​Kembara Xtra - Medicine - Gastroesophageal Reflux Disease

​Kembara Xtra - Medicine - Gastroesophageal Reflux Disease 
​"Heartburn," "acid indigestion," and "acid reflux" are all terms used to describe changes to the esophageal mucosa brought on by the reflux of gastric contents into the esophagus.

Prevention Incidence
5 per 1,000 person-years, on average
Prevalence
Chronic GERD is a risk factor for Barrett esophagus in 10–20% of Americans.
Adenocarcinoma risk without Barrett esophagus and without dysplasia is 0.1-0.5% every patient-year. Adenocarcinoma risk with high-grade dysplasia and Barrett esophagus is 6–19% per patient-year.
Children's population:
At four months old, 2/3 of newborns regurgitate at least once a day; this percentage drops to 21% at six to seven months and to 5% at ten to twelve months.

Pathophysiology and Etiology 
The severity of the condition affects the pattern and mechanism of reflux.
At the esophagogastric junction (EGJ), GERD starts when acidic stomach contents come into touch with the squamous mucosal lining of the esophagus.
Unwanted temporary relaxation of the lower esophageal sphincter (LES). Spicey, acidic, and high-fat foods, as well as coffee, alcohol, nicotine, anticholinergic drugs, nitrates, and smooth muscle relaxants, have an impact on LES relaxation.
Hiatal hernias are frequently present in people with severe GERD, and they have the potential to: - Trap acid in the hernia sac
- Reduce the EGJ sphincter pressure - Reduce acid emptying - Increase the rate of retrograde acid flow - Increase the frequency of brief LES relaxations
Genetics
The existence of genetic variability has been linked to GERD.

Risk factors include pregnancy, alcohol usage, tobacco use, scleroderma, hiatal hernia, and obesity.


Prevention 

Reduce your intake of meals and drinks that cause migraines, such as fatty, spicy, and alcoholic foods.
Weight reduction
Avoid lying down right after eating.
Eliminate alcohol and tobacco abstinence programs.
Lift the head of the bed at night.
Avoid eating right before bed.

 For infants: Use the car seat for two to three hours after eating, and give thicker feedings


Accompanying Conditions 

Irritable bowel syndrome, peptic ulcer disease, nonerosive esophagitis, erosive esophagitis, aspiration, persistent cough, laryngitis, vocal cord granuloma, sinusitis, and otitis media are all symptoms of extraesophageal reflux.
Halitosis, Hiatal hernia, Peptic Stricture, Barrett Esophagus, Esophageal Adenocarcinoma, and Zone of High Acidity in the Proximal Stomach Above the Diaphragm in 10% of GERD Patients

Presenting History: Typical symptoms include acid regurgitation, heartburn, and dysphagia (mostly postprandial); Atypical symptoms include epigastric fullness/pressure/pain, dyspepsia, nausea, bloating, belching, chest pain, and lump in throat; Extraesophageal signs and symptoms include chronic cough, bronchospasm, wheezing, hoarseness, and sore throat; Heartburn symptoms include retrosternal burning


clinical assessment 

Usually benign, but keep an eye out for danger:
Dental erosions, epigastric soreness, or a palpable epigastric mass

Differential diagnosis includes: Infectious esophagitis (Candida, herpes, HIV, cytomegalovirus); Chemical esophagitis; pill-induced esophagitis; Eosinophilic esophagitis; Nonulcer Dyspepsia; Biliary Tract Disease; Radiation Injury; Crohn's Disease; Angina/Coronary Artery Disease; Esophageal Stricture or Anatomic De

Laboratory Results History and clinical symptoms are frequently used to make a diagnosis.
Initial tests (lab, imaging) – The clinical presentation determines the need for a laboratory workup. Examine your blood for anemia (bleeding history; potential poor vitamin B12 absorption from long-term PPI use).
Correctly assess patients who exhibit symptoms that may be indicative of a heart condition.

Other/Diagnostic Procedures

Upper endoscopy is the first-line diagnostic procedure for people who have warning signals and unrelieved discomfort.
- Endoscopy indications:
Alarming signs such repeated vomiting, anemia, hemorrhage, dysphagia, and weight loss Patients under the age of 60 who develop dyspepsia suddenly. Men over the age of 50 who have chronic GERD (>5 years) and other risk factors, such as hiatal hernia, high BMI, cigarette use, and a high abdominal fat distribution.  Previous episodes of severe erosive esophagitis (evaluate recovery and look for UGI pathology, especially Barrett esophagus.) Monitoring (Barrett esophagus history) - About 50 to 70 percent of people with heartburn have unfavorable endoscopic results.

High-resolution manometry (HRM), especially in circumstances of refractoriness Not advised for primary GERD diagnosis; an alternative for people with GERD and normal endoscopy. - Used to assess peristaltic function and record LES pressure.Diagnose functional heartburn, achalasia, and distal esophageal spasm as motility disorders.
Ambulatory reflux (pH) monitoring: Determine whether patients who have GERD symptoms, a normal endoscopy, and no response to PPI are being exposed to too much acid.
Used to record how often reflux occurs; PPI should be stopped seven days before the operation.
Barium swallows are not utilized to diagnose GERD; instead, they are used to assess complaints of dysphagia or to highlight anatomical anomalies (hiatal hernia).

Management 
First-line intervention is a change in lifestyle:
Raise the head of the bed.

Avoid eating two to three hours before going to bed.

Avoid bending, stooping, and wearing clothing that is too tight.
Avoid taking anticholinergic medicines and calcium channel blockers, which relax the LES.
Encourage weight loss.

 Avoiding alcohol and quitting tobacco
Restrict intake of food triggers that are particular to the patient (complete exclusion of all reflux-causing foods is neither necessary nor advantageous).
Stepwise approach to therapy: Phase I involves dietary and lifestyle changes, antacids combined with H2 blockers, or PPIs. Phase II: If symptoms continue, think about having an endoscopic.
- Phase III: If problems continue, think about having surgery.

First Line of Medicine
Equipotent oral doses of H2 blockers, such as ranitidine 150 mg bid and famotidine 20 mg bid
- Renally dosed: Reduce the dose to 50 mg and check that the creatinine clearance is less than 50 mL/min.
– H2 blockers taken in divided dosages offer symptomatic relief to those with less severe symptoms, while being less effective than PPIs.

PPIs: irreversibly bind proton pump (H+/K+ ATPase), effective onset after 4 days; omeprazole (20-40 mg/day), pantoprazole (40 mg/day), esomeprazole (40 mg/day), lansoprazole (15-30 mg/day), dexlansoprazole (30 mg/day), and rabeprazole (20 mg/day). With the exception of dexlansoprazole, there are no significant differences in the effectiveness of PPIs. Dose 30 to 60 minutes before meals.
- PPIs may raise the risk of hip fracture, vitamin B12 deficiency, Clostridium difficile infection, hypomagnesemia, and community-acquired pneumonia.
PPI is more useful for treating erosive and nonerosive esophagitis than H2 blockers and prokinetics.
PPI is 90% effective after 8 weeks for erosive esophagitis.

Reassess symptoms 4 to 8 weeks after starting treatment.
Child Safety Considerations
There are antacids, liquid H2 blockers, and PPIs for sale.
Prokinetics play a very small role because of safety and efficacy issues.
Next Line
Breakthrough symptoms may be alleviated by antacids or barrier medications (sucralfate 1 g PO QID 1 hour before meals and at sleep for 4 to 8 weeks).
Metoclopramide 5 to 10 mg before meals is a prokinetic drug.
Precautions: Blood dyscrasias and anemia with PPIs and H2 blockers; risk of dystonia and tardive dyskinesia; tachyphylaxis may occur with H2 blockers; significant potential interactions: Warfarin, phenytoin, antifungals, digoxin, and multiple cytochrome P450 drug interactions with PPIs and H2 blockers.


persistent or severe sickness as a referral

Surgical Techniques 

The pressure gradient between the stomach and esophagus is increased through laparoscopic fundoplication, which involves wrapping the gastric fundus around the distal esophagus.
Bariatric surgery is recommended if the patient wants to stop taking medication, experiences negative side effects from medication, has a big hiatal hernia, has esophagitis that is resistant to medication, or exhibits persistent symptoms. The gastric bypass is recommended (4).[A].
- Manometry to exclude scleroderma, achalasia, or esophageal dysmotility before surgery (4)[A]
Child Safety Considerations
severe symptoms (apnea, choking, continuous vomiting) require surgery

Patient Follow-Up Monitoring

 Keep track of your symptoms over time. If symptoms don't go away after 8 weeks of PPI therapy, think about being checked out further and/or getting more treatment.
If there is a poor clinical response to medical therapy, repeat endoscopy should be done in 4 to 8 weeks, especially in elderly individuals.
Perform endoscopic surveillance every 2 to 3 years on Barrett esophagus patients who would like to receive therapy if cancer is found.

Education of Patients 
Modifications to lifestyle and diet: Eat small meals; refrain from lying down after meals; elevate head of bed; lose weight; stop smoking; stay away from alcohol and caffeine.

The prognosis is that when medication is stopped, symptoms and esophageal inflammation frequently return quickly. Continue antisecretory therapy (together with dietary and lifestyle changes) to prevent a return of symptoms.
More than H2 blockers, PPI maintenance medication probably enhances quality of life.
- For maintenance, full-dose PPIs are more successful than half-dose.
– Daily PPI maintenance therapy in erosive esophagitis avoids relapse; intermittent PPI therapy is less beneficial.
Both medical and surgical treatment can reduce symptoms just as well.

Surgery for antireflux: 90–94% symptom relief. Repeat anatomic examination (endoscopy or esophagram) should be performed on patients who have persistent symptoms.
– Some people who have undergone surgery eventually need medical treatment because their symptoms keep returning.
Despite rigorous medical or surgical therapy, Barrett epithelium regression does not frequently occur.

Complications 
Peptic strangulation: 10% to 15%
10% have Barrett's esophagus.
The annual incidence of adenocarcinoma cancer is 0.5%. Endoscopic radiofrequency ablation is the main treatment for Barrett esophagus with highgrade dysplasia.
Hoarseness, aspiration, and other extraesophageal symptoms, such as pneumonia  Mucosal bleeding from injury Noncardiac chest discomfort
Aspects of Geriatrics
More likely complications (such aspiration pneumonia)

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