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Gastro-Esophageal Reflux
Definition of GER
n    Definition: The movement of partially digested food or acid up from the stomach into the esophagus &/or beyond into the larynx/oral cavity.
Role of SLPs & GERD
n    ASHA Scope of Practice: “…swallowing or other upper aerodigestive functions such as infant feeding & aeromechanical events (evaluation of esophageal function is for the purpose of referral to medical professionals).”
Anatomy GI tract
30 ft long
Anatomy Esophagus
9 inch long. The esophagus is a muscular tube which extends from the pharynx through the esophageal hiatus of the diaphragm. n    3 layers: Outer layer of fibrous tissue, a middle layer of smooth muscle, & an inner membrane containing tiny glands. Innervation is via the CN X (Vagus).
GI tract responsible for:
n    GI tract is responsible for transferring nutrients from the external world to the internal cells via the circulatory system, while preventing retrograde movement of gastric contents.
Digestion begins with
chewing by breaking the food into smaller pieces.
Pharynx & esophagus provide
a pathway for the ingested food and liquid to reach the stomach
the wavelike muscular contractions which moves the food through the esophagus into the stomach.
Anatomy of LES
Located at lower end of the esophagus. Keeps stomach contents in the stomach. LES relaxes before the last contraction allowing food into the stomach. LES then immediately contracts to prevent regurgitation
LPR - Backflow from stomach all the way into the throat, 50% report heartburn, daytime reflux., GERD - backflow of stomach contents into the esophagus, usually reports heartburn, night-time reflux
LPS signs/Symptoms
Hoarseness (esp in morning), Dysphagia, Excessive mucous in throat, Chronic cough, Halitosis, Heartburn, Globus sensation/pain in chest, tooth decay, ear infections
"We all experience GER with meals, “Heartburn” is describes when the acid irritates the walls of the esophagus. When GER becomes pathologic, it is then known as GERD.
Esophageal Influences of GERD
"Transient lower esphageal tone, Decreased LES resting tone, Ineffective esophageal clearing - peristalsis not good?, Inability of esophageal tissue to resist injury or repair itself, Mechanical obstuctions (hiatal hernia, strictures, rings, cancer), Motility disorders (scleroderma, spasms, presebe esophagus (age))
Etiology of GERD Trauma/Surgery
Gastric or duodenal surgeries, Excessive vomiting, swallowed acid or foreign object, smoking
Etiology of GERD Infections influence
Fungal (candida) - cobblestone look, Viral (Herpes Simplex)
Etiology of GERD Food/ Liquid influences
Alcohol, Caffeine (chocolate), Spicy foods, Acidy foods, Fatty foods, Medications
Etiology of GERD Other Influences
Diminished Salivation, Prolonged NG intubation, Overeating, Obesity (pressure pushes food up), Tight clothing, Pregnancy, Body Posture, Hormones
Medications Causing GERD
Tranquilizers (valium, Xanax), Birth control pills, Respiratory meds (theophyllin), Anticholinergics (Donatol, Scopolamine), Beta Blockers (Tenormin), Anti-osteoporosis meds (Fosamax), Calcium channel blockers (Procardia, Cardizem), Non0steroidal anti-inflammatory (motrin, advil, Ibuprofen), Asprin, Vitamin C
Interesting Statistics
10% of GERD patients have refluxed material aspirated into lungs or trachoeobronchial tree, 45%-65% of adult asthmatics have GERD, 62% of children with asthma have GERD, Strictures (narrowing or blockage within the esophagus) occur in 10% of GERD patients, Study: 1/3 of 450 sleep apnea patients had GERD
" If left untreated, GERD can cause scarring and narrowing of the esophagus and make swallowing difficulty. Severe reflux can lead to Barrett’s esophagus where cells similar to the cells in the stomach lining begin to line the lower esophagus and can become cancerous.
"VFSE/MBS, Esophagram - barrium swallow study, UGI - look further into stomach, GI consult (EGD esophagogastroduodenoscory - swallow camera, PH monitoring - cost and invasiveness
Treatment for GERD
Behavioral modification - our area, Pharmacological intervention - let them know what meds on, Surgery
Treatment for GERD - Behavioral Modifications
Elevate the head of the bed 6-8 inches, Instead of 3 large meals a day, try 6 smaller meals, Don't lay down at least 2 hours after eating, Don't exercise right after eating, Don't wear tight clothing, Watch what you eat/drink, Watch your weight
Treatment for GERD Pharmacological Intervention
Antacids, H2 Receptor blockers, Proton Pump Inhibitors (PPI), Prokinetic Agents
Treatment for GERD Antacids
Maalox, Mylanta, Gelusil, Rolaids, Tums, Won't heal esophagus but neutralizes acid
Treatment for GERD H2 Blockers
Cimetidine (Tagament), Farnotidine (Pepcid), Nazatadine (Axid), Ranitidine (Zantax), Reduces production of acid by blocking histamine receptors
Treatment for GERD Proton Pump Inhibitors (PPI)
Lansoprazole (previcid), Omeprazole (Prilosec), Pantoprazole (Protonix), Esomeprazole (Nexium), Rabeprazole (Aciphex), Reduce production of acid)
Treatment for GERD Prokinetic Agents
Cisapride (Propulsid) banned in US in 2000 due to heart rhythm disturbance, Metoclopramide (Reglan), Help with peristalsis
Treatment for GERD Surgical Interventions
Esophageal dilatation - use balloon to stretch narrowing anywhere, cp sphincter, esophagus, Fundoplication - Wraps part of stomach around the lower esophagus which places more pressure on LES to keep it closed, Stretta system - electrode, Implantation of Inert Polymers - opposite of botox
What to look for in the esophagus?
Any physiologic abnormalities causing material to “hang up”, not go down smoothly, or reflux., Any anatomical abnormalities, If suspect esophagus look at AP to screen esophagus, thick liquids, Hiatal Hernia - part of stomach gets pulled up through diaphragm
Anatomy & Physiology
Esophageal sticture, Achalasia, Diffuse esophageal spasm, Schatzki's ring

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