Pathophysiology
Gastrointestinal Symptoms in an Adult
Case Study
Patient Profile
Name: Martin Richards
Age: 82
Gender: male
History of Present Illness
M.R. is an 82-year-old man who presents with a burning sensation in his stomach, chest, and throat.
Mr. Richards is a non-smoker who had an upper endoscopy 6 months ago because of longstanding GERD symptoms. That endoscopy detected low-grade dysplasia. He is due to have the endoscopy repeated to evaluate cellular changes, including potential Barrett’s esophagus. He presents to the clinic with complaints of returning stomach pain despite being on daily omeprazole. He describes the pain as a burning sensation in the upper abdomen and chest, often radiating to his throat. The pain occurs mostly after meals and when lying down. He also reports occasional regurgitation of sour-tasting fluid and occasional difficulty swallowing. He wears dentures daily and uses continuous positive airway pressure (CPAP) at night for sleep apnea.
- Onset: Symptoms began approximately ten years ago. Improved with omeprazole, but are now occurring again periodically.
- Duration: Pain lasts for 1-2 hours after meals.
- Location: Epigastric region, radiating to the chest and throat.
- Quality: Burning sensation.
- Severity: Moderate, rated 5/10 on a pain scale.
- Aggravating Factors: Large meals, spicy foods, raw onions, ice cream, coffee, alcohol, lying down, and bending over.
- Relieving Factors: Antacids, sitting upright, small, bland meals.
Social History
Retired school principal, Vietnam Veteran
Current Medications
Omeprazole 20 mg daily
Physical Assessment
Vitals
- Blood pressure: 147/76 mm Hg
- Heart rate: 78 bpm
- Respiratory rate: 16 bpm
- Temperature: 98.6°F
General Survey
- General: Alert, oriented, no acute distress.
- BMI: 32
- Throat: Mild erythema, no exudates, mild foul smell to breath.
- Lungs: Clear to auscultation bilaterally. No use of ancillary muscles, breathing easy.
- Cardiovascular: Regular rate and rhythm, no murmurs. Electrocardiogram (EKG) normal.
- Abdomen: Soft, non-tender, no masses, normal bowel sounds.
Diagnosis
GERD Flare Up and R/O Barrett’s Esophagus
Treatment Plan
Medication Adjustment: Increase omeprazole to 40 mg daily or switch to a different proton pump inhibitor (PPI). Encourage taking medications as prescribed.
Patient Education and Lifestyle Modifications:
- Explain the condition and its chronic nature.
- Elevate the head of the bed.
- Avoid large meals and eating before bedtime.
- Reduce intake of trigger foods (e.g., spicy foods, caffeine, alcohol).
- Maintain a healthy weight.
- Importance of regular endoscopy to monitor for dysplasia progression or early signs of cancer.
Follow-Up: Schedule repeat endoscopy, reassess symptoms, and endoscopy results in 4-6 weeks. If no improvement or cellular changes on endoscopy, refer back to the gastroenterologist.
Advised on recognizing severe symptoms that require immediate medical attention, such as chest pain mimicking a heart attack, dark-tarry stools, dysphagia, odynophagia, persistent vomiting, or significant weight loss.
Pathophysiology of GERD and Barrett’s Esophagus
Fill in the blanks with the correct term: lower esophageal sphincter, pyloric sphincter, calcium channel blockers, histamine blockers, squamous, columnar, metaplasia, adenocarcinoma, distal third, proximal third, hypertrophy
GERD occurs when the ______________________ fails to close properly, allowing stomach acid to flow back into the esophagus. This acid reflux causes irritation and inflammation of the esophageal lining. GERD esophagitis is characterized by inflammation, increased blood flow, and leukocyte infiltration. Symptoms include heartburn, regurgitation, and chest pain. Factors contributing to GERD include age, obesity, pregnancy, hiatal hernia, smoking, certain medications (e.g., smooth muscle relaxants like ______________________), and dietary habits. Older adults often have more laxity of the LES, decreased saliva production (thus decreased neutralizing bicarbonates), decreased digestive and pancreatic enzymes, and slower gastric motility, all of which can increase the risk of GERD.
Barrett’s esophagus (BE) is a condition where the normal ______________________ cells lining the lower esophagus are replaced by ______________________ cells, which are similar to the cells lining the intestines. This intestinal ______________________ is typically a response to chronic acid exposure from gastroesophageal reflux disease (GERD). Although it only happens in a small percentage of patients with BE, BE increases the risk of developing esophageal ______________________, which typically originates in the ______________________ of the esophagus. BE is most common in male patients over age 50. A family history of BE or esophageal cancer also increases risk.
Review Questions
Click the arrow to expand the section and view the correct answers.
- What is the primary cause of GERD?
- Overproduction of stomach acid.
- Weakness of the lower esophageal sphincter (LES).
- Excessive consumption of spicy foods.
- Hiatal hernia.
Answer:
B) Weakness of the lower esophageal sphincter (LES).
Feedback: GERD is primarily caused by the failure of the LES to close properly, allowing acid to reflux into the esophagus.
- Which of the following symptoms is most characteristic of GERD?
- Abdominal bloating
- Diarrhea
- Heartburn
- Constipation
Answer:
C) Heartburn
Feedback: Heartburn, a burning sensation of the chest, is the hallmark symptom of GERD.
- What lifestyle modification can help reduce GERD symptoms?
- Eating large meals.
- Lying down immediately after eating.
- Elevating the head of the bed.
- Drinking carbonated beverages.
Answer:
C) Elevating the head of the bed.
Feedback: Elevating the head of the bed helps prevent acid reflux by keeping stomach contents from flowing back into the esophagus.
- Which medication class is commonly used to treat GERD?
- Antibiotics
- PPIs
- Antidepressants
- Beta-blockers
Answer:
B) PPIs
Feedback: PPIs reduce stomach acid production and are commonly used to treat GERD.
- What is a common side effect of long-term PPI use?
- Increased risk of fractures
- Weight gain
- Hair loss
- Hypertension
Answer:
A) Increased risk of fractures
Feedback: Long-term use of PPIs can decrease calcium absorption, increasing the risk of fractures.
- Which of the following foods should be avoided to reduce GERD symptoms?
- Bananas
- Oatmeal
- Chocolate
- Rice
Answer:
C) Chocolate
Feedback: Chocolate can relax the LES and increase acid reflux, worsening GERD symptoms.
- Which symptom would warrant additional medical attention in a patient with GERD?
- Mild heartburn.
- Occasional regurgitation.
- Difficulty swallowing.
- Mild nausea.
Answer:
C) Difficulty swallowing.
Feedback: Chronic inflammation can cause scarring and esophageal strictures, which narrow the esophagus and make swallowing difficult and/or painful.
- What is the primary goal of GERD treatment?
- Cure the disease.
- Reduce acid production and prevent complications.
- Increase stomach acid.
- Constrict smooth muscle.
Answer:
B) Reduce acid production and prevent complications.
Feedback: The primary goal of GERD treatment is to reduce acid production, alleviate symptoms, and prevent complications such as esophagitis and Barrett’s esophagus.
- Which of the following is a common complication of untreated GERD?
- Peptic ulcer disease
- Barrett’s esophagus
- Crohn’s disease
- Celiac disease
Answer:
B) Barrett’s esophagus
Feedback: Chronic acid reflux can lead to Barrett’s esophagus, where the esophageal lining changes and increases the risk of esophageal cancer.
- What is the role of antacids in the management of GERD?
- Prevent acid production.
- Neutralize existing stomach acid.
- Strengthen the LES.
- Promote gastric emptying.
Answer:
B) Neutralize existing stomach acid.
Feedback: Antacids provide quick relief by neutralizing stomach acid, but they do not prevent acid production.
- What is the primary pathological change in Barrett’s esophagus?
- Inflammation of the esophageal lining.
- Replacement of squamous cells with columnar cells.
- Formation of esophageal ulcers.
- Increased production of stomach acid.
Answer:
B) Replacement of squamous cells with columnar cells.
Feedback: Barrett’s esophagus occurs when the normal squamous cells lining the lower esophagus are replaced by columnar cells, a change that results from chronic acid exposure from GERD. This change increases the risk of developing esophageal adenocarcinoma.
References
American College of Gastroenterology. (2023). Barrett’s Esophagus. Retrieved from https://gi.org/topics/barretts-esophagus
Heavey, E. (2024). Lecture on Gastrointestinal System. [Transcript]
Mayo Clinic. (2023). Barrett’s Esophagus. Retrieved from https://www.mayoclinic.org/diseases-conditions/barretts-esophagus/symptoms-causes/syc-20352841
Microsoft. (2024). Copilot [AI assistant]. Microsoft Corporation.
National Institute of Diabetes and Digestive and Kidney Diseases. (2023). Barrett’s Esophagus. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus
Spechler, S. J., & Souza, R. F. (2014). Barrett’s Esophagus. New England Journal of Medicine, 371(9), 836-845. DOI: 10.1056/NEJMra1314704
Tkacs, N. (Ed.). (2020). Advanced physiology and pathophysiology: Essentials for clinical practice. Springer Publishing Company.
A condition where the normal squamous cells lining the lower esophagus are replaced by columnar cells. It is associated with chronic exposure to stomach acids and gastroesophageal reflux disease (GERD), and it increases the risk of esophageal adenocarcinoma.
