GERD - Gastro-esophageal Reflux Disease Reflux Monica...

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Unformatted text preview: Gastro-esophageal Reflux Disease Reflux Monica Williams, MS 3 Morehouse School of Medicine CC: Follow up for hypertension, and “heart-burn” HPI: MM is a 45 y.o. African-American man with a HPI: history of asthma, that presents to the clinic for follow-up for hypertension. He currently reports gnawing epigastric pain, that is a 8/10 at it’s worst. He says he’s had it for years, but this past year, it comes at least once a day. It lasts for 1-2 hours after eating, and is relieved by antacids. The pain is usually accompanied by nausea, and on occasion vomiting. It is worsened by eating, laying down and alcohol. The patient feels that starchy foods, and dairy products trigger the “heartburn”. He denies fever, night sweats, cough, diarrhea, hematemesis, constipation, new medicines and shortness of breath. He reports using aspirin nightly, and smokes cigarettes (1ppd). and PMH: Well controlled hypertension (off PMH: meds for 2 years), and asthma. Negative for diabetes, and hyperlipidemia. for Meds: Tums, and pepto-bismal Allergies: NKDA FH: Mother – DM FH: Social History: Married and lives with Social spouse. 25 year history of smoking 1 ppd. Drinks about 10 drinks in a week. Denies recreational drug use. recreational VS: BP 117/74 R 15 P 65 Temp 97.8 PE: general: well nourished, well developed, no acute distress, speaking in general well complete sentences, sitting up in bed. HEENT: Normocephalic atraumatic. Pupils equal and equally reactive to HEENT light. No carotid bruit. No JVD. light. CVS: Regular rate and rhythm, S1, S2, no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. No wheezing or rales. Lungs Clear Abd: +BS, soft nontender, non distended. Negative hepatojugular reflex Abd Ext: no rashes. No Clubbing, cyanosis, or edema. Ext Neuro: Alert, oriented X3. C II-XII grossly intact. Neuro Psych: Grossly normal cognition, though and speech are coherent. Psych Labs: BMP - all within normal range. Lipid levels – all within normal range Lipid EKG- normal sinus rhythm Differential Diagnosis Differential Peptic ulcer disease GERD Gastritis Parasitic infection e.g. Giardia, Strongyloides, Ascaris Cholelithiasis Abdominal hernia MI/Angina Pulmonary Embolism Aortic Aneurysm Asthma Screening Questions Screening A feeling of pain that starts in stomach and feeling spreads up the front of chest? spreads A burning sensation deep in the throat? Bitter, salty, or sour taste in mouth? A feeling that something you ate a while ago is feeling coming back up? coming Awakened at night by a feeling of heartburn, Awakened coughing or choking. coughing Each question is rated on a scale of 1-5 based Each on frequency. A 91% of patients with a score under 21.5 did not have GERD. under Reasons to think GERD Reasons Patient had a burning sensation in his chest Patient when laying down. Felt sour taste in his mouth Scored 23 on screening exam Denies chest pain and SOB General PE of chest and abdomen were normal Gastroesophageal Gastroesophageal Reflux Disease (GERD), is a condition that affects 36% of the US population. population. GERD is a GERD multifactorial problem usually involving transient relaxation of the lower esophageal sphincter (LES). sphincter Diagnostic Tests Diagnostic Endoscopy: shows esophagitis Barium swallow: may show reflux from stomach Barium to esophagus to Manometry: shows decreased LES pressure Bernstein test: Soln of 0.1 M HCl is dripped into Bernstein distal esophagus at 8 cc/hr. A positive test reproduces patients symptoms. Saline is used as a control. as 24 hour esophageal pH monitoring Treatment Treatment Lifestyle modification: Stop smoking Stop alcohol consumption Avoid bedtime snacks Lose weight Avoid the following foods: Chocolate Citrus juices Coffee Cola Avoid the following drugs: Alpha adrenergic blockers Anticholinergics CCB Narcotics Theophylline Treatment Treatment Antacids Calcium Carbonate Calcium Tums Maalox Bismuth Pepto-Bismol Sucralfate Carafate Bicarbonate Alka-Seltzer Treatment Treatment Histamine 2 receptor antagonist Cimetidine Tagamet 400 or 800 mg twice daily Famotidine Pepcid 20 or 40 mg twice daily Rantidine Zantac 150 or 300 mg twice daily Proton pump inhibitors Lansoprazole Nexium 20 or 40 mg daily Omperazole Priolsec 10 or 20 mg daily Promotility agents Metoclopramide Reglan Surgical Intervention Surgical fundoplication for incapacitating disease Complications Complications Ulcers Strictures Barrett's esophagus Cough and asthma Inflammation of the throat and larynx Fluid in the sinuses and middle ears (mainly in children) (mainly When to Refer When Patients who have not responded to treatment in Patients 3 months or those with atypical symptoms should be referred for endoscopy. should Patient with longstanding GERD and older then Patient 50 yrs old should have at least one endoscopy to screen for metaplasia. to Patients with Barrett’s esophagus should go for Patients endoscopy every 2-3 years endoscopy Discussion/Questions Discussion/Questions History alone is often insufficient to distinguish a History cardiac source of pain from an esophageal source. source. Cardiac disease must be excluded first b/c of its Cardiac more serious consequences. Patient was educated on lifestyle modification. Patient Patient was started on H2RA, Pepcid. References References Zimmerman J. Validation of a brief inventory for Zimmerman diagnosis and monitoring of symptomatic gastrodiagnosis esophageal reflux. Scand J Gastroenterol 2004; esophageal 39: 212-6. 39: Washington Manual for Family Medicine, GI Washington problems, 11.2, John P. Muench and Alexandra Verdieck 306-308 Verdieck Journal of Long-Term of Medical Implants, 15(4) Journal 375-388 (2005) Management of Gastro esophageal Reflux Disease: Medication, Surgery, or Endoscopic Therapy?, Zhi, Kavic, Park Park ...
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This note was uploaded on 01/12/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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