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Gastroesophageal Reflux Disease GERD
-Backflow of stomach acid into the esophagus.
GERD Signs / Symptoms
- - Pyrosis
- - Regurgitation, bitter sour/bitter taste
- - Tooth erosion
- - Hoarseness
- - Eructation
- - Flatulence
- - Dysphagia
- - Odynophagia
- - Nocturnal cough
- - Wheezing
- Heartburn: burning & pressure sub sternal and retrosternal, radiates up neck, jaw and back. Mimics angina.
-Post meal: 20 min 2 hrs after meals
- Reflux salivary hyper-secretion that does not taste bitter.
- Difficulty swallowing
- Painful swallowing
Dx Tests for GERD
- -Usually diagnosed by symptoms
- - Bernstein Test: + if pain if felt when HCL is applied to esophagus
- - Esophagogastroduodenoscopy (EGD)
- - Barium swallow (upper GI series) : identifies hiatal hernia
- - Teach Diet & lifestyle changes
- - Avoid problem foods / beverages
- - Stop smoking
- - Eat 4-6 smaller meals
- - Lose weight
- - Eliminate alcohol
- - Remain upright 1-2 hrs after meals
- - Avoid tight clothing
- - Medication therapy
- H2 receptor antagonists
- Proton pump inhibitors
-aluminum hydroxide, Mylanta
H2 Receptor Antagonists
- - cimetidine, Tagament
- - ranitidine, Zantac
- - famotidine, Pepcid
- - nizatidine, Axid
Proton Pump Inhibitors
- - omeprazol, Prilosec
- - esomeprazole, Nexium
- - pantoprazol, Protonix
- - rabeprazol, Aciphex
- - lansoprazole, Prevacid
- secralfate, Carafate
Prokinetics (promotility agents)
- - metoclopramide, Reglan :
- - increases peristalsis therefore, promotes gastric emptying & reduces risk of GERD
- surgery to strengthen the LES and lessen the possibility of acid reflux also done to correct hiatal hernia.
Complications of GERD
- - Barrett's esophagus: Normal squamous epithelium is replaced w/columnar epithelium, increasing risk of esophageal cancer
- - Can trigger Asthma attacks
- - Chest pain resulting in bleeding
- - Narrowing or chronic irritation of esophagus
- - Can cause esophageal ulcerations and hemorrhage
- - Risk for aspiration
- - Increased risk for Adenocarcinoma
- - Scarring can permanently damage esophagus tissue & produce stricture
- Cardiospasm: an abnormal condition characterized by the inability of a muscle to relax, particularly the cardiac sphincter of the stomach.
Achalasia Signs & Symptoms
- - Dysphagia
- - Regurgitation
Dx tests for Achalasia
- - Esophagoscopy
- - Radiologic studies: show esophageal dilation
- - Manometry: shows absence of primary peristalsis
- - Drug Therapy: to reduce pressure in the LES
- - Nitrates
- - Calcium channel blockers
- - Dilation with balloon similar to PCTA
- - Cardiomyotomy: incision in the muscle layer of the esophagus allowing expansion
- - High calorie, high protein diets.
- - A protrusion of the stomach and other abdominal viscera through an opening, or hiatus in the diaphragm, results of a weakness of the diaphragm.
- - Anatomical condition not a disease
- - Treated by fundoplication
Hiatal Hernia Symptoms/ Complication
- - GERD
- - Strangulation of the herniated organ
- - Infarction
- - Ulceration
- - Ulcers of the mucous membrane or deeper structures of the GI tract
- - Stomach & duodenum
- - results from acid and pepsin imbalances
Four major causes of peptic ulcers
- - Excess of gastric acid (duodenal ulcers)
- - Decrease in ability of GI mucosa to protect itself fr acid & pepsin (Gastric Ulcers)
- - H. Pylori
- - NSAIDS, aspirin or corticosteroids.
Factors contributing to Gastric Ulcers
- - H. Pylori
- - Type A personality
- - Genetics
- - NSAIDS, salicylates
- - Tobacco
- - Diet
Physiologic stress ulcers
- - Transient ischemia of the gastric mucosa associated with hypotension, severe injury, extensive burns and complicated surgery
- - Blood flow bypass the gastric mucosa.
- - Produces an imbalance between the destructive properties of hydrochloric acid & pepsin and protective factors of the stomach's mucosal barrier especially in the fundus portion
Causes of Duodenal Ulcers
- - Excessive production or excessive relies of gastrin or increased sensitivity to gastrin.
- - Lack of buffering ability in the duodenum.
Signs & Symptoms of Peptic Ulcers
- - Pain that is dull, burning, boring or gnawing.
- - Dyspepsia: Nausea, eructation, distention.
- - Gastric ulcers: associated w/ food intake
- - Gastric ulcers: hemorrhage, bleeding is difficult to control, may require surgery
- - Duodenal Ulcers: pain wakes up pt from sleep
- - Duodenal Ulcers: chronic bleeding, prone to perforation can lead to bacterial peritonitis
- - Hematemesis: Vomiting blood
- - Melena: tarlike, fetid smelling stool w/ undigested blood
- - Gastric outlet obstruction: relieved by constant NG aspiration.
Peptic Ulcer Dx Tests
- -Esophagogastroduodenoscopy: specimen for biopsy or ID of H.pylori.
- - Urea Breath Test: pt drinks solution containing carbon 13-enriched urea. Finding of CO213 upon exhalation confirms H. pylori infections.
- - IgG serologic testing: Id H. Pylori
- - Occult Blood
Drug therapy for Peptic Ulcer Disease
- -Antiacids: neutralize or reduce acidity
- -Histamine (H2) receptor blockers: Decrease acid secretion by blocking histamine receptors
- -Proton Pumt Inhibitors: Inhibit secretion of gastrin by the parietal cells of the stomach.
- -Mucosal Healing agents: cytoprotetive drugs that form an ulcer-adherent complex that covers and protect ulcers from evasion of pepsin, acid and bile salts.
- -Antibiotic Therepy: eradicates H.Pylori
Sugical Interventions for Peptic Ulcer Disease
- - Antrectomy
- - Gastroduodenostomy: Billroth I
- - Gastrojejunostomy: Billroth II
- - Total gastrectomy
- - Vagotomy
- - Pyloroplasty
- Removal of the antrum (gastric producing potion of the lower stomach)
- -Billroth I
- - Anastomosis of the fundus to the duedenum
- - Billroth II
- - Closure of the duodenum and anastomosis of the fundus into the jejumum (middle section of sm intestine)
- Removal of the entire stomach.
- - Removal of the vagal innervation to the fundus.
- decreasing acid production of the parietal cells of the stomach (usually done with Billroth I or II)
- - Decreases gastric motility and subsequently gastic emptying.
- - Surgical enlargement of the pyloric sphincter,
- - Facilitates passage of contents from the stomach. commonly done after Vagotomy.
Complications on surgery
- -Bleeding: up to 7 days after surgery. Indications include abdominal rigidity, abdominal pain, restlessness, elevated temp, increased pulse, decreased BP and leukocytosis.
- - Dumping symdrom
- - Diarrhea
- - Reflux esophagitis
- - Nutritional deficits
- - Pernicious anemia
- - complication of peptic ulcer surgery
- - Rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of hypertonic food.
- signs/symptoms: diaphoresis, nausea, vomiting epigastrsic pain, explosive diarrhea, borborygmi.
- -Treatment: 6 sm meals/ day, high protein, low carb, avoice liquids during meals 1) anticholinergic agents 2) recline for 1 hr after meals.
- -symptoms are self limiting.
- - Caused by a deficiency of the intrisic factor, produced in the stomach which aids intestinal absorption of vitamin B12.
- - pt's are recommended to have blood serum B12 mesured every 1-2 years
- -and replacement therepy of vitamin B12 monthy injection or weekly vial nasal route.
- - Inflammation of the vermiform appendix
- - likely to occure in teenagers and young men 20-30
- - Appendix is in LRQ attached to the cecum
- - Becomes obstructed with stool and become infected, inflamed and can perferate.
Appendicitis signs & symptoms
- - LRQ pain
- - Rigid abdomen
- - Absent or decreased bowel sounds
- - Tenderness / rebound / McBurney's Point
- - N/V, anorexia, fever, constipation.
- Halfway between the umbilicus and the anterior crest of the right ileum.
Appendicitis Diagnostic Tests
- WBC and differential