so you need to survey these
00:20:44
patients if they have any alarm symptoms
00:20:46
such as vomiting they have dysphasia
00:20:49
they have anemia they have weight loss
00:20:51
you really should be doing an EGD if
00:20:53
they have no dysplasia on an EGD then
00:20:55
you should at least check it every 3 to
00:20:57
5 years but if they do have any evidence
00:20:59
of dysplasia you want to catch it right
00:21:01
then and there and ablate that area of
00:21:03
cancer or resect that area of cancer and
00:21:05
that's something that we'll talk about a
00:21:06
little bit more when we talk about
00:21:08
esophageal cancer in the actual oncology
00:21:10
section all right my friends that covers
00:21:13
gird I hope that made sense I hope that
00:21:15
you guys enjoyed it and as always until
00:21:17
next
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00:21:27
time
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[Music]
