Updated: 6/19/2019

Gastroesophageal Reflux Disease (GERD)

Topic
Review Topic
0
0
Questions
6
0
0
Evidence
6
0
0
https://upload.medbullets.com/topic/120148/images/peptic_stricture.jpg
Snapshot
  • A 45-year-old man with hypertension and obesity presents with complaints of heartburn and regurgitation with a sour taste that is aggravated by drinking coffee and eating spicy foods. He also endorses intermittent night time coughing when he eats a late dinner with occasional sore throat and hoarseness. He has tried an antacid with slight improvement but his symptoms are still bothersome.
Introduction
  • Clinical definition
    • reflux of gastric contents into the esophagus
  • Epidemiology
    • demographics
      • common
      • increases with age
    • risk factors
      • alcohol
      • smoking
      • coffee
      • pregnancy
      • obesity
  • Pathogenesis
    • ↓ lower esophageal sphincter (LES) tone allowing gastric contents to reflux into the esophagus
    • ↓ esophageal motility leading to ↓ clearance of retrograde gastric contents
    • ↓ gastric emptying
  • Associated conditions
    • hiatal hernia
    • gastric outlet obstruction
    • scleroderma
Presentation
  • Symptoms
    • classic
      • postprandial retrosternal pain, may radiate to neck or chest
      • regurgitation or sour taste
    • other
      • hypersalivation
      • dysphagia or globus sensation
      • odynophagia
      • cough
      • hoarseness
      • early satiety
      • weight loss
  • Physical exam
    • dental enamel erosion
    • wheezing
    • benign abdominal exam
Studies
  • Diagnostic testing
    • diagnostic approach 
      • classic presentation does not require work up below
      • may require ruling out cardiac etiology
    • imaging
      • esophagogastroduodenoscopy (EGD) with biopsy 
        • visualize erosive disease, complications, and other anatomical abnormalities 
        • first test of choice for atypical presentations
    • studies
      • manometry
        • evaluate LES and motility
        • indicated if empirical therapy fails or atypical work up
      • 24-hour intraesophageal pH monitoring
        • gold standard diagnostic test but not always indicated
        • indicated for atypical history or inconclusive EGD
Differential
  • Angina pectoralis
    • distinguishing factor
      • not associated with eating
  • Chemical esophagitis
    • distinguishing factor
      • no reflux
  • Peptic ulcer disease
    • distinguishing factor
      • localized epigastric or central abdominal pain that does not radiate
Treatment 
  • Management approach
    • empiric treatment with lifestyle modification and acid suppression therapy for classic presentation
    • step-up therapy for mild or intermittent symptoms
      • histamine H2 receptor antagonist → proton pump inhibitor
    • step-down therapy for severe or erosive symptoms for faster relief
      • proton pump inhibitor → histamine H2 receptor antagonist
  • All patients
    • lifestyle modification
      • avoid triggering foods (fatty, caffeine, acidic, and alcohol)
      • stop smoking
      • sleep in an elevated position
    • antacids
  • Mild to intermittent symptoms
    • histamine H2 receptor antagonist 
      • cimetidine, famotidine, or ranitidine
  • Moderate to severe symptoms
    • proton pump inhibitor 
      • omeprazole or lansoprazole
      • side effects include pneumonia, Clostridium difficile, hypergastrinemia, fractures, and hypomagnesemia
  • Surgical
    • fundoplication
      • for failed medical management or complications
Complications
  • Barrett esophagus
  • Esophageal cancer
  • Esophageal ulcer with bleeding or perforation
  • Peptic stricture
  • Pulmonary aspiration
 

Please rate topic.

Average 5.0 of 6 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M3.GI.31) A 40-year-old overweight man presents to the office complaining of heartburn for 6 months. He describes burning in his chest brought on by meals. He has a 20 pack-year smoking history and drinks 2 glasses of red wine with dinner nightly. He denies dysphagia, odynophagia, weight loss, melena, and hematemesis. Over the past month, he has reduced his intake of fatty and spicy foods with some moderate relief of his symptoms; however, his symptoms are still present. He also has stopped smoking. Which of the following is the most appropriate next step in the care of this patient? Review Topic

QID: 102660
1

Esophagogastroduodenoscopy

0%

(0/2)

2

Nissen fundoplication

100%

(2/2)

3

Omeprazole

0%

(0/2)

4

Pantoprazole, sucralfate, and amoxicillin

0%

(0/2)

5

Ranitidine

0%

(0/2)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.GI.60) A 38-year-old obese male smoker presents to the emergency department complaining of severe chest pain. The pain is stabbing, burning and retrosternal. The pain has occurred intermittently for the last few months. The pain is not brought on by exercise, but he does experience it often at night upon lying down after dinner. He denies any dysphagia, weight loss, vomiting, or bloody stools, but does endorse a foul taste in his mouth. Vitals signs are T 98.8 F, HR 79 bpm, BP 123/89, RR 16 Sat 100%. Exam reveals an obese male with dental erosions; cardiopulmonary exam is unremarkable. An EKG is shown in Figure A. What is the next best step in management? Review Topic

QID: 104066
FIGURES:
1

Aspirin, morphine, sublingual nitroglycerin, and cardiac enzyme labs

0%

(0/1)

2

Esophageal manometry

0%

(0/1)

3

Upper endoscopy

0%

(0/1)

4

Upper GI series

0%

(0/1)

5

Treatment with a Proton Pump Inhibitor (PPI)

100%

(1/1)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
ARTICLES (8)
Topic COMMENTS (27)
Private Note