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
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI 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/LFemale: 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/mLFemale: 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/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative 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/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 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/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 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/minFemale: 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 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 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 ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK 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: A 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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK