GERD

Presentation outline

PART I

DISEASE’S PATHALOGY & MANGEMENT

1- introduction

2- Causes

3- Sings & Symptoms

4- Complication

5- Diagnosis

6- Management

Presentation outline

PART II

CASE’S EXEPLATION

PART I

DISEASE’S PATHALOGY

& MANGEMENT

What is GERD

GERD states it is a condition that occurs

when the refluxed stomach contents lead

to trouble.

Disorder in lower esophagus sphincter

GERD affects all ages especially after 40

years

The gender doesn't play a role in the

disease .

The mortality of GERD is rare .

Death occur in Barrett’s esophagus that

lead to esophagus adenocarcinoma

Diagnosis

Symptoms (Heartburn , Regurgitation)

Barium Swallow

An upper endoscopy

Esophageal manometry

Ambulatory–pH monitoring test

Barium Swallow

Barium sulfate is a metallic

compound that shows up on X-

rays

The X-rays track its path

through patient digestive

system .

o Patient drink a preparation

containing this solution

An upper endoscopy

visually examine upper

digestive system with a tiny

camera on the end of a long,

flexible tube.

Esophageal manometry

Esophageal manometry is a test to measure how

well the esophagus is working.

A thin, pressure-sensitive tube is passed through

patient nose, down the esophagus, and into patient

stomach.

What is GERD ?

GERD states it is a condition that occurs when the refluxed stomach contents lead to trouble symptoms and/or complications.

GERD affects all ages espacially after 40 years.

The gender doesn't play a role in the disease

The mortality of GERD is rare .

Phathophysiology

The main problem in the

development of GERD is the

abnormal reflux of gastric

contents from the stomach into

the esophagus.

This is due to :

1- Lower Esophageal Sphincter Pressure

2- anatomical causes

GERD Causes

*Lower Esophageal Sphincter Pressure

Different mechanisms by which defective

LES pressure lead gastroesophageal

reflux.

1- LES relaxations that are not

associated with swallowing. Although

the exact mechanism is unknown.

2- postprandially, may play an important

role in symptom-based esophageal

reflux syndromes.

3- intraabdominal pressure (stress

reflux)

Anatomical factor

Disruption of the normal anatomic barriers

by a hiatal hernia (when a portion of the

stomach

protrudes through the diaphragm into the

chest) was once thought to be a primary

etiology of

gastroesophageal reflux

Special casePregnancy

1- hormonal effects on esophageal muscle

2- physical factors (increased intraabdominal

pressure)

Composition of Refluxate

the combination is gastric acid, pancreatic

enzymes pepsin, and/or bile is a potent

refluxate in producing esophageal

damage.

The composition, pH , volume of the

refluxate

are important aggressive factors in

determining the GERD

Defensive mechanism

Esophageal clearance

Mucosal resitance

Gastric empting

Food & Medications may worse GERD

causjGERD

Sings & Symptoms

Heartburn

Regurgitation

Water brash

( hyper salivation)

belching

Atypical Symptoms

Nonallergic asthma

Hoarseness

Pharyngitis

Chest pain

Dental erosions

Complication

Alarm symptoms symptoms may be

indicative of complications of GERD such

as

Stricture

Barrett’s esophagus

esophageal adenocarcinoma

Other alarm symptoms

Dysphagia

Odynophagia

Bleeding

Weight loss

Diagnosis

Symptoms (Heartburn , Regurgitation)

Barium Swallow

An upper endoscopy

Esophageal manometry

Ambulatory–pH monitoring test

Barium Swallow

Barium sulfate is a metallic

compound that shows up on X-

rays

The X-rays track its path

through patient digestive

system .

o Patient drink a preparation

containing this solution

An upper endoscopy

visually examine upper

digestive system with a tiny

camera on the end of a long,

flexible tube.

Esophageal manometry

Esophageal manometry is a test to measure how

well the esophagus is working.

A thin, pressure-sensitive tube is passed through

patient nose, down the esophagus, and into patient

stomach.

After the tube is in the stomach, the tube is pulled

slowly back into patient esophagus.

At this time, patient is asked to swallow

The pressure of the muscle contractions is

measured along several sections of the tube.

While the tube is in place, other studies of your

esophagus may be done. The tube is removed after

the tests are completed.

Ambulatory–pH monitoring

test

Small tube passed through the nose into

the esophagus at the level of the LES.

A pH sensor at the tip of the tube collected

on a portable computer.

Treatment

1) Non-Pharmacologic treatment

Lifestyle changes

2) Pharmacologic treatment therapy with antacids,nonprescription H2-receptor antagonists, and/ornonprescription proton pump inhibitors Providesymptomatic relief, and prescription strengthacid-suppression therapy .

3) Anti-reflux surgery .

Elevating the head end of the bed by approximately (15

to 20 cm) with a foam wedge under the mattress .

Weight loss

Avoid food that may decrease lower esophageal

sphincter like ( fat, chocolate, cola, spearmint,

alcohol(wine), pepper, Garlic, onion )

Avoid food that have the direct irritant of esophageal

mucosa like (spicy, citrus juice, tomato, coffee,

Tobacco )

Include protein rich meal in diet (augment ( increase )

lower esophageal sphincter )

Always take drugs in the setting upright .

Avoidance of tight-fitting clothes .

Lifestyle modifications

DosesRecommended drug

30ml need after meal, and at bedtime

15ml need after meal, and at bedtime

Maalox

Gaviscon

10mg up to twice daily /2weekFamatodine ( Pepcid Ac )

75mg up to twice daily /2week Rantidine ( Zentac )

20mg up to twice daily /2weekOmeprazole ( Prilosec )

15mg up to twice daily /2weekLanzoprazole ( Prevacid )

Pharmacologic treatment

The goal of antireflux surgery is to reestablish the antirefluxbarrier, to position the LES within the abdomen where itis under positive ( intraabdominal ) pressure, and to closeany associated defect in the diaphragmatic hiatus byreinforcing the crural muscles .

Antireflux surgery should be considered for patients :

Who fail to respond to pharmacologic treatment.

Who opt for surgery despite successful treatmentbecause of lifestyle considerations, including age, time,or expense of medications.

Who have complications of GERD (e.g., Barrett’sesophagus, strictures).

Who have atypical symptoms and reflux documentedwith ambulatory pH monitoring .

Anti-reflux surgery

Management

Patient with

compliant of

heartburn

Life style

modification

OTC drug

Anti-acid 2 W.

H2-receptor

antagonist twice

daily

PPI one a day

4-8 W.

PPI twice daily

4-16 W.

Reduce or

Stop

medicine

Mano&

Amb.

pH

Endoscopy

Surgical

intervent

ion

Maintenance

Therapy

With minimum

eff. dose

NO

No

No

No

No

Yes

Yes

A

L

A

R

M

S

y

m

p

t

o

m

s

Chief Complaint

“I’m having a lot of heartburn, especially aftereating. These pills and liquids I’ve tried seem towork for a little while, but then they wear off.”

History of Present Illness

George Anderson is a 58-year-old man

complaints of heartburn four to five times a weekover the last 4 months .

episodes of regurgitation, after which he is left withan acidic taste in his mouth

symptoms wake him up at night approximatelyonce a week

tried Extra Strength Maalox liquid first and then

Pepcid AC tablets .

He took the Pepcid AC 10 mg twice daily for 1 week .

This worked intermittently but didn’t provide enough

relief

Past Medical History

HTN × 12 years

CKD × 2 years

Type 2 DM × 5 years

Social History

• He drinks one to two beers a day after work, 4–5 days per week.

• He has a 25 pack-year history of tobacco use and currently smokes 1 ppd.

Medication history

Amlodipine 5 mg once daily

Glyburide 5 mg twice daily

Aspirin 81 mg daily

Ibuprofen 200–400 mg PRN for headaches and pain

Reports occasional tension

Headaches but no visual changes, aura, or dizziness .

(–) Shortness Of Breath , cough, or hoarseness .

(+) frequent episodes of a burning pain in his

stomach area and travels up his chest associated

with an acidic taste in his mouth .

(–) N/V

(–) Bright red blood per rectum or dark/tarry stools

(–) dysuria, nocturia, or frequency;

Reports some mild ankle swelling in both ankles

He has gained approximately 8 pounds over the last 6

months

Physical Examination

VS : BP 149/89, P 87, RR 17, T 36°C; Wt 99 kg, Ht 5'10''

Abd : Obese;

(+) BS;

MS/Ext : No CVA tenderness;

( 1+) pitting LE edema bilaterally

Labs

Fasting Glu 200mg/dL ( high)

TC 230 mg/dL ( high)

LDL 146 mg/dL ( high)

TG 187 mg/dL ( high)

HDL 39 mg/dL ( Low )

Assessmentman presenting with uncontrolled GERD symptoms

despite self-treatment with OTC H2RA and antacid

therapy .

Problem Identification :

Drug therapy problems

Identification

Efficacy

Safety

Compliance

SOAP Notes

GERD★Insufficient drug therapy S: Uncontrolled GERD symptoms (Heartburn (4-5)times in

week , regurgitation, acidic taste in his mouth) .

O: ____________

A: May be due to the patient didn’t take enoughdose & time of Pepcid AC therapy .

Usual adult dose for GERD :20mg orally /twicedaily up to 6 weeks .

Or the patient didn’t take the first line therapy ofGERD ( PPI)

P:

Aim /

a- Alleviate the patient symptoms

b- Decrease frequency of recurrent disease .

c- Prevent GERD complications (strictures, Barrett’sesophagus, or possibly adenocarcinoma )

Therapy /

Non pharmacological therapy :

Pharmacological therapy :

Using PPI, the drug of choice for patient withmoderate to severe GERD

Omeprazole 20mg orally twice daily up to 4 weeks .

Monitoring :

Efficacy of PPI ( Omeprazole ) : according to relied

of symptoms in the patient or Ambulatory PH

monitoring .

Toxicity of Omeprazole ( Ca+2, Mg+2, Vit B12 Levels )

.

★Unsafe drug therapy

S: Uncontrolled GERD symptoms

O: ____________

A: also, may result from using CCB (Amlodipine ),which decrease lower esophageal sphincter pressure& delay gastric emptying .

P:

Aim :

• Alleviate the patient symptoms

• Decrease frequency of recurrent disease .

• Prevent GERD complications (strictures, Barrett’sesophagus, or possibly adenocarcinoma ) .

Therapy :

• Stop Amlodipine, & start to use ACEI for HTN

treatment

• ACEI : are recommended as the first line therapy of

Hypertension in patient with CKD & DM .

S: GERD symptoms

O: ____________

A: Maalox antiacid ( Al(OH)3 + Mg(OH)2 )

( This drug contain Al+3 which lead to toxicity in thispatient, who is suffering from CKD ) .

Toxicity due to accumulation Al+3 in patient with CKD :

Osteomalacia

Alzehimers disease

P:

Aim :

To prevent toxicity of Al+3

Therapy :

Stop Maalox

★Improper Drug Selection :

S: Headache, Pain .

O: ____________

A:

Ibuprofen 200mg PRN for headache & pain

The use of NSAID drugs or aspirin is an

additional risk factor that may suitable to the

development or worsening of GERD complication

.

( NSAIDs cause direct irritation )

P:

Aim :

• Alleviate the patient symptoms

• Decrease frequency of recurrent disease .

• Prevent GERD complications (strictures,

Barrett’s esophagus, or possibly

adenocarcinoma ) .

Therapy :

Stop Ibuprofen and replaced with Paracetamol for

headache and pain when needed .

Hypertension

★ Ineffective drug therapy

S: ____________

O: B.P = 149/89mmHg

A: this drug didn’t effective to decrease SBP<

140mmHg .

P :

Aim :

• Decrease SBP < 140mmhg & DBP < 90mmHg

• To reduce renal mortality & morbidity, also decrease

CV risk .

Therapy :

Non pharmacology therapy :

• Maintain normal body weight ( during weight

loss ) ( BMI 18-25 )

• BMI of this patient 31.2

• Eating food rich in Fruits, Vegetables, Grains,

Low in fats & cholesterol .

• Reduce dietary Na+ :2,4 g/day Na+ (not more )

• Exercise ( Walking ) 30min/day .

• Limit alcohol drinking .

• Smoking cessation .

Pharmacological therapy :

• Stop Amlodipine ( unsuitable for patient state ) ,

• Use ACEI ( Enalapril 5mg/twice daily ) .

• according to American recommendation, ACEI is used

as first line treatment in Hypertension patient with

Chronic Kidney Disease ( CKD ) or with Diabetes

mellitus

• ACEI has beneficial effect on renal function, make

efferent arteriolar vasodilatation , decrease

intraglomerular pressure .

Monitoring :

Efficacy of Enalapril : B.P measurement .

Toxicity of Enalapril : CrCl, K+ level .

★Unsafe drug therapy :

S: Mild ankle swelling in both ankles.

O: ____________

A: this patient’s adverse effect result from using ofAmlodipine therapy .

P:

Aim :

• The removal of this adverse effect .

• Enhance quality of life of patient .

Therapy : Stop Amlodipine therapy.( replacedwith ACEI ) .

Monitoring : Disappearance of this adverse effect( ankle swelling ) .

★Inappropriate indication for drug use

S: ____________

O: TC 230 mg/dL , LDL 146 mg/dL , TG 187 mg/dL , HDL 39mg/dL

A: This patient has high lipid profile ( Total cholesterol, LDL,TG, Low HDL )

Which is additional risk for CV events, and he doesn't takeAnti-hyperlipidemia therapy .

P:

Aim /

• Normal level of lipid profile ( TC=less than 200 mg/dl,LDL=below 100 , TG=below 150 , HDL=40-60 or more

• Decrease risk for CV

Therapy :

• non-pharmacological :

• Weight loss

• Reduce intake of Fat & Cholesterol

• Increase intake of Omega 3

• Pharmacological

Use of statin : Atorvastatin 20 mg

Diabetes mellitus

★Insufficient & Improper Drug Selection :

S: ____________

O: Fasting glucose = 200 mg/dl A1C = 8,6 %

A:

Glyburide didn't decrease his blood glucose.

This patient didn't use preferred initial agent which is

has beneficial effect in this pt. (wt. gain, high risk of

CV event )

★Unsafe drug therapy :S: ____________

O: BMI = 31.2 obese

A:

Obesity in this pt. may results from use Glybruide

(it's is one of adverse effect: wt. gain),

This is risk factor which increase CV events in the

other risk factors present in this pt.

P:Aim

Control blood glucose level

Prevent DM complications ( nephrophathy, neurpathy

& retiropathy )

Therapy :

NON pharmacological :

• Diet

• Weight loss

• Physical activity

Pharmacological :

• Stop glyburide ( not effective in decrease glucose

level, And has disadvantage : weight gain)

• Replaced it with Metformin, initiate with dose 500 mg

twice daily

No dose adjustment in this patient ( which is

suffering from CKD ) .

According to :

Cockreft-gault Eq. CrCl = 59.34 ml/min ( in stage 3 -

moderate- )

Dose adjustment of Metformin in renal disease if

CrCl<30 ml/min

Monitoring of Metformin :

Efficacy :

Fasting glucose test

A1C

Toxicity :

Vit B12 level ( it cause vit B12 deficiency ) .

Aspirin 81mg , Why ??!!!