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Transcript of GERD
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GERD GERD GERD
Dr. Rocky Danilo Willis, M.D., AMT
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CASE 1
•J.D.•28 years old•Male•Roman Catholic
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Chief complaint
CHEST PAIN
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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
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• Few hours ptc – still w/ s/s now with feeling of
nausea hence consult to opd
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Past Medical history
•Unremarkable
Family History- unremarkable
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Personal and Social History
•( + )10 pack/year smoker ( + ) occasional alcoholic beverage drinker ( + ) heavy coffee drinker consuming 3-4 cups ( - ) allergy to food and drugs
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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
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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
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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
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• 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
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• 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
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• Abdomen:• Globular abdomen, hypoactive bowel sounds,
distended, non tender, no hepatosplenomegaly
• Extremities:no cyanosis, full and equal pulse
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Diagnosis
GASTROESOPHAGEAL REFLUX DISEASE
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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
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ANTI REFLUX MECHANISMS
•LES•Crural diaphragm•Anatomic location of GE junction below
diaphragmatic hiatus
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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
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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
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•Reflux esophagitis- complication of reflux
•Peptic stricture – results from fibrosis causing luminal obstruction
- occur in 10 % patient untreated gerd
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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
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EXTRAESOPHAGEAL MANIFESTATIONS
•due to reflux of gastric contents to pharynx,larynx,nose and mouth
•Can cause – chronic cough, laryngitis, pharyngitis and mouth, moarning hoarseness
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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
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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
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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
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Documentation of Pathophysiology•Indicated for management decisions of
antireflux surgery•Esophageal motilility – useful for
quantitative information of competence of LES or esophageal motor function
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TREATMENT
GOALS 1. Symptomatic relief2. Heal erosive esophagitis3. Prevent complications
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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
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•DRUGS ( h2 receptor blocker ) - cimetidine 300 mg qid - ranitidine 150 mg bid - famotidine 20 mg bid - nizatidine 150 mg bid
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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
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•ANTI REFLUX SURGERY – gastric fundus wrapped around esophagus ( fundoplication)
so it can create anti reflux barrier
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THANK YOU