Heartburn

Heartburn

1. Anatomy & Histology of Esophagus

   • extends from pharynx to stomach
   • has 3 portions: cervical/thoracic/abdominal
   • blood supply
     • arterial: abdominal part supplied by left gastric and left inferior phrenic arteries
     • venous: abdominal part drained by left gastric of potral system, inferior venacava and hemiazygos
   • lymphatics
     • abdominal part by celiac group of lymph nodes
   • innervation
     • sympathetic
       • greater, lesser, and least splanchnic nerves and celiac plexus
     • parasympathetic
       • vagus and recurrent laryngeal nerves
   • histology

2. Anatomy & Histology of Stomach

   • lies mostly in epigastric region and partly in left hypochondriac region
   • has a fungus, body, antrum, and pylorus
   • blood supply
     • arterial: celiac trunk and branches
     • venous: corresponds to arteries and drain into portal vein
   • lymphatics
     • celiac nodes and left supraclavicular nodes
   • innervation
     • sympathetic
       • greater and lesser splanchnic nerves, celiac, and hepatic plexuses
     • parasympathetic
       • anterior and posterior vagal trunks
   • histology

3. Stages Of Swallowing

   • oral phase
     • voluntary and initiates swallowing process
   • pharyngeal phase
     • involuntary passage of food through pharynx into oesophagus
   • oesophageal phase
     • involuntary passage of food from oesophagus into stomach

4. Functional Disorders Of Oesophagus

   • achalasia
     • oesophageal motility disorder due to inability of LES to relax
     • may be primary or secondary
   • zenker's diverticulum
     • out pouching of mucosa through the muscular layer of oesophagus
     • may result in halitosis and regurgitation
   • oesophagitis
     • chemicals
       • lye/ alcohol
     • infectious
       • HSV/ CMV/ candida albicans

5. GERD

   • signs & symptoms
     • typical
       • heartburn/ regurgitation
     • atypical
       • dysphagia/ odynophagia/ burping/ chest pain
   • risk factors
     • obesity
     • alcohol
     • smoking
     • medications
     • food
     • hiatal hernia
   • disease that involves the reflux of acidic stomach juices or foods from stomach into oesophagus
   • management
     • lifestyle modifications
     • mild GERD
       • low dose H2RA
       • if symptoms persist, high dose H2RA
     • severe GERD
       • standard dose PPIs
       • if symptoms persist, high dose PPIs
         • if symptoms only controlled by high dose PPI -> may be referred to Nissen's Fundiplication

6. Barrett's Esophagus

   • complication of chronic GERD
   • characterised by intestinal metaplasia
   • risk factors
     • gender/ age/ history/ race
     • GERD
     • increasing intraabdominal pressure
     • obesity
   • signs & symptoms
     • progressive heartburn
     • hoarseness of voice
     • chest pain
     • black, tarry blood stools
     • dysphagia
     • weight loss
   • management
     • pharmacological
       • antacids
       • H2RA
       • proton pump inhibitors
       • promotility agents
       • aspirin/ NSAIDs
     • non-pharmacological
       • endoscopic surveillance
       • endoscopic ablative therapy
       • esophagectomy
       • endoscopic mucosal resection

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