- Define gastroesophageal reflux disease (GERD). What causes it?
GERD means that stomach acid refluxes into the esophagus. It is due to inappropriate,
intermittent relaxation of the lower esophageal sphincter. The incidence is increased greatly in
patients with a hiatal hernia (see question 4).
- Describe the classic symptoms of GERD. How is it treated?
The main complaint is usually “heartburn,” often related to eating and lying supine. GERD also may
cause abdominal or chest pain. Initial treatment is to elevate the head of the bed and to avoid
coffee, alcohol, tobacco, spicy and fatty foods, chocolate, and medications with anticholinergic
properties. If this approach fails,
antacids, histamine-2 blockers, and
proton-pump inhibitors may be
tried. Many patients have already
tried over-the-counter remedies
before presentation, and many
physicians begin empiric treatment
at the first visit, since “lifestyle
modifications” usually fail. Surgery
(Nissen fundoplication) is reserved
for severe or resistant cases.
- What are the sequelae of
Sequelae of GERD include
esophagitis, esophageal stricture
(which may mimic esophageal
cancer), esophageal ulcer,
hemorrhage, Barrett’s metaplasia,
and esophageal adenocarcinoma
- What is a hiatal hernia? How is it different from a paraesophageal hernia?
A hiatal hernia is a sliding hernia, which means that the whole gastroesophageal junction moves
above the diaphragm, pulling the stomach with it. This common and benign finding may predispose
to GERD. In a paraesophageal hernia, the gastroesophageal junction stays below the diaphragm,
but the stomach herniates through the diaphragminto the thorax. This type of hernia is uncommon
but serious; it may become strangulated and should be repaired surgically.
- How does peptic ulcer disease (PUD) present?
PUD classically presents with chronic, intermittent, epigastric pain (burning, gnawing, or
aching) that is localized and often relieved by antacids or milk. Look for epigastric tenderness.
Other signs and symptoms include occult blood in the stool and nausea or vomiting. PUD is
more common in men. The two types of PUD are gastric and duodenal ulcers.
- What is the diagnostic study of choice for PUD?
The gold standard is endoscopy (most sensitive test), but an upper gastrointestinal barium
study is cheaper and less invasive. Empirical treatment with medications may be tried in the
absence of diagnostic studies if the symptoms are typical. If endoscopy is done, a biopsy of
any gastric ulcer is mandatory to exclude malignancy. Duodenal ulcers do not have to be
biopsied initially, because malignancy is rare.
- What is the most feared
complication of PUD? What
should you suspect if an
ulcer does not respond to
The most feared complication of
PUD is perforation. Look for
peritoneal signs, history of PUD,
and free air on an abdominal
radiograph (Fig. 12-2). Treat with
antibiotics and laparotomy with
repair of the perforation. If ulcers
are severe, atypical (e.g., located
in the jejunum), or nonhealing,
think about stomach cancer or
(gastrinoma; check gastrin level).
PUD is also a cause of GI
bleeding, which can be severe in
- How is PUD treated initially?
First, remember that diet changes
are not thought to help heal
ulcers, although reduced alcohol
and tobacco use may speed healing. Start treatment with antacids, histamine-2 receptor
blockers, proton-pump inhibitors, and antibiotics to eliminate Helicobacter pylori. Many
regimens exist, but the most commonly used is triple therapy with a proton pump inhibitor,
clarithromycin, and amoxicillin.