Define gastroesophageal reflux disease (GERD). What causes it?

  1. 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).
  2. 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.
  3. 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
    (Fig. 12-1).
  4. 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.
  5. 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.
  6. 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.
  7. 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
    Zollinger-Ellison syndrome
    (gastrinoma; check gastrin level).
    PUD is also a cause of GI
    bleeding, which can be severe in
    some cases.
  8. 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.