Unformatted text preview: Gastro-esophageal
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
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
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
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
complete sentences, sitting up in bed.
HEENT: Normocephalic atraumatic. Pupils equal and equally reactive to
light. No carotid bruit. No JVD.
CVS: Regular rate and rhythm, S1, S2, no murmurs, rubs, or gallops.
Lungs: Clear to auscultation bilaterally. No wheezing or rales.
Abd: +BS, soft nontender, non distended. Negative hepatojugular reflex
Ext: no rashes. No Clubbing, cyanosis, or edema.
Neuro: Alert, oriented X3. C II-XII grossly intact.
Psych: Grossly normal cognition, though and speech are coherent.
BMP - all within normal range.
Lipid levels – all within normal range
EKG- normal sinus rhythm Differential Diagnosis
Differential Peptic ulcer disease
Parasitic infection e.g. Giardia, Strongyloides, Ascaris
Asthma Screening Questions
Screening A feeling of pain that starts in stomach and
feeling spreads up the front of chest?
A burning sensation deep in the throat?
Bitter, salty, or sour taste in mouth?
A feeling that something you ate a while ago is
coming back up?
Awakened at night by a feeling of heartburn,
coughing or choking.
Each question is rated on a scale of 1-5 based
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
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. GERD is a
GERD multifactorial problem
transient relaxation of
the lower esophageal
sphincter Diagnostic Tests
Diagnostic Endoscopy: shows esophagitis Barium swallow: may show reflux from stomach
to Manometry: shows decreased LES pressure Bernstein test: Soln of 0.1 M HCl is dripped into
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
Stop alcohol consumption
Avoid bedtime snacks
Avoid the following foods: Chocolate Citrus juices Coffee Cola
Avoid the following drugs: Alpha adrenergic blockers Anticholinergics CCB Narcotics Theophylline Treatment
Calcium Tums Maalox
Bicarbonate Alka-Seltzer 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
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
3 months or those with atypical symptoms
should be referred for endoscopy.
should Patient with longstanding GERD and older then
50 yrs old should have at least one endoscopy
to screen for metaplasia.
to Patients with Barrett’s esophagus should go for
endoscopy every 2-3 years
Discussion/Questions History alone is often insufficient to distinguish a
cardiac source of pain from an esophageal
source. Cardiac disease must be excluded first b/c of its
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;
39: Washington Manual for Family Medicine, GI
problems, 11.2, John P. Muench and Alexandra
Verdieck Journal of Long-Term of Medical Implants, 15(4)
375-388 (2005) Management of Gastro
esophageal Reflux Disease: Medication,
Surgery, or Endoscopic Therapy?, Zhi, Kavic,
View Full Document
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.
- Fall '11