Understanding
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Heartburn and Its Absence. "What's so bad about some heartburn?" "Lots of people get heartburn, just avoid eating things that seem to cause the sensation", is the typical sentiment. "It doesn't
bother me that much; I just take something".
Objectives: 3/26/04 Grand Rounds, Battle Creek Health Systems presentation by Dr. Kurt Barrett - Beyond the Esophagus: Extraluminal GERD - Acknowledge that symptoms related to GERD represent one of the most common, and often confusing, health problems seen in primary care. (University of Virginia School of Medicine, 2003) - Name two or more respiratory problems that can be associated with GERD. - Name two or more of the synonyms for extraluminal GERD. - Acknowledge that heartburn/indigestion can be absent or infrequent despite ongoing pathological gastroesophageal reflux.
GERD review---Nov. 2004 Gastroesophageal Reflux Disease (GERD) is dramatically affecting our society and its occurrence is on the rise. In fact, it is so common that the dividing line between that which would occur normally (physiological) and pathological needs to be more clearly defined. This is not as easy as it may seem. World class authorities will acknowledge that everyone in our society has reflux after meals. In other "primitive" cultures (less industrialized peoples) there is NO REFLUX AFTER MEALS (post-prandial retrograde movement of gastric contents into the distal esophagus). It is counterintuitive to accept the presence of digestive contents in contact with the squamous epithelium of the esophagus as "physiologic". I believe the concept of post-prandial reflux as a "physiologic" event to be an honest disagreement, the result of diverse perspectives. If this is "normal"(physiologic) why does it not occur in all cultures? It may be "normal" for the given circumstances. By that I mean it is normal for the patellar reflex to occur when the tendon is rapidly depressed by the reflex hammer: similarly it is "normal" for the body to respond to refluxed gastric contents in a somewhat predictable manner. Hence this makes the bodies response to the event of gastric contents contacting esophageal squamous epithelium a "physiologic" event: a reflex mediated response aimed at the autonomous clearance of the contents of the esophagus. This is a desirable result. But the stimulus that initiated the response must logically be considered a pathological event in that it serves no plausible benefit aside from allowing hydraulic pressure relief. And it does NOT happen in all societies! It could be argued that reflux of non-food, acidic gastric content periodically might be "natures way" of maintaining a sterile luminal environment in the lower esophagus. Vomiting is the only other occurrence of stomach contents moving retrograde in the esophagus. The assertion by gastroenterologists/scientific researchers that post-prandial reflux and other numerous episodes of retrograde movement of gastric contents are to be ignored is based on observation. What we do (and call scientific) is based on what was done by the researcher/scientist that preceded us. Thus when new information/concepts emerge, any departure from the established norm is automatically disputed and opposed. Thus change comes slowly if at all. A blatant example is the arbitrary placement of the pH electrode 5 centimeters above the lower esophageal sphincter. Why not 6 centimeters, 4 centimeters, 1 centimeter or, for that matter, 10 centimeters? The usual answer is "That's the way it's done". Why? I have found in the history of pH testing that the first pH electrode placement in the1950's was able to recognize the abrupt acid/alkaline change. In the interest of not being influenced by vigorous tilt table positioning the electrode was withdrawn "5 centimeters". Given the rudimentary equipment and the seminal nature of the research, it seems logical. It also means that all these years later the probe is placed 2 inches (5 cm) beyond nature's barrier to gastroduodenal reflux. WHY? In 1985 the Archives of Internal Medicine reported…"reflux and its many manifestations are extremely common problems". In 1983 The Journal of Pediatric Surgery reported … "bradycardia caused by gastroesophageal reflux …may be an important cause of sudden infant death". Gastroenterology, 1983, concluded…"esophageal acid perfusion tests…can induce myocardial ischemia". There are innumerable citations since the 1980's pronouncing the common and pathological nature of refluxed digestive contents. Numerous correlation's with respiratory pathology, multiple system involvement including syncope and seizure have been documented. Due to the complexity of the protective reflexes involved, it appears difficult to prove a "cause and effect" relationship. With the evolving popularity of potent antisecretory drugs more of these associations are becoming apparent to alert clinical observers. This unique situation appears to be somewhat of a paradox given the magnitude of the rift between research findings and clinical outcomes. I believe the research seems lagging, stifled by conventional wisdom, political and litigation concerns.
Extraluminal GERD: Beyond the Esophagus Kurt A Barrett D.O. Grand Rounds, Battle Creek Health Systems…3/26/04 Synonyms: a reflection of the ubiquitous nature of GERD - Atypical GERD - Silent GERD - Supraesophageal GERD - Extraesophageal GERD - GORD…"over seas" the food tube is the oesophagus hence the designation - NERD…nonerosive GERD - ENRD…endoscopy negative reflux disease - Acid Reflux, acid/alkaline reflux - LPR…laryngopharyngeal reflux - sGERD…symptomatic GERD - SNERD...silent nonerosive gastroesophageal reflux disorder
Inherent Protective Mechanisms Vasodilatation…. widening of the lumen of blood vessels Extravasation….to exude from or pass out of Edema…..accumulation of an excessive amount of watery fluid Smooth muscle constriction…. Mast cell degranulation…. Transudate….low protein Exudate….high protein…(injury/inflammation)…exude…ooze or pass gradually out Extrude….thrust, force or press out Permeable…permitting the passage of…through a membrane or other structure …(permeability) Neurogenic (originating in, starting from, or caused by, the nervous system) inflammation* (a fundamental pathologic process consisting of a dynamic complex of cytologic and chemical reactions that occur in the affected blood vessels and adjacent tissues in response to injury or abnormal stimulation) …vagally mediated reflexes Embrologic evidence….distal esophagus originates from the lung bud…(shared innervation by the vagus nerve) Waterbrash… spontaneous filling of the mouth with saliva initiated through a vagally mediated esophago-salivary reflex *inflammation…caused by a physical, chemical, or biologic agent, including: 1) the local reactions and resulting morphologic changes, )2 the destruction or removal of the injurious material, 3) the responses that lead to repair and healing. The so-called "cardinal signs" are:rubor ,redness; calor, heat; tumor, swelling; and dolor; pain; a fifth sign, functio laesa, inhibited or lost function, is sometimes added.
Reilly's phenomenon, Reilly's syndrome (splanchnic vasoplegia, sympathetic irritation syndrome) A syndrome in which experimental irritation of the sympathetic nervous system with various agents, such as allergens, bacterial toxins, and physical irritants, produces vasomotor disorders, increased capillary permeability, edema, and lesions of the reticuloendothelial system.
"Food" for intellectual "digestion" …Dr. Kurt Barrett GERD is Epidemic/Pandemic, and the incidence appears to be increasing.
Autonomic Activation Syndrome (AAS) Autonomic Activation Syndrome (AAS) is the consequence (unintended) of intense stimulation of the autonomic nervous system (ANS) in response to pathologic events
occurring in visceral organs. Effects can be profound: laryngeal edema, middle ear effusion, massive nasal turbinate swelling/hypertrophy, pulmonary congestion,
cough, inordinate respiratory mucus production to name but a few. Deterioration of sleep is common. The enormity of the event causes the response to become
generalized, not confined to the eliciting tissue, i.e. loss of specificity. In essence your body tissues have come under "friendly fire". Respiratory and
cardiovascular manifestations are the result of vasodilatation, interstitial edema, change in vascular permeability, exstravasation, smooth muscle contraction,
mucus production and immune system changes due to ANS command rather than an infecting organism or external environmental stimulus as provocation.
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