Gastroenterology Book

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Gastroesophageal RefluxAka: Reflux Esophagitis, Heartburn, Acid Reflux, Acid Regurgitation, Water Brash, Pyrosis, GERD

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  1. See Also
    1. Pediatric Reflux
    2. Hiatal Hernia
  2. Epidemiology
    1. Incidence: 36% in U.S.
    2. Most take OTC medications and do not seek medical help
    3. GERD patients wait 1-3 years before seeing a doctor
  3. Risk Factors for reduced LES pressure
    1. Smooth muscle relaxants
      1. Aminophylline
      2. Nitrates
      3. Calcium Channel Blockers
      4. Caffeine
      5. Inhaled Albuterol
        1. Crowell (2001) Chest 120:1184
    2. Tobacco abuse
    3. Pregnancy
    4. Scleroderma
  4. Complications of Gastroesophageal Reflux
    1. Barrett's Esophagus (10-20% Incidence)
    2. Asthma
    3. Persistent Chest Pain
    4. Chronic Cough
    5. Dental Erosions (dental enamel loss)
    6. Hoarseness
    7. Laryngeal cancer
    8. Persistent Pharyngitis
    9. Vocal Cord Polyps
    10. Subglottic stenosis
  5. Symptoms: Classic
    1. Heartburn (Initial GERD symptom)
      1. Location: Epigastric and retrosternal
      2. Characteristic: Caustic or stinging
      3. No radiation to the back
    2. Acid regurgitation (Water Brash or Pyrosis)
      1. Suggests progressing GERD
      2. Provoked by lying supine or leaning forward
      3. Regurgitation of digested food or clear burning fluid
      4. Undigested food suggests alternative diagnosis
        1. Achalasia
        2. Esophageal Diverticulum
    3. Difficult swallowing (Dysphagia)
      1. See Dysphagia from Esophageal Cause
      2. Mechanical obstruction of solid foods
        1. Suggests peptic stricture
      3. Liquid obstruction suggests alternative diagnosis
        1. Neuromuscular disorder
        2. Neoplasm
        3. Esophageal diverticulum
  6. Symptoms: Atypical
    1. Abdominal Pain (29%)
    2. Chronic Cough (27%)
    3. Hoarseness (21%)
    4. Belching (15%)
    5. Bloating (15%)
    6. Aspiration (14%)
    7. Wheezing (7%)
    8. Globus Hystericus (4%)
    9. Recurrent Pharyngitis
  7. Signs: Orofacial effects of chronic acid reflux
    1. Dental Erosions (yellow discoloration)
    2. Masticatory Mucosa inflammation
    3. Chronic Sinusitis
  8. Red Flag Symptoms Indicating Evaluation (e.g. Endoscopy)
    1. Dysphagia
      1. Immediately assess for Barrett's Esophagus
    2. Odynophagia
      1. Assess for Esophageal Ulcer
    3. Weight Loss (Suggests Dysphagia or Odynophagia)
    4. Early satiety or Vomiting
    5. Aspiration
    6. Wheezing or cough
    7. Gastrointestinal Bleeding
    8. Unexplained Iron Deficiency Anemia
      1. Suggests esophageal ulcer
    9. High risk patients
      1. Male over 45 years old with longstanding symptoms
      2. Elderly with reflux (use high level of suspicion)
        1. Even serious pathology may present as mild GERD
        2. Johnson (2004) Gastroenterology 126:660
  9. Differential Diagnosis
    1. Myocardial Ischemia (Angina)
    2. Peptic Ulcer Disease
    3. Cholelithiasis
  10. Pathophysiology
    1. Transient relaxation of lower esophageal sphincter
  11. Diagnosis: Indicated for complicated or refractory cases
    1. pH probe (24 hour pH monitoring)
      1. Test Sensitivity: 70 to 96%
      2. Test Specificity: 70 to 96%
    2. Upper endoscopy
      1. Test Sensitivity and Specificity are low
      2. Standard for evaluating GERD complications
  12. Management: General Measures
    1. Drink 8 glasses (8 ounces) non-caffeinated fluid daily
    2. Decrease provocative foods
      1. Decrease or eliminate caffeine
      2. Avoid spicy foods
      3. Avoid milk products toward end of day
      4. Avoid chocolate
      5. Avoid fatty foods
    3. Tobacco Cessation
    4. No eating food 2-3 hours before bedtime
    5. Elevate head of bed to 30 degrees
      1. Place 6-8 inch blocks under legs at head of bed
      2. Place Styrofoam wedge under mattress
    6. Symptomatic therapy for mild intermittent symptoms
      1. OTC Antacid medications (e.g. Maalox, Tums, Rolaids)
        1. More effective than Placebo for GERD symptoms
        2. Chatfield (1999) Curr Med Res Opin 15:152
      2. Antacid chewing gum (Surpass by Wrigley)
  13. Management: Medications
    1. Institute general measures above
    2. Proton Pump Inhibitor
      1. All Proton Pump Inhibitors equivalent in GERD
        1. Klok (2003) Aliment Pharmacol Ther 17:1237
      2. Initial treatment for 6 to 12 weeks
        1. Use high dose (twice daily) for severe symptoms
      3. Taper to lower dose for 4 to 8 weeks
      4. Trial off Proton Pump Inhibitor
    3. Consider H2 Blocker maintenance therapy
    4. Medications not found to be beneficial
      1. Sucralfate (Carafate) offers minimal benefit in GERD
  14. Management: Refractory (recurs off Proton Pump Inhibitor)
    1. Restart Proton Pump Inhibitor (e.g. Omeprazole)
    2. Consider Endoscopy (EGD)
      1. Evaluate for Barrett's Esophagus
    3. Consider evaluation for Anti-Reflux Surgery
      1. Upper Endoscopy (evaluate for Barrett's Esophagus)
      2. Upper Gastrointestinal Series (defines anatomy)
      3. Manometry
      4. 24-Hour pH Monitoring
  15. Follow-up
    1. Normal upper endoscopy (EGD)
      1. No repeat EGD for 10 years unless symptoms progress
      2. Schnell (2001) Gastroenterology 120:1607
  16. References
    1. Feldman (1998) Sleisenger GI, Saunders, p. 509-17
    2. Townsend (2001) Sabiston Surgery, Saunders, p. 755-66
    3. Devault (1999) Am J Gastroenterol 94:1434
    4. Heidelbaugh (2003) Am Fam Physician 68:1311
    5. Horgan (1997) Surg Clin North Am 77(5):1063
    6. Peters (1998) Ann Surg 228(1):40

Gastroesophageal reflux disease (C0017168)

Definition (MSH)Retrograde flow of gastric juice (GASTRIC ACID) and/or duodenal contents (BILE ACIDS; PANCREATIC JUICE) into the distal ESOPHAGUS, commonly due to incompetence of the LOWER ESOPHAGEAL SPHINCTER. Gastric regurgitation is an extension of this process with retrograde flow into the PHARYNX or MOUTH.
Definition (NCI)(GAS-tro-eh-sof-a-JEE-al REE-flux diz-EEZ) Also called GERD. A common disorder marked by frequent or severe heartburn. The burning feeling occurs when stomach acid flows up into the esophagus.
ConceptsDisease or Syndrome (T047)
ICD9530.81
EnglishAcid reflux, Esophageal Reflux, Gastresophageal reflux, Gastresophageal reflux disease, Gastro Esophageal Reflux, Gastro oesophageal Reflux, gastroesophageal reflux, GASTROESOPHAGEAL REFLUX DIS, Gastroesophageal reflux disease, Gastrooesophageal reflux disease, GE REFLUX, GER, GERD, GERD1, Oesophageal reflux
ItalianMalattia da reflusso g.e.
Spanishenfermedad por reflujo gastroesofágico, enfermedad por reflujo gastroesofagico, ERGE, esofagitis por reflujo, reflujo ácido, reflujo acido, reflujo esofágico, reflujo esofagico, reflujo gastroesofágico, reflujo gastroesofagico, RGE
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Heartburn (C0018834)

Definition (MSH)Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus.
ConceptsSign or Symptom (T184)
ICD9787.1
BasqueURDAIL SAMINTASUNA/BIOTZERRE
DanishHalsbrand/kardialgi/sure opstod
DutchZuurbranden
EnglishBRASH, Burning reflux, HEART BURN, Heartburn, Heartburn symptom, Pyroses, Pyrosis
FinnishNARASTYS
FrenchBrulant/brulement/brulures, Pyrosis
GermanSodbrennen
Hebrewtzarevet
Hungariangyomoreges
ItalianPirosi
NorwegianHALSBRANN/KARDIALGI/SURE OPPSTOT
PortugueseAzia/pirose
Spanishacedía, acedia, acidez, pirosis
SwedishHALSBRANNA
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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