DDSEP® 8 Quick Quiz

May 2016 Quiz 1

Publish date: May 3, 2016

A 24-year-old woman presents for continuing management of gastroesophageal reflux disease. Although her heartburn has resolved on twice-a-day omeprazole therapy, she continues to have postprandial regurgitation. She has no nocturnal symptoms. Prior evaluation has demonstrated a 3-cm sliding hiatus hernia, but no erosive esophagitis. She is overweight with a body mass index of 32 kg/m2. Physical examination is normal.

Which of the following is the primary mechanism for her continuing regurgitation?

A. Obesity-induced increased intra-abdominal pressure

B. Ineffective esophageal smooth muscle motor function

C. Weak lower esophageal sphincter resting pressure

D. Postprandial transient lower esophageal sphincter relaxations

E. Hiatus hernia

Q1: Answer: D

Rationale: The most frequent mechanism for gastroesophageal reflux is transient lower esophageal sphincter relaxation (TLESR). In the setting of a compliant esophagogastric junction, TLESRs allow movement of content from stomach to esophagus. Gastric distension following meals is a prime trigger for TLESRs, and this is why reflux is most frequent after a meal.

Further, there can be an unbuffered layer of acid floating above the ingested meal (acid pocket) in close proximity to the esophagogastric junction, which is immediately available for reflux during TLESRs. All the other mechanisms listed contribute to the pathophysiology of reflux disease. Increased intra-abdominal pressure contributes to the pressure gradient promoting reflux.

Weak lower esophageal sphincter tone and hiatus hernia are structural deficiencies at the esophagogastric junction that add to the compliance of the esophagogastric junction, making it easier for reflux to occur during a TLESR. Ineffective esophageal body motility contributes to prolonged exposure of the esophageal mucosa to refluxed content, as this can impact clearance of the refluxate, particularly in the recumbent position.

References

  1. Wu J.C., Mui L.M., Cheung C.M., et al. Obesity is associated with increased transient lower esophageal sphincter relaxation. Gastroenterology 2007;132:883-9.
  2. Mittal R.K., Lange R.C., McCallum R.W. Identification and mechanism of delayed esophageal acid clearance in subjects with hiatus hernia. Gastroenterology 1987;92:130-5.

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