CASE STUDY GERD

this slides provides case study on GERD

1. GASTROESOPHAGEAL REFLUX DISEASE ANIL DHAKAL

2. INTRODUCTION GASTRO ESOPHAGEAL REFLUX DISEASE IS THE TERM USED TO DESCRIBE ANY SYMPATOMATIC CLINICAL CONDITION OR HISTOPATOLOGICAL ALTERATION RESULTING FROM EPISODES OF THE REFLUX OF ACID, PEPSIN AND OCASIONALLY BILE INTO THE ESOPHAGUS FROM THE STOMACH.

3. EPIDEMIOLOGY COMMON IN ALL AGES. MORTALITY IS RARE. RISK FACTORS AND COMORBIDITIES THAT CONTRIBUTE TO THE WORSENING OR DEVELOPMENT OF GERD SYMPTOMS INCLUDE FAMILY HOSTORY, OBESITY, SMOKING, ALCOHOL CONSUMPTION, RESPIRATORY DISEASE, AND REFLUX CHEST PAIN SYNDROME.

4. PATHOPHYSIOLOGY KEY FACTOR IN THE DEVELOPMENT OF GERD IS THE ABNORMAL REFLUX OF GASTRIC CONTENTS FROM THE STOMACH INTO THE ESOPHAGUS, ORAL CAVITY, OR LUNG. DECREASED GASTROESOPHAGEAL SPHINCTER PRESSURES RELATED TO -: SPONTANEOUS TRANSIENT LES RELAXATIONS TRANSIENT INCREASES IN INTRA-ABDOMINAL PRESSURE AN ATONIC LES, ALL OF WICH MAY LEAD TO THE DEVELOPMENT OF GATROESOPHAGEAL REFLUX. PROBLEMS WITH OTHER NORMAL MUCOSAL DEFENCE MECHANSIMS ABNORMAL ESOPHAGEAL ANATOMY IMPROPER ESOPHAGEAL CLEARANCE REDUCED MUCOSAL RESISTANCE TO ACID DELAYED OR INEFFECTIVE GASTRIC EMPTYING INADEQUATE PRODUCTION OF EPIDERMAL GROWTH FACTORS REDUCED SALIVARY BUFFERING OF ACIDS

5. ESOPHAGEAL CLEARANCE ESOPHAGEAL ACID CLEARANCE NORMALLY OCCURS AS A TWO-STEP PROCESS. THE INITIAL STEP OF EMPTYING MOST OF THE FLUID VOLUME CONTAINED WITHIN THE ESOPHAGUS OCCURS QUICKLY BY GRAVITY OR BY ONE OR TWO PERISTALTIC SEQUENCES . MUCOSAL RESISTANCE WITHIN THE ESOPHAGEAL MUCOSA AND SUBMUCOSA THERE ARE MUCUS SECRETING GLANDS. THE MUCUS SECRETED BY THESE GLANDS MAY CONTRIBUTE TO THE PROTECTION OF THE ESOPHAGUS. BICARBONATE MOVING FROM BLOOD TO THE LUMEN CAN NEUTRALIZE ACIDIC REFLUXATE IN THE ESOPHAGUS. WHEN THE MUCOSA IS REPEATEDLY EXPOSED TO THE REFLUXATE IN GERD, OR IF THERE IS ANY DEFECT IN THE NORMAL MUCOSAL DEFENSES, HYDROGEN IONS DIFFUSES INTO THE MUCOSA, LEADING TO THE CELLULAR ACIDIFICATION AND NECROSIS THAT ULTIMATELY CAUSE ESOPHAGITIS.

6. GASTRIC EMPTYING DELAYED GASTRIC EMPTYING CONTRIBUTES TO GASTRO ESOPHAGEAL REFLUX. AN INCREASE IN GASTRIC VOLUME MAY INCREASE BOTH THE FREQUENCY OF REFLUX AND AMOUNT OF GASTRIC FLUID AVAILABLE TO BE REFLUXED. GASTRIC VOLUME IS RELATED TO THE VOLUME OF MATERIAL INGESTED, RATE OF GASTRIC SECRETION, RATE OF GASTRIC EMPTYING AND AMOUNT OF FREQUENCY OF DUODENAL REFLUX TO STOMACH. FATTY FOODS MAY INCREASE THE POSTPARANDIAL GASTRO ESOPHAGEAL REFLUX BY INCREASING GASTRIC VOLUME, DELAYING THE GASTRIC EMPTYING RATE AND DECREASING THE LOWER ESOPHAGEAL SPHINCTER PRESSURE.

7. SYMPTOMS OF GERD HEART BURN USUALLY AFTER EATING, WHICH MIGHT BE WORSE AT NIGHT CHEST PAIN DIFFICULTY IN SWALLOWING SENSATION OF LUMP IN THROAT REGURGITATION OF FOOD OR SOUR LIQUID EXCESSIVE SALIVATION GAS FORMATION BLOATING TROUBLE SLEEPING SENSITIVE TO SOME FOOD AND LIQUIDS IF NIGHT TIME ACID REFLUX CHRONIC COUGH LARYNGITIS NEW OR WORSENING ASTHMA DISRUPTED SLEEP

8. COMPLICATIONS Esophagitis and Barrett’s esophagus ESOPHAGITIS CAN VARY WIDELY IN SEVERITY WITH SEVERE CASES RESULTING IN EXTENSIVE EROSIONS, ULCERATIONS AND NARROWING OF THE ESOPHAGUS. ESOPHAGITIS MAY ALSO LEAD TO GASTROINTESTINAL (GI) BLEEDING. UPPER GI BLEEDING MAY PRESENT AS ANEMIA, HEMATEMESIS, COFFEE-GROUND EMESIS, MELENA, AND WHEN ESPECIALLY BRISK, HEMATOCHEZIA. CHRONIC ESOPHAGEAL INFLAMMATION FROM ONGOING ACID EXPOSURE MAY ALSO LEAD TO SCARRING AND THE DEVELOPMENT OF PEPTIC STRICTURES, USUALLY PRESENTING WITH THE CHIEF COMPLAINT OF DYSPHAGIA. PATIENTS WITH PERSISTENT ACID REFLUX MAY BE AT RISK FOR BARRETT’S ESOPHAGUS, DEFINED AS INTESTINAL METAPLASIA OF THE ESOPHAGUS

9. IN BARRETT’S ESOPHAGUS, THE NORMAL SQUAMOUS CELL EPITHELIUM OF THE ESOPHAGUS IS REPLACED BY COLUMNAR EPITHELIUM WITH GOBLET CELLS, AS A RESPONSE TO ACID EXPOSURE. CHANGES OF BARRETT’S ESOPHAGUS MAY EXTEND PROXIMALLY FROM THE GASTROESOPHAGEAL JUNCTION (GEJ) AND HAVE THE POTENTIAL TO PROGRESS TO ESOPHAGEAL ADENOCARCINOMA, MAKING EARLY DETECTION VERY IMPORTANT IN THE PREVENTION AND MANAGEMENT OF MALIGNANT TRANSFORMATION

10. DIAGNOSIS

11. DIAGNOSIS A- ENDOSCOPY AND BARIUM RADIOLOGY IT IS THE TECHNIQUE FOR ASSESSING THE MUCOSA FOR ESOPHAGITIS AND BARRETT’S ESOPHAGUS. IT ENABELS THE VISUALIZATION AND BIOPSY OF ESOPHAGEAL MUCOSA . B- PROVACTIVE AND PH TESTING CONTINIOUS PH MONITORING CAN BE PERFORMED BY PASSING A SMALL ELECTRODE PH PROBE INTRANASALLY AND PLACING IT APPROXIMATELY 5CM ABOVE LOWER ESOPHAGEAL SPHINCTER. THIS TEST IS USED TO ESTABLISH A CASUAL RELATIONSHIP BETWEEN PATIENT SYMPTOMS AND ABNORMAL ACID EXPOSURE, ESPECIALLY WHEN ESOPHAGITIS IS NOT PRESENT.

12. C- ESOPHAGEAL MANOMETRY IT IS TO EVALUATE PERISTALTIC FUNCTION SHOULD BE PERFORMED IN ANY PATIENT WHO IS A CANDIDATE FOR ANTIREFLUX SURGERY. A MULTILUMEN TUBE IS PASSED INTO THE STOMACH AND THE PRESSURES ARE MEASURED AS THE TUBE IS PULLED BACK ACROSS LES, ESOPHAGUS AND PHARYNX. D- OMEPRAZOLE TEST THE EMPERIC USE OF STANDARD DOSE OR EVEN DOUBLE DOSE, OMEPRAZOLE AS A THERAPEUTIC TRIAL FOR DIAGNOSING THE PRESENCE OF GERD.

13. TREATMENT

14. N ON PHARMACOLOGICAL TREATMENT

15. SURGICAL TREATMENT THE GOAL OF ANTI REFLUX SURGERY IS TO REESTABLISH THE ANTI REFLUX BARRIER TO POSITION THE LOWER ESOPHAEGAL SPHINCTER WITHIN THE ABDOMIN WHERE IT IS UNDER POSITIVE PRESSURE AND TO CLOSE ANY ASSOCIATED HIATAL EFFECT . IT SHOULD BE CONSIDERED IN PATIENTS A- WHO FAIL TO RESPOND TO PHARMACOLOGIC TREATMENT. B- WHO OPT FOR SURGERY DESPITE SUCCESSFUL TREATMENT BECAUSE LIFESTYLE CONSIDERATIONS, INCLUDING AGE, TIME OR THE EXPENSE OF MEDICINES. C- WHO HAVE COMPLICATION OF GERD.

16. PHARMACOLOGICAL TREATMENT 1- ANTACIDS WITH ANTACID-ALGINIC PRODUCTS 2- ACID SUPRESSION WITH H2 RECEPTORS ANTAGONIST 3- ACID SUPRESSION WITH PROTON PUMP INHIBITORS 4- PROKINETIC AGENTS 5- MUCOSAL PROTECTANTS

17. ANTACID WITH ANTACID-ALGINIC PRODUCTS AN ANTACID PRODUCT COMBINED WITH ALGINIC ACID FORM A HIGHLY VISCOUS SOLUTIONT THAT FLOATS ON THE SURFACE OF GASTRIC CONTENTS. THIS VISCOUS SOLUTION SERVES AS A PROTECTIVE BARRIER FOR THE ESOPHAGUS AGAINST REFLUX OF GASTRIC CONTENTS. IT ALSO REDUCES THE FREQUENCY OF REFLUX EPISODES. EXAMPLE: GAVISCON ADR: DIRRHOEA OR CONSTIPATION AND ALTERATION IN MINERAL METABOLISM AND ACID-BASE DISTURBANCE.

18. ACID SUPRESSION WITH H2 RECEPTORS ANTAGONIST FOR SYMPTOMATIC RELIEF OF MILD GERD, LOW DOSE, NONPRECISION H2-RECEPTOR ANTAGONISTS MAY BE BENEFICIAL CIMETIDINE 800 MG TWICE DAILY FAMOTIDINE 40 MG TWICE DAILY NIZATIDINE 150 MG FOUR TIMES DAILY RANITIDINE 150 MG FOUR TIMES DAILY ADR: DIARRHOEA, HEADACHE, RASHES, HEPATOXICITY

19. ACID SUPRESSION WITH PROTON PUMP INHIBITORS PROTON PUMP INHIBITORS BLOCK GASTRIC ACID SECRETION BY INHIBITING GASTRIC H+/K+ ADENOSINE TRIPHOSPHATASE IN GASTRIC PARIETAL CELLS. THIS PRODUCES A PROFOUND, LONG-LASTING ANTISECRETORY EFFECT CAPABLE OF MAINTAINING THE GASTRIC PH. ADR: DIRRHOEA, HEADACHE, ABDOMINAL PAIN

20. PROKINETIC AGENTS THIS IS GIVEN GIVEN TO THE PATIENTS WHO HAVE FAILED HIGH-DOSE PROTON PUMP INHIBITOR THERAPY. PROKINETIC AGENTS HAVE ALSO BEEN USED AS ADJUNCTIVE THERAPY WITH AN H2 RECEPTOR ANTAGONISTS.

21. MUCOSAL PROTECTANTS IT IS NONABSORBABLE ALUMINIUM SALT OF SUCROSE OCTASULFATE, HAS VERY LIMITED VALUE IN THE TREATMENT OF GERD. SUCRALFATE HAS SIMILAR HEALING RATES AS H2 RECEPTOR ANTAGONISTS FOR PATIENTS WITH MILD ESOPHAGITIS. SUCRALFATE 1G/10ML ADR: CONSTIPATION, NAUSEA, DRY MOTH, DIZZINESS

22. NAME: AB AGE: 60 YRS SEX: MALE CHIEF COMPLIANTS : Abdominal discomfort since 10 days, heartburn after eating, Regurgitation of sour liquid, Trouble sleeping "Bloating, epigastric pain. Past Medical history : Bronchial asthma since 3 years. Past Medication history : Salbutamol Inhalation loomcg /actuation SUBJECTIVE

23. Objective( laboratory parameters) ENDOSCOPY: isolated round erosion extending from the junction upwards not involving entire circumference. PARAMETER DETECTED VALUES NORMAL RANGE RBC 4.26 x 10¹²/L ↓ 4.3-5.9 x 10 12 /L Hb 10.5 g/dl ↓ 13.8-17.2g/dl WBC 14.0 x 10⁹/L ↑ 4.5-11.0 x 10 9 /L ESR 32 mm/ hr ↑ <15mm/ hr RBS 205 mg/dl ↑ Less than 200mg/dl LDL 265 mg/dl ↑ Less than 100mg/dl HDL 20 mg/dl ↑ 50mg/dl or higher

24. THE PATIENT WAS DIAGNOSED WITH GERD( GASTRO ESOPHAEGAL REFLUX DISEASE)

25. ASSESSMENT(TREATMENT GIVEN) DAY 1 DAY 2 DAY 3 INJ RANTAC 2ML INJ RANTAC 2ML INJ RANTAC 2ML SYP DIGENE 2TSP BD SYP DIGENE 2TSP BD SYP DIGENE 2TSP BD TAB DOLO 650 PO TAB DOMSTAL 10MG BD TAB DOMSTAL 10MG BD DISCHARGE MEDICATION TAB RANTAC 150MG BD TAB DOMSTAL 10MG SOS SYP DIGENE 2TSP BD

26. INTERVENTION 1-The patient had high cholesterol but no drug was given for that. 2- The perferred treatment option would be PPIs which was not given to the patient. 3- Dolo was given to the patient without checking the temperature. 4- Since the was anaemic and there was no treatment given for that. 5- patient RBS is high then the normal, so the patient is found to be diabetic.

27. MY PLAN DRUG DOSE FREQUENCY Cap. Omeprazole 20mg OD T. Ferrous sulphate 325mg OD T. Atorvastatin 10 mg h.s Syrup digene 2 tsp SOS paracetamol 500mg SOS metformin 500mg OD

28. PATIENT COUNSCELING

29. ABOUT DISEASE GERD OCCURS DUE TO THE REFLUX OF THE GASTRIC CONTENTS FROM THE STOMACH TO THE ESOPHAGUS. THE SIGN AND SYMPTOMS OF GERD INCLUDE CHEST PAIN, DIFFICULTY SWALLOWING, BLOATING, SLEEPING TROUBLE. ABOUT DRUGS TAKE TAB OMEPRAZOLE ATLEAST 30 MINUTES BEFORE FOOD. ADVISED TO TAKE MEDICATION ON TIME REGULARLY. ADVISED NOT TO TAKE DOUBLE DOSE IF THE DOSE IS MISSED. TAKE TAB PARACETAMOL WHEN THERE IS PAIN OR FEVER. ABOUT LIFESTYLE PATIENT WAS ADVISED TO EAT 2-3 SMALL MEALS. ADVISED TO AVOID IRRITANTS FOODS. AVOID EATING IMMIDIATELY PRIOR TO SLEEP. AVOID WEARING TIGHT FITTING CLOTHS.

30. REFRENCES Clarrett DM, Hachem C. Gastroesophageal Reflux Disease (GERD). Mo Med. 2018 May-Jun;115(3):214-218. PMID: 30228725; PMCID: PMC6140167. Poddar U. Gastroesophageal reflux disease (GERD) in children. Paediatr Int Child Health. 2019 Feb;39(1):7-12. doi : 10.1080/20469047.2018.1489649. Epub 2018 Aug 6. PMID: 30080479. Chen J, Brady P. Gastroesophageal Reflux Disease: Pathophysiology, Diagnosis, and Treatment. Gastroenterol Nurs . 2019 Jan/Feb;42(1):20-28. doi : 10.1097/SGA.0000000000000359. PMID: 30688703. Sharma P. Barrett Esophagus : A Review.  JAMA.  2022;328(7):663–671. doi:10.1001/jama.2022.13298 JOSHEP T. DIPIRO, EECILY V. DIPIRO PHARMACOTHERAPY HANDBOOK 11 TH EDITION 2021. . Gastroesophageal Reflux Disease | The University of Kansas Health System . Kansashealthsystem.com. Retrieved from https://www.kansashealthsystem.com/care/conditions/gastroesophageal-reflux-disease . sami , S., & Ragunath , K. (2013). The Los Angeles Classification of Gastroesophageal Reflux Disease.  Video Journal And Encyclopedia Of GI Endoscopy ,  1 (1), 103-104. https://doi.org/10.1016/s2212-0971(13)70046-3