1.7 GERD / PUD

Question 1

What risk factors are associated with GERD?

What are common presenting sx?

What are the most concerning symptoms of GERD?

Answer 1

• Risks for GERD
  
  • Obesity
  • Pregnancy
  • Smoking
  • NSAIDs
  • Glucocorticoids
  • Hiatal hernia
• GERD Sx
  
  • ‘Chest pain’
  • Gnawing/burning pain
  • Usually retrosternal / xyphoid process
    
    • Can be substernal/straight through back
  • Worse lying down/bending over ‘tie shoes’
  • Relieved from sitting up
  • Relieved from antacids / water / food
  • Pyrosis = heartburn
  • Regurgitation / acidic, bitter taste in mouth in morning
  • Sore throat, hoarseness
  • Belching, hiccups
  • Dysphagia / odynophagia (painful swallowing)
  • Cough won’t go away
  • Asthma exacerbations increased
  • Nausea and vomiting
• Concerning Sx
  
  • Dont get better with treatment
  • Dysphagia
  • Odynophagia
  • Early satiety
  • Evidence of bleeding/anemia
  • Persistent, recurrent vomiting
  • Unintentional weight loss

Question 2

How do you diagnose your patient w/ GERD?

What’s on your DDx?

When will you consult GI?

Answer 2

• Diagnosis
  
  • GERD is a clinical diagnosis
  • Based on sx, exam findings, response to tx
  • Obese, pregnant, and smokers = highest risk
• DDx
  
  • Barrett’s
  • Esophageal cancer
  • Esophageal strictures (esp with painful/diffuclty swallowing)
  • Gastric cancer
  • Hiatal hernia
  • Hypersecretory states
    
    • Excess production of gastrin or histamine
  • PUD
• Consult GI
  
  • FH of GI cancers, or age > 45
    
    • Esp if concerning sx present
  • Signs of blood loss, acute bleeding
  • Persistent sx despite tx

Question 3

What causes the vast majority of duodenal peptic ulcers (90%), and the majority of gastric ulcers (75%)?

What are risk factors for developing PUD?

Answer 3

• Majority
  
  • H pylori
• Risk factors
  
  • NSAIDs, ASA, glucocorticoids
  • 3x more common in men
  • Duodenal ulcer incidence ages 30-55
  • Gastric ulcer incidence ages 55-65
  • More common in smokers > 1/2 pack per day
  • Stress ?

Question 4

Compare/contrast the abd pain associated with gastric ulcers vs duodenal ulcers

Answer 4

• Gastric
  
  • Pain shortly after eating
  • Increased risk of gastric cancer
• Duodenal
  
  • Pain 2-3h after eating

Question 5

Describe physical exam findings in your PUD patient, including mild and worst-case scenarios

Answer 5

• Mild
  
  • Epigastric tenderness
• GI Bleeding
  
  • Hematemesis, coffee ground emesis, melena
• Perforation
  
  • 5-10% of cases
  • Severe epigastric pain
  • Boardlike, rigid abdomen
  • Absent bowel sounds
  • Acute abd sx

Question 6

You’re concerned for PUD in your patient. What labs and diagnostics will you seek?

Answer 6

• Anemia on CBC (+/-)
  
  • If acute bleeding suspected, recheck CBC as indicated
• Consider Upper Endoscopy
  
  • Usually within first 24h of admission
• Consider H Pylori testing
  
  • ID active infxn:
    
    • Urea breath test, fecal antigen test, endoscopic biopsy
  • Positive H Pylori?
    
    • Have to be treated
  • Prior Positive H Pylori?
    
    • Need to be tested again unless clearly cured
  • Low grade gastric mucosa, early gastric cancer, lymphoma, endoscopic resection
    
    • Also test
  • GERD - don’t always test for H Pyloria unless reason to believe PUD
  • Unexplained iron deficiency anemia
    
    • Test!

Question 7

Your patient with gastric pain and anemia tests positive for H Pylori. How will you treat for PUD?

Answer 7

• Three drug regimen for PUD
  
  • 2 abx and PPI x 14days
    
    • Clarithromycin AND
    • Amoxicillin OR Metronidazole
  • Can also be FQ (levoflox) plus Amox plus PPI
• Four Drug Regimen
  
  • PPI, bismuth, tetracycline, metronidazole x 10-14 days
    
    • Useful for PCN allergy or hx of macrolide exposure
    • 4x per day = can limit compliance
    • H Pylori resistance to Clarithromycin?
      
      • Do this 4 drug regimen

Question 8

How will you treat chronic GERD?

Answer 8

• PPI or H2 receptor blocker
• Pts with high risk symptoms should be treated with antisecretory meds
  
  • Misoprostol (if NSAID induced GERD)
  • Sucralfate (short term for ulcers)
  • Metoclopramide - Prokinetic agents (Benefits vs risks?)
  • Antacids - AS NEEDED only

Question 9

What lifestyle medications will you recommend for your chronic GERD patient?

Answer 9

• Discuss w patients and include education in d/c
• Avoid:
  
  • Fatty, fried foods
  • Chocolate
  • Peppermint
  • EtOH
  • Coffee
  • Carbonated drinks
  • Ketchup and mustard
  • Vinegar
  • Tomato sauce
  • Citrus
  • Juices
• Smoking cessation
• Lose weight
• Small portions
• No food <3h before bedtime
• Raise HOB 4-6inches

Question 10

When would you refer to surgery for chronic GERD?

What surgical interventions are available?

Answer 10

• Reasons for surgery
  
  • Side effects from medical therapy
  • Poor compliance with medical therapy
  • Concern about/wish to d/c chronic medical therapy
  • Symptomatic/large hiatal hernia
  • Regurgitation
  • Not interested in medical therapy
  • Abnormal pH test despite max PPI dose
  • Sx correlate with nonacid reflux while on max PPI
• Types of surgery for GERD
  
  • Endoluminal therapy (endoscopic)
  • Hiatal hernia repair
  • Fundoplication
  • Vagotomy