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