Lack of Perseverance

Ayman El-Kholi — Fri, 14 Mar 2008 13:10:39 +0000

A year almost had passed since I started with this idea. A whole year and only one post to show for it, that explains a lot, and shows a lot.

Apparently I don’t have the necessary perseverance to follow through with writing projects. I can’t start to fathom the reasons behind that. But lack of it has caused this one to end quite prematurely as you are about to see.

Another reason this can’t go on is the presence of wonderful other accumulative and collaborative writings about the same issue. And as much as I hate being a copy, I MEGA-LOATH being a really bad copy. The guys in Emedicine and MedScape are doing a wonderful job and filling in the spaces. Publishing within such ‘already-established’ institutions sounds more fruitful to me. Look how they handled the Edema of Uncertain Etiology issue!

A last thing, I thought I’d have more time and grasp of the science during the internship period. I was dead wrong. All project designated to that period have been either brought to halt, or permanent dismantling. I could of course sit home and play video games, but I won’t. I find myself rather humbled by what I don’t know, and what I have to do. And in reply to that feeling, no less than absolute dedication can be offered.

And so dear non-readers, I declare this page on halt until further notice. It’s been a pleasure viewing medicine this way. May be one day when I retire, if I still have the spirit to view it as fun, I will do it again.

Burp!

Ayman El-Kholi — Thu, 19 Apr 2007 23:37:05 +0000

Dear eructating agonizing reader

Yes, you. You can’t possibly deny it. Nobody can. Gastro-esophageal Reflux Disease (GERD) is a very common disease; to the extent that you can safely assume that every living Homo sapiens went through it at a particular time through their life, for the simple fact that; it’s a normal physiological phenomenon.

Batata: Now I’m confused; is it a physiological phenomenon? Or is it a disease?

It is both. It’s a physiological phenomenon that happens occasionally whilst the stomach is evacuating gas upwards, or during straining, and probably certain positions. Normal subject has about 20 minutes of reflux during waking hours, which is usually cleared down by the normal reflex of swallowing of saliva, along with the esophageal peristalsis. It’s however tolerable within limits. Taking place more often, or in excessive amounts; the GERD would start to show its pathological ugly face.

‘LES is more’ or so they say…

LES or Lower Esophageal Sphincter is your Guardian Angel. Day and night, this martyr stands alone heroically against the raging oceans of concentrated burning acid of the gastric secretions, preventing its tide from reaching the shores of the delicate esophageal mucosa.

As you can see, your capable hero in the picture is but a mere scarecrow. This isn’t a true sphincter. It’s but a physiological combination of six factors that form this magnificent gate.

The reasons why such a spectacular mechanism should fail one day could simply be summated into two major categories. Logically; either the gate itself will collapse even though the attackers are practically stable, which we refer to as Primary GERD, and reasons may range from Hiatus Hernia, to even excess chocolate and tea consumption. Alternatively, the attackers would change in character, and then the gate wouldn’t be able to hold them back any longer, and that is what we call Secondary GERD. Usually it takes place due to pyloric stenosis, or spasm, which leads of course to Delayed Gastric Emptying state.

Cucu: But people get reflux everyday, they never show up at my clinic. When would a patient show up complaining from such a thing?

Of course, patients don’t consider seeing a doctor unless their condition is too advanced, that they can tolerate a doctor better. You see, they don’t usually like us; we are too boring, and typically ‘thieves’ from where they are looking. A GERD patient would typically show up at your clinic with a complication such as Peptic Ulcer, Esophageal Stricture, Short Esophagus, Monilial invasion, or rarely; Hematemsis, and Inhalation Pneumonitis. The mucosa would turn columnar (become intestinal, or Barrett’s Esophagus) before it turns malignant in the very advanced cases.

You should know a little bit about the GERD Vicious Circle technique, a technique that leads to all the aforementioned complications through a very simple direct mechanism.

Reflux esophagitis is characterized by superficial ulceration which heals and recurs repeatedly. However, it never perforates and rarely causes severe hemorrhage. Meanwhile, the irritation causes a spasm in the longitudinal muscle layer, which draws up the cardia more and more into the thorax, deactivating the sphincter mechanism, and causing more reflux.

Eventually, it leads to fibrosis, progressive narrowing, and shortening. In the clinic, the patient history would come typically in the following story.

An obese patient complaining from burning retrosternal pain/heartburn, worsening dysphagia, anemic, and probably complicating with occult blood. The patient is usually a smoker, and has a history with using antacids.

In such a case, you need to perform a 24-hours pH monitoring to confirm the reflux first of all. Then, through fiber-optic esophageoscope you can detect the patency of the cardiac opening, as it opens during inspiration whereas it should close and descend. You could also detect the inflammation extent, along with any other changes as leukoplakia or superficial ulceration, which of course helps you to determine the grade of the reflux. And eventually, you may perform a barium meal in Trendelenburg’s position to reveal causative sliding hernia, or developing stenosis.

~~N.B. Grading system:~~

- ~~Grade I – Erythema~~
- ~~Grade II – Linear nonconfluent erosions~~
- ~~Grade III – Circular confluent erosions~~
- Grade IV – Stricture or Barrett esophagus (Barrett esophagus [grade IV] is thought to be caused by the chronic reflux of gastric juice into the esophagus. Barrett esophagus occurs when the squamous epithelium of the esophagus is replaced by the intestinal columnar epithelium. Barrett esophagus is present in 8-15% of patients with GERD and may progress to adenocarcinoma.

How would you proceed from this point depends on the results of your investigations. Whereas in early cases the management would be conservative all along, through changing lifestyle by adopting semi-sitting position during sleeping, avoiding increased intra abdominal pressure on all costs, like heavy work, lifting weights, excessive bending, and tight corset, also weight reduction, and small non-bulky, frequent meals-diet. Drugs in such case are only for symptomatic treatment, as alkalis and antacids.

On the other hand, complicated cases and frequently recurring ones, also the ones with intra abdominal lesions requiring surgery such as gall stones, the treatment is solely surgical.

Still considering how advanced the case might be, surgeries might fall in one of two categories:

I-Surgeries to protect the esophagus and lungs from damage (Anti-Reflux Measures/no stricture):

Nissen’s Fundoplication: where you’d completely wrap the lower part of the esophagus with the fundus of the stomach, forming an air-tight jacket around the lower part of the esophagus, which completely seals the way up. A very effective operation, which can be applied through many routs, and accompanied by other procedures, however, your patient would be banging their heads to the wall in a couple of days, since they wouldn’t be able to burp, they would even crave vomiting!! A syndrome called Gas-Bloat syndrome. Suggestions were made to loosen out the sutures at the wrapping site, to allow some air up.

Belsey Mark IV operation: to avoid that syndrome, a modification was made to allow the patient to pass some gas upward. Fundoplication is done only to the anterior 2/3 of the esophagus, and then the whole complex is sutured under the diaphragm to fix it there. A less effective technique that however excluded the previous complications.

Anglchic Prosthesis: a very dubious procedure, where you’d fix the hiatus hernia through surrounding the esophageo-gastric junction with a horse shaped prosthesis just above the cardia by tapes. The large size of the prosthesis would hold down the hernia and prevent it from accessing the chest. And though it’s simple and easy maneuver, the prosthesis is quite expensive, not to mention that serious late complications appeared such as persistent dysphagia, stenosis, displacement of the prosthesis, or perforation. And of course, being a very recent technique, so it’s too early to evaluate long term values.

Collis Gastroplasty: in cases where the esophagus has shortened too much that the reduction of the hernia is quite impossible, we reshape the fundus of the stomach into an elongation of the esophagus, then perform Fundoplication and then fix it under the diaphragm.

II- Surgical procedures to relieve obstruction in presence of a stricture:

In benign strictures, you should dilate the dilatable ones, and you may perform Thal’s patch in non-dilatable ones (a longitudinal incision through the stricture that is closed transversely, making the place wider and relieving the obstruction).

There would be malignant strictures, that should be dealt with in the context of esophageal carcinoma (according to operability; operable tumors should be subjected to radiotherapy as well, and then excised in some sort of esophageo-gastrectomy, whilst inoperable ones should be subjected to palliative treatment by variable bypass maneuvers). The prognosis is very bad though.

This is how you should remember GERD, and always.. *burps* pardon me. You are what you eat.

ReWrite!

Lack of Perseverance

Burp!