gerd
TRANSCRIPT
GERD GERD GERD
Dr. Rocky Danilo Willis, M.D., AMT
CASE 1
•J.D.•28 years old•Male•Roman Catholic
Chief complaint
CHEST PAIN
History of present illness
1 week ptc ------ ( + ) chest pain, 3/10 in pain scale ,non radiating w/ feeling of burning like sensation especially when lying down,and relieved by sitting down position ( + ) dysphagia ( - ) nausea/vomiting ( - ) dizziness ( - ) dob
• Few hours ptc – still w/ s/s now with feeling of
nausea hence consult to opd
Past Medical history
•Unremarkable
Family History- unremarkable
Personal and Social History
•( + )10 pack/year smoker ( + ) occasional alcoholic beverage drinker ( + ) heavy coffee drinker consuming 3-4 cups ( - ) allergy to food and drugs
Review of Systems
• General: no fever, no chills, (-) body weakness, no body malaise
• Neuro: no headache, no dizziness• Cardivascular: ( + )chest pain, no palpitations,
no orthopnea• Respiratory: no cough, no colds, no dob, no
shortness of breath
Review of systems
• Digestive: ( + )nausea, no vomiting, no retching, no epigastric pain
• Genitourinary: no polyuria, no dysuria, no increase in frequency
• Hematology: no bleeding manifestations
Physical examination
• General Survey• conscious, coherent, ambulatory
• Vital Signs:• BP: 120/80mmHg HR: 76 bpm • RR: 20 cpm T: 36.6°C• Wt: 110 kgs
• Head/EENT:• pink palpebral conjunctivae, anicteric sclerae, no
nasoaural discharge, non hyperemic posterior pharyngeal wall
• Neck• supple neck, no cervical lymph adenopathies
• no neck vein engorgement
• Chest/Lungs:• symmetrical chest expansion, no retractions,
clear breath sounds
• Heart:• adynamic precordium, normal rate, regular
rhythm, apex beat at 5th LICS MCL, no murmur
• Abdomen:• Globular abdomen, hypoactive bowel sounds,
distended, non tender, no hepatosplenomegaly
• Extremities:no cyanosis, full and equal pulse
Diagnosis
GASTROESOPHAGEAL REFLUX DISEASE
GERD
- Most prevalent GI disorders- 15 % individuals have heartburn 1x/week- 7 % symptoms daily- Caused by backflow of gastric acid and
other gastric contents into esophagus due to incompetent barriers at the GE junction
ANTI REFLUX MECHANISMS
•LES•Crural diaphragm•Anatomic location of GE junction below
diaphragmatic hiatus
REFLUX
- occurs when gradient pressure between LES and stomach is lost- Due to sustained or transient decrease in
LES stone Secondary causes of LES incompetence- Scleroderma-like
disease,myopathy,pregnacy,smoking,anticholinergic drugs,smooth muscle relaxants,esophagitis surgical damage to LES
Apart of incompetent barriers, reflux are most likely due to1. Gastric volume is increased – after
meals,in pyloric obstruction, gastric stasis, during hyperacid secretion states
2. Gastic contents are near to GE junction – recumbency, lying down, hiatal hernia
3. Inc. Gastric pressure - obesity, pregnacy,ascites, tight clothes
•Reflux esophagitis- complication of reflux
•Peptic stricture – results from fibrosis causing luminal obstruction
- occur in 10 % patient untreated gerd
CLINICAL FEATURES
•Heartburn and regurgitation of sour material
-characterized symptoms of GERD -induced by contact of refluxed material with sensitized or ulcereated esophageal mucosa
- Angina like symptoms or atypical chest pain occurs in some patient
EXTRAESOPHAGEAL MANIFESTATIONS
•due to reflux of gastric contents to pharynx,larynx,nose and mouth
•Can cause – chronic cough, laryngitis, pharyngitis and mouth, moarning hoarseness
DIAGNOSIS
•Can be made by history alone•Therapeutic trial of PPI x 1 week –support
for diagnosis DIAGNOSTIC APPROACH1. Documentation of mucosal injury2. Documentation and quanification of
reflux3. Definition of pathophysiology
Documentation of mucosal injury• barium swallow- reveal ulcer
• esophagoscopy- reveals erosions,ulcers, peptic strictures,barrets metaplasia w/ or w/o ulcer, adenoCA
- not diagnostic of gerd- Mucosal biopsy- 5 cm above LES
- Bernsteins test- infusions of solutions of 0.1 N hcl or NSS into esophagus
Documentation and Quantification of Reflux•24-48 hr esophageal pH monitoring - achored to esopahgeal mucosa via endoscope - evaluation of acid refluxImpedance test – documenation of non acid test
Documentation of Pathophysiology•Indicated for management decisions of
antireflux surgery•Esophageal motilility – useful for
quantitative information of competence of LES or esophageal motor function
TREATMENT
GOALS 1. Symptomatic relief2. Heal erosive esophagitis3. Prevent complications
MILD CASES - weight reduction - sleeping w/ head elevated 4-6 cms - eliminate factors causes of increase abdominal pressure - no smoke - avoid fatty foods,coffee,chocolate, alcohol- AVOID DRINK LOTS OF FLUIDS W/ MEALS
•DRUGS ( h2 receptor blocker ) - cimetidine 300 mg qid - ranitidine 150 mg bid - famotidine 20 mg bid - nizatidine 150 mg bid
Proton Pump Inhibitors
•More effective•Prevent recurrence - omeprazole 20 mg od - lansoprazole 30 mg od - esomeprazole 40 mg od - rabeprazole 20 md > x 8 weeks can heal erosive esophagitis in 99 % patients
•ANTI REFLUX SURGERY – gastric fundus wrapped around esophagus ( fundoplication)
so it can create anti reflux barrier
THANK YOU