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Gastroesophageal Reflux Disease (GERD)

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Topic updated on 04/19/17 7:54am

Snap Shot
  • A 65 year-old male presents complaining of heartburn, belching, and epigastic pain. His symptoms are aggravated by drinking coffee and eating fatty foods. His heartburn improves when he takes calcium carbonate.
Introduction
  • Symptomatic reflux of gastric contents into the esophagus
  • Transient lower esophageal spincter relaxation is the most common cause 
  • Other causes include
    • pregnancy
      • ↓ motility secondary to progesterone
    • ↑ gastric acidity
    • gastric outlet obstruction
    • ↓ esophageal motility
    • hiatal hernia
    • obesity
  • Associated with:
    • tobacco
    • alcohol
    • scleroderma
Presentation
  • Symptoms
    • heartburn 30-90 minutes after a meal
      • worse with reclining
      • improves with antacids
    • regurgitation
    • dysphagia
    • may mimic asthma/MI
Evaluation
  • Diagnosis based on history
  • Upper endoscopy 
    • should be performed if patient has longstanding symptoms
    • look for Barrett's esophagus and adenocarcinoma 
  • 24-hour intraesophageal pH monitoring
    • gold standard 
  • Manometry
    • reveals decreased LES pressure
Treatment
  • 1st line - lifestyle changes
    • don't lie down after eating
    • avoid spicy foods
    • eat small servings
  • 2nd line
    • H2 receptor antagonists (cimetidine, ranitidine) or
    • a promotility agent (cisapride) in patients with LES
  • 3rd line
    • proton pump inhibitors (omeprazole, lansoprazole)
      • PPI's are often used as the best initial therapy and are both diagnostic and therapeutic
  • 4th line
    • surgical fundiplication or hiatal hernia repair
      • wrapping of stomach around GE junction


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