Case 1 A 28-year-old graduate student complains of chronic heartburn that intens

Question

Case 1

A 28-year-old graduate student complains of chronic heartburn that intensifies when lying in bed. The condition became prevalent during his qualifying exams five years previously and has recurred as he is approaching his final thesis defense. The patient had been taking omeprazole (Prilosec™) to manage the symptoms of acid reflux.

The doctor first asks the patient to wean off of the proton pump inhibitor (Prilosec™), but the patient reports that previous attempts led to recurrence of heartburn when he went to bed. She decides to run tests to determine the source of the reflux and first orders upper GI radiography (barium swallow).

Case 1 Question 1: What tissue layers make up the wall of the stomach (start list with layer adjacent to the lumen)?

Case 1 Question 2: Explain the mechanism of action for a drug like omeprazole. How does an antacid like Tums(TM) work? (Do not write your answer like a commercial for these drugs, stick to scientific explanations.)

Case 1 Question 3: What is the risk of chronic acid reflux?

Case 1 Question 4: If the barium swallow is inconclusive, what is another test that can be ordered that will look for evidence of abnormal growths (polyps) in the upper GI tract?

Explanation / Answer

Layer of stomach

Lumen of the Stomach

Mucosa - has three layers and also contains the gastric pits (openings of passageways that extend towards the inner stomach wall)

Mucosal Layer of Mucosal epithelium
Mucosal Layer of Lamina propria
Muscosal Layer of Muscularis mucosa

Submucosa

Muscularis externa - three layers of muscle tissue, whose fibres are orientated in different directions

Muscle Layer of Oblique
Muscle Layer of Circular
Muscle Layer of Longitudinal

Serosa

arrangement of the outer (muscle) layers: it cantain dense network of blood vessel.

The epithelial cells that line the stomach form the mucosal epithelium layer.When the stomach is empty the mucosa lies in large folds called rugae and which look like wrinkles. The rugae flatten as the stomach fills. In order to identify the different types of cells that line the stomach and the functions of each of these types of cells it is necessary to describe the inner-layers of the stomach (i.e. the layers of the mucosa).

The surface of the mucosa is a layer of nonciliated simple columnar epithelial cells called surface mucous cells.

There are also many columns of secretory cells called gastric glands that line narrow channels called gastric pits. That is, epithelial cells not only line the inside surface of the stomach, but also form many narrow passages called gastric pits that lead from the lumen of the stomach outwards towards the inner stomach wall, or submucosa.

Explain the mechanism of action for a drug like omeprazole. How does an antacid like Tums work.

An antacid is a substance which neutralizes stomach acidity, used to relieve heartburn, indigestion or an upset stomach

Antacids are distinct from acid-reducing drugs like H2-receptor antagonists or proton pump inhibitors and they do not kill the bacteria Helicobacter pylori, which causes most ulcers.

Mechanism of action Omeprazole is a selective and irreversible proton pump inhibitor. It suppresses stomach acid secretion by specific inhibition of the H+/K+-ATPase system found at the secretory surface of gastric parietal cells

Mechanism of action in the treatment of peptic ulcers is based on ability of antacids to react with hydrochloric acid and thus increase gastric pH. With usual doses, antacids generally do not increase and maintain gastric pH above 4–5.

Antacid like Tums work?

Calcium carbonate, sold under the brand nameTums, can be used to relieve symptoms of stomach upset due to acid reflux (heartburn) or gas. Calcium carbonate belongs to group of drugs called antacids, which work by neutralizing stomach acid in the body.

What is the risk of chronic acid reflux?

Barrett's esophagus. Barrett's esophagus is a condition that develops in some people (about 10%) who have long-term GERD. It is a risk factor for cancer of the esophagus. Damage from acid reflux can cause abnormal changes in the lining of the esophagus.

If left untreated for many years, constant acid reflux cancause precancerous changes in cells, a condition known as Barrett's esophagus. A small fraction of people with Barrett's esophagus develop esophageal cancer, which is often deadly.

If the barium swallow is inconclusive, what is another test that can be ordered that will look for evidence of abnormal growths (polyps) in the upper GI tract?

Barium swallow is a type of upper GI series; the endoscopy x-ray happens the same way, but is limited to the pharynx and esophagus. Barium swallow is not designed to detect issues with a patient’s stomach and small intestine. The procedure involves drinking a barium contrast solution and using a special kind of x-ray referred to as fluoroscopy is used to capture moving images of the patient’s upper GI tract.

Another test

High-sensitivity fecal occult blood tests (FOBT). Both polyps and colorectal cancers can bleed, and FOBT checks for tiny amounts of a blood in feces (stool) that cannot be seen visually. (Blood in stool may also indicate the presence of conditions that are not cancer, such as hemorrhoids.)

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