gerd case study slideshare

• AGA Journals
• AGA University
• AGA Research Foundation
• AGA Community
• AGA Job Board
• Create Account

Clinical Guidance

Our clinical guidelines and updates help you make the best evidence-based decisions for your patients.  

• Library AGA’s guidelines, practice updates and care pathways in one place.
• Guideline Toolkits Comprehensive resources for managing diseases – Crohn’s disease now available.

Journals & Publications

Latest research and ideas from the GI field.

• Gastroenterology The premier journal in GI.
• Clinical Gastroenterology and Hepatology (CGH) The go-to resource in clinical GI.
• Cellular and Molecular Gastroenterology and Hepatology (CMGH) Impactful digestive biology research.
• Techniques and Innovations in Gastrointestinal Endoscopy (TIGE) Cutting-edge advances in GI endoscopy.
• Gastro Hep Advances Open access GI and hepatology journal.
• GI & Hepatology News AGA’s official newspaper.
• The New Gastroenterologist Insights for fellows and early career GIs.

Meetings & Learning

Earn CME, MOC and improve your skills.

• AGA University Your hub for the best in GI education – AGA Postgraduate Course, Tech Summit and more.
• Digestive Disease Week® The most prestigious GI meeting.
• Crohn's & Colitis Congress® The premier meeting on IBD.
• Maintenance of Certification Resources for maintaining certification.
• DDSEP® The leading self-assessment tool for GI.
• Inside Scope Podcast An AGA podcast with bite-sized education.

More than 16,000 professionals worldwide call AGA their professional home.

• Join AGA Join our diverse mix of professionals.
• Renew Membership Continue to receive exclusive benefits and discounts.
• Benefits Unrivaled by any other GI organization.
• Membership Directory Contact other AGA members.
• Recognition Awards We honor our esteemed members.
• Initiatives & Programs Advancing the science and practice of GI.
• Get Involved with AGA Help us achieve a world free from digestive diseases.
• Advocacy & AGA PAC Advancing public policies that support gastroenterology.

Practice Resources

Tools to maximize efficiency and help you deliver high-quality care.

• Practice Tools Cutting-edge resources to improve your patient care.
• New Technology & Techniques The latest innovations in GI.
• Quality & Performance Measures Support to meet reporting requirements.
• Reimbursement Tools to understand policies and advocate for reimbursement.
• GI Patient Center By specialists, for patients.

Research & Awards

Funding opportunities and other initiatives advancing discovery.

• Research Awards More than $2 million in annual research funding.
• Registries & Studies Data to support new techs and treatments.
• Gut Microbiome One of GI’s most promising areas of research.
• AGA Research Foundation Funding the future of gastroenterology.

Fellows & Early Career

Resources designed for early career gastroenterologists.

• Resources Resources for every stage of your career.
• Fellowship Match Information for programs and candidates.
• AGA GTE® The first training exam for GI programs and fellows.
• Mentoring Connect with prospective mentors.
• Job Board Find your next opportunity.

GERD and Refractory GERD: A Case Based Approach

Review of treatments GERD:

Download the session audio:

Download the PowerPoint presentation:

4930 Del Ray Avenue, Bethesda, MD 20814 301-654-2055

Connect with aga.

©   American Gastroenterological Association

• Privacy Overview
• Strictly Necessary Cookies
• Cookie Policy

This website uses cookies so that we can provide you with the best user experience possible. Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful.

Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings.

If you disable this cookie, we will not be able to save your preferences. This means that every time you visit this website you will need to enable or disable cookies again.

More information about our Cookie Policy

Gastroesophageal reflux disease

Raika Jamali M.D.

Gastroenterologist and hepatologist

Sina Hospital

Tehran University of Medical Sciences

Definition of GERD according to �Geneva Workshop

• The term GERD should be used for individuals exposed to the risk of physical complications of reflux, or in whom reflux causes significant impairment of health related well-being or QoL, after adequate reassurance of the benign nature of their symptoms

Pathogenic Factors in GERD

• Heartburn and Regurgitation
• Dysphagia and Odynophagia (stricture and severe esophagitis)
• Barrett’s esophagus
• Esophageal adenocarcinoma
• Noncardiac chest pain
• E.N.T Complications
• Sore Throat
• Hoarseness/Laryngitis
• Globus sensation
• Throat Clearing
• Chronic Otitis media and Sinusitis
• Dental erosions
• Laryngeal cancer
• Pulmonary complicationc
• Chronic dry cough
• Aspiration Pneumonia
• Bronchiectasis
• Pulmonary Fibrosis
•   Miscellaneous
• Dyspepsia (nausea, vomiting, abdominal Pain)
• Anorexia, Wt. Loss
• Anemia, Fatigue
• Burning Mouth
• Sleep disturbances

Clinical Manifestations of GERD

Indications for diagnostic testing in suspected GERD

• Uncertain diagnosis
• Atypical symptoms ( chest pain, ENT, Pulmonary)
• Symptoms associated with complications (dysphagia, odynophagia, unexplained weight loss, bleeding, anemia)
• Inadequate response to therapy
• Recurrent symptoms
• Prior to anti-reflux surgery

Diagnostic studies in GERD

• Diagnosis and Evaluation of GERD is based on Clinical Presentation and Diagnostic tests.There is no real gold standard, each test answers a part of the question:
• Barium swallow: test of choice for evaluating DYSPHAGIA
• EGD: If there is any DAMAGE or COMPLICATION
• pH monitoring : if there is pathologic ACID REFLUX
• Manometry: If there is any FUCTIONAL MOTILITY ABNORMALITY predisposing to reflux, and before surgery
• Empiric trial of acid suppression a PRACTICAL approach
• Intra luminal Electrical Impedance: if there is ANY REFLUX AND SYMPTOM CORRELATION

INCOMPETENT LES

HIATUS HERNIA

Endoscopy Findings in GERD

Gastroentrology; 98: A100, 1990

LOS ANGELES CLASSIFICATION OF MUCOSAL DAMAGE

• A- one or more mucosal break <5mm
• B- one or more mucosal break >5mm
• C- mucosal break contiguous between tops of 2 or more folds but involving <75% of esophageal circumference
• D- same as C but >75% of circumference

The goal of GERD management

• Symptom control
• Improve patients’ health-related quality of life
• Promote mucosal healing (pH>4>12-15 hrs/24h)
• Prevent complications and symptom relapse

Medical therapy for GERD

• Life style modification
• Antisecretory therapy
• - H2 Blockers
• Promotility therapy

H 2 -RA (standard dose)

H 2 -RA (anti-reflux dose)

PPI Pharmacology and Optimal Dosing

• Short half life 0.5-2hr
• Incompletely absorbed, needs acidic environment
• Accumulate at the cannalicular surface of parietal cell
• Bound irreversibly to activated proton pumps
• Inhibits 70% of the active proton pumps

Pharmacodynamic effects of PPIs

• PPIs inhibit meal stimulated, night and day acid secretion
• Use before breakfast, if 2nd dose needed before dinner
• Takes several days to reach steady state, sooner with bid1st week
• Faster steady state in pts with corpus predominant HP gastritis

Johnson et al. Am J Gastroenterol 2000

Maintenance of Healing of Erosive Esophagitis� (n = 318)

esomeprazole 40 mg

esomeprazole 20 mg †

esomeprazole 10 mg

* P < 0.001 vs placebo

% patients in remission

Duration of treatment (months)

Hierarchy of PPI use

• PPI once daily, may substitute ppi,
• 40% failure
• PPI plus H2 RA at bed time
• PPIs bid or double the dose
• PPI bid plus H2RA at bed time
• PPI+ Prokinetics, diabetics or narcotic user
• PPI + TLESR reducer, Baclofen, DGER
• PPI+ pain modulators, Tricyclics, SSRIs, Trazadone, NCCP

TREATMENT GUIDELINES BASED ON EGD FINDINGS

• NERD treat with ppi till better, then use on demand or intermittent (except elderly)
• Erosive Esophagitis Rx till heals, and continue Rx
• Barrett’s esophagus Rx for good
• Peptic stricture dilate and Rx
• Extra-esophageal manifestations

Side effects of PPIs

• Headache, nausea, abdominal pain, diarrhea
• Fundic gland polyps
• ? B12 and Iron malabsorption, concern, not proven
• Increased risk of gram negative pneumonia in ICU, odd ratio 1.8,
• Two fold increase in C-Difficile colitis ( hospitalized, children, on antibiotics, immune suppressed )
• Increased salmonella and campylobacter gastroenteritis
• Increased risk of bacterial infection (reduced PMN activity)
• Increased risk of hip fracture , odd ratio 2.0 (calcium malabsorption)
• PPIs induced interstitial nephritis
• Reduced thyroxine absorption

GERD in Elderly Patients

• GI tract changes with age:
• -Decrease normal peristalsis and increased nontransmitted and simultaneous contractions
• - Decrease saliva
• - increase prevalence of HH
• - Increase swallowing time due to decrease muscle mass
• - Multiple medications that lowers LESP
• - Use of NSAIDs
• Decline of severe heartburn in spite of severe GERD
• Elderly pts >65 may present with anorexia, wt. loss , anemia, dysphagia,respiratory symptoms and chest pain.
• Incresed incidence of:
• - Erosive Esophagitis (37% in >70 vs 17% in <21)
• - Barrett’s Esophagus
• - Esophageal Adenocarcinoma
• EGD is indicated in all elderly pts with GERD symptoms
• Long term PPI if heartburn, HH, and EE originally

Omeprazole requirement in �GERD

• 65% omeprazole 20mg/d
• 20% omeprazole 20mg bid
• 21% Omeprazole 40mg bid

Some reasons why PPIs may fail to control gastric acidity

• Improper dosing time, see if taken with food or antacid
• Weakly acidic reflux
• Bile reflux
• Nocturnal reflux
• Significant intersubject variability in bioavailability of PPIs which may be even further when taken with food
• Acid reducing effect of PPIs is reduced in Helicobacter pylori negative patients
• Acid Hypersecretors (rare)
• Rapid metabolizers of PPIs by cytochrome P-450 cyp 2c isoenzyme
• Incorrect diagnosis
• Eosinophilic esophagitis
• Visceral hypersensitivity
• Psychological comorbidity
• Drugs such as aspirin, NSAIDs and other drugs known to cause direct topical injury
• Factors including gastric stasis, ineffective peristalsis.
• Patients with GERD often have symptoms including bloating, distention,nausea which may be unmasked by PPI even though the classic reflux symptoms have improved

Impedance Technology Fundamentals

Intraluminal Catheter

AC Current Generator

The Impedance Scale

Esophageal Lining

Low Conductivity = High impedance

High Conductivity = Low impedance

MultiChannel Intraluminal Impedance

Bolus Entry

Bolus Movement

Impedance pH and Manometry

• Impedance determines refluxate presence, distribution, clearing time, liquid, gas or mixed
• MII pH shows GER contents
• Acid reflux (pH<4.0)
• Non-acid reflux (pH>4.0 and up to 1 pH point drop)
• Minor acid reflux (pH>4.0 but 2 pH point drop)
• Acid re-reflux (pH <4.0 and may not change)
• MII Manometry determines bolus transfer of liquids and solids

Clinical indications of combined MII-pH testing

• Patients with persistent symptoms on bid, PPI therapy (refractory GERD, reason for GI referral)
• Patients with ? GERD related ENT and Pulmonary symptoms
• Patients with reflux symptoms and achlorhydria (I.e. atrophic
• Patients with reflux symptoms after surgical gastrectomy

Persistent heartburn on PPI

• In patients with persistent symptoms when on bid PPI Impedance pH studies reveals
• 20% have Acid reflux = drop in pH to < 4.0
• 40% Non-Acid reflux = pH stays above 4.0
• and does not drop more than1 pH unit
• 40% No Reflux preceding symptoms

Symptoms Not Correlated with Reflux

GERD Diagnostic Algorithm�

Acid Reflux with Symptoms

Nonacid Reflux with Symptoms

Possible GERD Symptoms

Symptom Relief

Antireflux Medication Trial

Impedance-pH Monitoring

(On Medication)

Persistent Symptoms

New formulation of PPI

• IR-OME, naked omeprazole+Na bicarb, eliminates meal timing, no need for food, good for on demand rx
• Kapidex 60mg, dual delayed release Lansoprazole
• Tenatoprazole 40 mg, half-life 9.3 hrs, like40 mg bid esomeprazole
• S-Tenatoprazole-Na (STU-Na) 60mg effect on nocturnal heartburn present 5 days after D/C in it
• AGN201,9047 600mg acid stable product of omeprazole producing continuous metered absorption
• K competetive acid blocker, AZD0865 rapid onset, bid
• GABA-B agonist Baclofen, reduces TLESR, reduces all refluxes, specially nonacid reflux
• XP19986 prodrug of R-Baclofen 40 mg dose
• 5-HT4receptor agonist Tegaserod, prokinetic and sensitivity modulator, 6mg bid

Night time GERD

• Day and night GERD 65%, day only GERD 20% and night only GERD 13%
• Asthma, morning cough and phlegm is 2 to 3 times more common with nighttime GERD
• Predictors of nighttime gerd:
• Obesity (increased intragastric pressure, increase HH, dietary factors, ? Humoral factors), HTN (? Meds), Benzodiazepines ( lowers LESP), Carbonated beverages , Insomnia, Snoring, and sleeping during the day

GERD and Asthma

• Up to 70% of asthmatics complain of heartburn
• Prevalence of GERD in asthmatics is 30% to 80%.
• GERD produces or exacerbate asthma by reflex and reflux
• Asthma conversely produces or aggravate GERD by :
• Flattening diaphragm
• Relaxing LES (Flattening diaphragm and albuterol inhalers dose dependant decrease in LESP and peristalsis amplitude, anticholinergics)
• Increasing acid exposure of distal and proximal esophagus high dose steroids for more than 7 days)
• HH, supine position and dietary factors more frequent in asthmatics
• Pts with asthma>60 yo have 13x more chance of having GERD than healthy pts < 20 yo.
• EGD is normal in >60% of asthmatics

Got any suggestions?

We want to hear from you! Send us a message and help improve Slidesgo

Top searches

Trending searches

5 templates

170 templates

education technology

258 templates

welcome back to school

111 templates

meet the teacher

30 templates

20 templates

Gastroesophageal Reflux Clinical Case

It seems that you like this template, gastroesophageal reflux clinical case presentation, free google slides theme, powerpoint template, and canva presentation template.

Clinical cases help medicine students understand better the symptoms, treatment and development of a disease. They’re also very valued in the international scientific community, as they foster communication between professionals so they can learn new techniques and practises. This clinical case is focused on Gastroesophageal reflux disease (GERD). What symptomatology does it have? What treatments are now available and how are they applied? These slides have all the resources you need for explaining medical concepts in a visual and clear way!

Features of this template

• 100% editable and easy to modify
• 27 different slides to impress your audience
• Contains easy-to-edit graphics such as graphs, maps, tables, timelines and mockups
• Includes 500+ icons and Flaticon’s extension for customizing your slides
• Designed to be used in Google Slides, Canva, and Microsoft PowerPoint
• 16:9 widescreen format suitable for all types of screens
• Includes information about fonts, colors, and credits of the resources used

How can I use the template?

Am I free to use the templates?

How to attribute?

Attribution required If you are a free user, you must attribute Slidesgo by keeping the slide where the credits appear. How to attribute?

Related posts on our blog.

How to Add, Duplicate, Move, Delete or Hide Slides in Google Slides

How to Change Layouts in PowerPoint

How to Change the Slide Size in Google Slides

Related presentations.

GERD: Symptoms and Presentation

• First Online: 30 September 2020

Cite this chapter

• Diana M. Winston Comartin 2 &
• Peter H. Stein 2  

Gastroesophageal reflux disease (GERD) is the process of stomach contents refluxing into the esophagus, with resultant symptoms and/or mucosal damage. A wide range of symptoms exist associated with GERD, not limited to the classic symptoms of heartburn and regurgitation. Multiple symptom indices have been developed to predict the response of a patient with GERD symptoms to medical treatment.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

• Get 10 units per month
• Download Article/Chapter or Ebook
• 1 Unit = 1 Article or 1 Chapter
• Cancel anytime
• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Gastroesophageal Reflux Disease: Pathophysiology

Gastroesophageal Reflux Disorders: Diagnostic Approach

An Overview of Gastroesophageal Reflux Disease

Feldman M, Friedman L et al. Sleisenger and Fordtran’s gastrointestinal and liver disease pathophysiology, diagnosis, management. 9th ed.: Saunders.

Google Scholar  

Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101:1900.

Article   Google Scholar  

Vakil N, Traxler B, Levine D. Dysphagia in patients with erosive esophagitis: prevalence, severity, and response to proton pump inhibitor treatment. Clin Gastroenterol Hepatol. 2004;2:665.

Article   CAS   Google Scholar  

Kahrilas PJ, Hughes N, Howden CW. Response of unexplained chest pain to proton pump inhibitor treatment in patients with and without objective evidence of gastro-oesophageal reflux disease. Gut. 2011;60:1473.

Brzana RJ, Koch KL. Gastroesophageal reflux disease presenting with intractable nausea. Ann Intern Med. 1997;126:704.

Martinucci I, Albano E, Marchi S, Blandizzi C. Extra-esophageal presentation of gastroesophageal reflux disease: a new understanding in a new era. Minerva Gastroenterol Dietol. 2017;63:221–34.

PubMed   Google Scholar  

Lundell LR, et al. Endoscopist assessment of oesophagitis: clinical and functional correlation and further validation of the Los Angeles classification. Gut. 1999;45:172.

Ollyo JB, et al. Savary-Miller’s new endoscopic grading of reflux oesophagitis: a simple reproducible, logical, complete and useful classification. Gastorenterology. 1990;98:A 100.

Wiener GJ, Richter JE, Copper JB, Wu WC, Castell DO. The symptom index: a clinically important parameter of ambulatory 24-hour esophageal pH monitoring. Am J Gastroenterol. 1988;83:358–61.

CAS   PubMed   Google Scholar  

Weusten BL, Roelofs JM, Akkermans LM, Van Berge-Henegouwen GP, Smout AJ. The symptom-association probability: an improved method for symptom analysis of 24-hour esophageal pH data. Gastroenterology. 1994;107:1741–5.

Connor J, Richter J. Increasing yield also increases false positives and best serves to exclude GERD. Am J Gastroenterol. 2006;101:460–3.

Moayyedi P, Eikelboom JW, et al. Safety of proton pump inhibitors based on a large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin. Gastroenterology. 2019;157:682–91.

Download references

Author information

Authors and affiliations.

Division of Gastroenterology, Phelps Hospital Northwell Health, Sleepy Hollow, NY, USA

Diana M. Winston Comartin & Peter H. Stein

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Diana M. Winston Comartin .

Editor information

Editors and affiliations.

ENT and Allergy Associates, LLP; Voice and Swallow Division, Tarrytown, NY, USA

Craig H. Zalvan

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Winston Comartin, D.M., Stein, P.H. (2020). GERD: Symptoms and Presentation. In: Zalvan, C.H. (eds) Laryngopharyngeal and Gastroesophageal Reflux. Springer, Cham. https://doi.org/10.1007/978-3-030-48890-1_19

Download citation

DOI : https://doi.org/10.1007/978-3-030-48890-1_19

Published : 30 September 2020

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-48889-5

Online ISBN : 978-3-030-48890-1

eBook Packages : Medicine Medicine (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

• Cell Biology

Case Study: Gastroesophageal Reflux Disease

Related documents.

Add this document to collection(s)

You can add this document to your study collection(s)

Add this document to saved

You can add this document to your saved list

Suggest us how to improve StudyLib

(For complaints, use another form )

Input it if you want to receive answer

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 34:  Gastroesophageal Reflux Disease: A Burning Question Level II

Brian A. Hemstreet

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Learning objectives, patient presentation.

• CLINICAL PEARL
• Full Chapter
• Supplementary Content

Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services ( [email protected] ) for more information.

After completing this case study, the reader should be able to:

Describe the clinical presentation of gastroesophageal reflux disease (GERD), including typical, atypical, and alarm symptoms.

Discuss appropriate diagnostic approaches for GERD, including when patients should be referred for further diagnostic evaluation.

Recommend appropriate nonpharmacologic and pharmacologic measures for treating GERD.

Develop a treatment plan for a patient with GERD, including both nonpharmacologic and pharmacologic measures and monitoring for efficacy and toxicity of selected drug regimens.

Outline a patient education plan for proper use of drug therapy for GERD.

Chief Complaint

“I’m having a lot of heartburn. These pills I have been using have helped a little but it’s still keeping me up at night.”

Janet Swigel is a 68-year-old woman who presents to the GI clinic with complaints of heartburn four to five times a week over the past 5 months. She also reports some regurgitation after meals that is often accompanied by an acidic taste in her mouth. She states that her symptoms are worse at night, particularly when she goes to bed. She finds that her heartburn worsens and she coughs a lot at night, which keeps her awake. She has had difficulty sleeping over this time period and feels fatigued during the day. She reports no difficulty swallowing food or liquids. She has tried OTC Prevacid 24HR once daily for the past 3 weeks. This has reduced the frequency of her symptoms to 3–4 days per week, but they are still bothering her.

Atrial fibrillation × 12 years

Asthma × 10 years

Type 2 DM × 5 years

HTN × 10 years

Patient is married with three children. She is a retired school bus driver. She drinks one to two glasses of wine 4–5 days per week. She does not use tobacco. She has commercial prescription drug insurance.

Father died of pneumonia at age 75; mother died at age 68 of gastric cancer

Diltiazem CD 120 mg PO once daily

Hydrochlorothiazide 25 mg PO once daily

Metformin 500 mg PO twice daily

Aspirin 81 mg PO daily

Fluticasone/salmeterol DPI 100 mcg/50 mcg one inhalation twice daily

Peanuts (hives)

Get Free Access Through Your Institution

Pop-up div successfully displayed.

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• HHS Author Manuscripts

A 52 year old man with heartburn: Should he undergo screening for Barrett’s esophagus?

Clinical scenario.

A 52-year-old man is referred to your gastroenterology practice for a history of gastroesophageal reflux disease (GERD). The patient reports a long history of heartburn symptoms, dating back at least 5 years. His symptoms were responsive to over the counter remedies including antacid tablets and liquids, but eventually became such a regular occurrence that he sought medical care from his primary care physician. He was initially prescribed an H2 blocker, which was incompletely effective, so he was started on proton pump inhibitor therapy. He currently takes 20mg of omeprazole daily which is effective, but notes that if he misses a dose, he sometimes experiences heartburn. He denies dysphagia, nausea or vomiting, blood in his stool, or unintentional weight loss. He has no other chronic medical conditions and takes no other medications. He is a nonsmoker who drinks alcohol in moderation, and has no family history of gastrointestinal cancer. Paperwork from the referring physician states that the reason for consultation is: “screening for Barrett’s esophagus.”

The Problem

In the United States, GERD is a frequent disorder, affecting 10–20% of the population on a regular basis. 1 Barrett’s esophagus (BE) is a metaplastic change of the normal esophageal mucosa, in which the normal squamous epithelium of the esophagus is transformed into columnar epithelium with goblet cells in response to chronic inflammation from reflux of acidic gastric contents. Barrett’s esophagus is significantly less common than GERD in the general population, occurring in roughly 1–2 out of 100 persons in the US. 2 , 3 However, BE is quite common amongst GERD sufferers, occurring in 6 – 18% of cases. 2 , 4 , 5 It is important to note that Barrett’s epithelium is not necessarily associated with symptoms, and its effect on overall mortality is unclear, and may be negligible. 6 – 8 Therefore, BE is of interest because it is considered a pre-malignant condition. Pathologically, BE can progress to dysplasia of the esophageal mucosa and subsequently, to the development of invasive adenocarcinoma. 9 – 11 In epidemiologic studies, BE is associated with a substantially increased risk of esophageal adenocarcinoma (EAC), at least 40-fold higher than the general population. 12 , 13 Current estimates place the risk of EAC among patients with BE between 0.5 and 1% per patient per year. 14 Gastroesophageal reflux disease is also highly associated with esophageal adenocarcinoma, as has been shown by several case control studies. 15 – 17 Such studies also consistently show higher odds of esophageal cancer depending on duration and frequency of symptoms. Though the absolute risk of esophageal cancer in persons with GERD cannot be directly measured by such studies, it is undoubtedly quite low given the low incidence of esophageal cancer and the high prevalence of GERD. 18

Adenocarcinoma of the esophagus is a relatively rare condition, with <10,000 cases per year in the US. 19 However, EAC is on the rise, with several population-based cohort studies demonstrating a 300–500% increase in incidence since the 1970s. 20 , 21 The reason for this increased frequency of EAC is uncertain, but may be due to increased rates of obesity. 22 Rates of esophageal cancer are highest among white men, while women and African Americans have lower rates. 21 African Americans have significantly higher esophageal cancer mortality than whites, however. 23 Esophageal adenocarcinoma is amongst the most lethal cancers, with an overall 5 year survival of 17%. 24 Most esophageal cancers are diagnosed at an advanced stage, when local resection is not possible. 19 The primary surgical treatment of advanced esophageal cancer is esophagectomy, which is associated with substantial morbidity and some decrement in quality of life. 25 , 26

Despite the fact that EAC is an uncommon cancer, a targeted screening approach is of interest because of the morbidity and mortality associated with this disease. Given the widespread use of upper endoscopy to manage GERD, large numbers of subjects with BE are likely to continue to be discovered serendipitously. The question, therefore, is whether a screening endoscopic examination in persons with GERD specifically to detect BE or EAC is a worthwhile pursuit, and whether this approach would lead to decreased burden of esophageal adenocarcinoma.

Management Strategies and Supporting Evidence

Controversy abounds over the issue of BE screening, particularly in regards to which patients should be screened, or if gastroenterologists should screen anyone at all. Screening for BE is typically performed via esophagogastroduodenoscopy (EGD) with biopsies of the esophagus if and when characteristic Barrett’s-type mucosa is seen. Barrett’s esophagus is diagnosed when these biopsies contain intestinal metaplasia. The rational for such screening is that BE is a major risk factor for development of EAC, and that early detection may lead to improved survival. The initial enthusiasm of screening and surveillance programs for BE may have been in part fueled by early reports of cancer risk in BE. These reports might have overestimated the true cancer risk by 50% or more, due to publication bias. 27 Also, studies subject to length and lead time bias claimed early detection led to a survival benefit. 28 , 29 Over the past two decades, as understanding of the natural history of BE and EAC has evolved, several schools of thought have arisen with respect to screening, including (1) screening all patients with GERD; (2) screening patients with specific clinical characteristics; and (3) no screening at all.

Screening all patients with GERD symptoms is one option for detecting BE, but would represent an enormous challenge to medical resources and endoscopists’ time. Current estimates are that approximately 20 – 40% of the U.S. population suffers from heartburn on a weekly or monthly basis. 30 , 1 In some BE patients, esophageal acid exposure manifests with the classical symptoms of heartburn and acid reflux. However, many patients with longstanding acid exposure may have no symptoms at all. Such patients would presumably be missed by a strategy which focused endoscopic screening on those with GERD symptoms. Several prospective studies have demonstrated that a substantial proportion of incident BE occurs in persons without typical reflux symptoms ( Table 1 ). 3 , 31 – 35 Thus, while patients with symptomatic heartburn may have a slightly increased incidence of BE, screening on the basis on GERD alone may miss more subjects with BE than it finds. Further evidence regarding the insensitivity of GERD symptoms as a criterion for entry into endoscopic screening programs comes from case-control studies demonstrating that up to half of subjects who develop adenocarcinoma of the esophagus do not have chronic GERD symptoms. 15 – 17

Prospective studies comparing prevalence of BE in GERD and non-GERD patients demonstrating substantial prevalence of BE in subjects who do not have typical GERD symptoms.

In light of the limitations of screening all patients with GERD for BE, other strategies have been proposed in support of screening GERD patients with certain symptoms or clinical characteristics. BE has been found to occur more often in Caucasian males over the age of 50 with longstanding GERD symptoms. 17 Inadomi et al. have shown cost effectiveness for one time screening of such patients. 36 This screening strategy is only cost effective, however, if only those patients with BE and dysplasia undergo endoscopic surveillance. Furthermore, even using such patient characteristics to focus screening, the number of subjects necessary to screen to detect one cancer remains prohibitively high. 37

A primary question, then, is whether we should screen for BE at all. It should be noted that the case of screening for BE or EAC lacks many of the characteristics of a useful screening strategy by established criteria. 38 , 39 As discussed above, the burden of disease, while increasing, remains small, given the enormous pool of at risk subjects. The preclinical phase cannot be adequately identified or targeted as many patients with BE have no GERD symptoms. Finally, and most importantly, screening has not been sufficiently proven to improve outcomes such as mortality from esophageal cancer. 39

Areas of Uncertainty

The benefits of screening and surveillance programs remain unclear. Several studies do show a potential benefit from endoscopic screening and surveillance in BE. Subjects who have their cancer diagnosed as part of a screening and surveillance program are less likely to have nodal involvement, and demonstrate a better two year survival than those presenting symptomatically. 28 , 40 However, such studies showing a benefit from screening and surveillance of patients with BE are largely retrospective and complicated by selection bias, lead time bias and length bias. In fact, a recent nested case-control study performed in the U.S. Veterans’ Affairs system demonstrated that subjects with adenocarcinoma who had had an upper endoscopy in the five years prior to diagnosis did not have significantly different survival than those presenting symptomatically. 41

The best evidence to establish the benefit of screening for BE would be a randomized controlled trial of endoscopic screening in GERD patients, measuring the outcome of esophageal cancer mortality. However, such a trial would be cumbersome and costly; given the rarity of esophageal adenocarcinoma and the long latency time between BE and development of cancer, a randomized trial of BE screening in all persons with GERD or in the general population would require large numbers of participants followed for a long period. Therefore, we must rely on indirect evidence that links screening GERD patients with reduced mortality from esophageal cancer. By applying U.S. Preventative Services Task Force guidelines to the decision to perform endoscopy in this setting, one can see the number of unanswered questions to be addressed prior to understanding the utility of such screening and surveillance programs ( Figure 1 ). 42

Important questions in considering whether GERD patients should be screened for Barrett’s esophagus to prevent esophageal adenocarcinoma. Questions labeled with asterisks are either poorly described or currently debated in the medical literature. Based on the US Preventive Health Service Task Force generic framework for screening topics. 42

1: Is there direct evidence that screening for Barrett’s esophagus (BE) leads to reduced risk of morbidity or mortality from esophageal cancer?*

2: Is there direct evidence that screening for dysplasia in patients with BE leads to reduced risk of morbidity or mortality from esophageal cancer?*

3: Is there direct evidence that treatment of dysplasia leads to reduced risk of morbidity or mortality from esophageal cancer?

4: What is the prevalence of GERD? What is the prevalence of esophageal cancer in persons with GERD? Can a high risk group be identified?

5: What is the prevalence of BE? What is the prevalence of esophageal cancer in persons with BE? Can a high risk group be identified?

6: What is the prevalence of esophageal cancer? Does all esophageal cancer act the same way? Are there indolent forms of the disease?*

7: Can screening tests accurately identify BE?

8: Can screening tests accurately identify dysplasia?*

9: How effective are treatments for dysplasia? Does treatment of dysplasia reduce the risk of esophageal cancer?

10: How effective is treatment of esophageal cancer? Does treatment improve outcomes for people diagnosed by screening vs. those diagnosed clinically?*

11: What are the adverse effects of screening for BE in people with GERD?*

12: What are the adverse effects of screening for dysplasia in people with BE?*

13: What are the adverse effects of treatment of dysplasia?

14: What are the adverse effects of treatment of esophageal cancer?

Some recommendations for screening and surveillance may show efficacy in study settings but lack effectiveness in the real world. There are standardized techniques for taking biopsies of the esophagus, but clinical practice varies. In both Europe and the United States, professional associations recommend four quadrant biopsies every two centimeters within a segment of suspected BE. 43 , 44 However, a significant number of endoscopists fail to utilize proper biopsy technique or even identify standardized landmarks during endoscopy for BE. 45 , 46 In clinical practice, hiatal hernia, inflammation and tortuosity of the esophagus may make accurate technique difficult. Furthermore, biopsy of a normal GE junction may lead to a false positive screen for BE (due to the high prevalence of goblet cells at the normal GE junction in those with chronic GERD symptoms) and biopsies performed in the setting of inflammation may falsely identify dysplasia. 47 , 48

Once biopsies are obtained, expert pathologic assessment is required to accurately interpret BE specimens. Alikhan et al demonstrated considerable inter-operator variability among community pathologists when interpreting standardized BE pathology. 49 High and low grade dysplasia were correctly identified by only 30 and 35% of pathologists, respectively and many incorrectly identified gastric metaplasia as BE. Expert confirmation of BE pathology is only recommended for dysplastic BE and thus misclassified patients may receive inappropriate surveillance.

Additionally, there are costs and risks to screening that are not often factored into the discussion of screening and surveillance programs for BE. These risks become important especially when the disease (esophageal cancer) is rare and the screening population (patients with GERD) is large. Therefore, the potential good done for the very few must outweigh the risks, costs and inconvenience to the many. While uncommon, EGD has risks associated with sedation, perforation, infection and bleeding. These small risks become significant when EGD is applied to millions of people to screen for a rare cancer. 18 There may be a risk in labeling patients with BE as well. 50 Quality of life is diminished for patients diagnosed with BE and those participating in surveillance programs compared to population norms. 51 , 52 Many patients overestimate their cancer risk and add psychological stress that is difficult to quantify. 53 Finally, patients with BE have increased insurance premiums compared to those without BE. 54

Screening for BE with or without subsequent surveillance remains a controversial topic. The current state of technology, available data in the published literature and growing concern over costs in medical care all raise substantial concerns about the utility of such programs. Several potentially disruptive technologies hold the promise of changing this calculus. Ultra-thin trans-nasal endoscopy may allow screening of unsedated patients, greatly lessening the cost of screening, and allowing higher throughput. 55 Capsule endoscopy or other novel imaging may also obviate the need for per oral endoscopy for screening. 56 Multiple imaging technologies hold the promise to improve our ability to detect dysplasia, perhaps allowing subsequent surveillance intervals to be lengthened or omitted altogether. 57 – 59 Ablative therapies may allow for intervention that would obviate the need for follow-up endoscopy and may change the natural history and downstream costs associated with the lesion. 60 All of these possibilities are intriguing, and may change our approach to cancer prevention, but the potential of the interventions in the screening setting remains unproven.

Published Guidelines

There are a number of published guidelines that address the question of BE screening amongst persons with GERD ( Table 2 ). The American Gastroenterological Association (AGA) published a medical position statement on the management of GERD in 2008, which utilized explicit evidentiary methodology. 61 The AGA guidelines determined that there was insufficient evidence to recommend for or against routine upper endoscopy in the setting of chronic GERD symptoms to diminish the risk of death from esophageal cancer. The AGA guidelines also determined that there was insufficient evidence to recommend for or against endoscopic screening for BE and dysplasia in adults 50 years or older with greater than 5–10 years of heartburn to reduce mortality from esophageal adenocarcinoma.

Recommendations from published guidelines regarding screening for Barrett’s esophagus

GERD: Gastroesophageal reflux disease; BE: Barrett’s esophagus

The American College of Gastroenterology (ACG) also published guidelines addressing the management of GERD and BE in 2005 and 2008 respectively. 43 , 62 These guidelines also recognize that screening for BE is controversial due to the lack of documented impact on esophageal cancer mortality. Similar to the AGA guidelines, the ACG guidelines report inadequate evidence to recommend routine screening for BE in any specific high-risk population (such as GERD patients or older individuals).

The American Society for Gastrointestinal Endoscopy (ASGE) published guidelines on the role of endoscopy in BE and GERD in 2006 and 2007, respectively. 44 , 63 The ASGE recommends that screening for BE should be considered “in selected patients with chronic, longstanding GERD.” However, the ASGE does not recommend additional screening following a negative initial screening examination. Endoscopy at the time of presentation with GERD symptoms is also recommended for persons “at risk of Barrett’s esophagus,” including patients with a prolonged history of GERD symptoms (>5 years), white race, male sex, older age (>50), and family history of BE and/or adenocarcinoma of the esophagus. However, the ASGE graded this recommendation 2C, indicating a very weak recommendation with unclear benefit.

The British Society of Gastroenterology guidelines state that endoscopic screening of patients suffering from heartburn in order to detect BE is not recommended. 64 The United States Preventive Services Task Force (USPSTF) does not currently have any published guidelines addressing screening for esophageal cancer.

There is perhaps no area in gastroenterology where the clinical practice is more at odds with the published data and guidelines than in endoscopic screening for BE. Although, as noted above, guidelines are either unsupportive or equivocal on such practices, data suggest that the overwhelming majority of gastroenterologists in the U.S. enthusiastically support them. 65 , 66 Interestingly, fear of litigation from missed lesions appears to be a significant motivating factor of screening behavior. 66

Recommendations for Patient

The patient described in the scenario above has typical GERD symptoms, and received appropriate initial management including a trial of lifestyle modification. He is in a high risk category for BE in that he has a history of GERD for over 5 years, is over 50 years of age, and is a white male. However, he does not have any alarm symptoms that would prompt a diagnostic endoscopic exam. A simple algorithm summarizes an approach to BE screening in GERD patients ( Figure 2 ). At this time, there is insufficient evidence to recommend routine screening for BE or esophageal cancer in persons with GERD, even those with risk factors for BE, and, based on the evidence and guidelines discussed above, this patient would not require endoscopic screening for BE. It is incumbent on physicians who elect to discuss endoscopic screening with patients to fully inform them of the potential pros and cons of this maneuver, as well as the weak nature of the data supporting endoscopic screening ( Figure 3 ).

Modified diagram for use of endoscopy in the setting of GERD, based on published AGA and ACG guidelines.

GERD: Gastroesophageal reflux disease

Weighing the potential benefits and harms of screening for Barrett’s esophagus amongst patients with Gastroesophageal reflux disease

Whether persons with GERD should be screened for BE is a common question of both primary care physicians and gastroenterologists alike. Current guidelines recommend either no screening or screening only in individuals at high risk of esophageal cancer. Esophageal cancer is a relatively rare entity in patients with heartburn, and the vast majority of patients with GERD are unlikely to benefit from screening for BE. The evidence supporting screening efforts is weak and inconsistent. Therefore, wide scale endoscopic screening in its currently practiced form cannot be recommended on a routine basis. Further developments in technology may make screening more effective and cost-effective. Finally, the changing epidemiology of this cancer demands that we revisit this issue frequently, as the value of effective screening would presumably increase as the incidence of esophageal cancer rises. While lack of evidence in favor of endoscopic screening does not indicate lack of efficacy, until more data are available to support this practice, screening efforts might be better directed at interventions with proven benefits.

Suggested Reading 17 , 18 , 31 , 36 , 43 , 44 , 61 – 63

• Barry R. Katz, M.D.
• Raaj K. Popli, M.D.
• Sanjay K. Reddy, M.D.
• Harry H. Shephard, M.D.
• Jorge A. Zapatier, M.D.
• Robert A. Shultz, D.O.
• Zachary I. Field, M.D.
• Hanna R. Agard, MSN, APRN
• Jeanine Febres, MSN, APRN-C
• Naomi Ringer, APRN
• Accepted Insurances
• Patient Portal

Case Study: Self Diagnosis, Denial and Danger With GERD

In a previous blog, we introduced you to GERD patient, Elena , our DDC Orlando case study. She continued to endure worsening heartburn and acid reflux for years.  Yet she had barely mentioned her self-diagnosed GERD problem to her doctor.  She tried to shrug it off as indigestion, dyspepsia and just a bad stomach.

Here at DDC Orlando, in Dr. Sanjay Reddy’s words, “Not all GERD is just dyspepsia.”  As we continue Elena’s case study over several more blogs, you will see that not every case of GERD simply signifies indigestion.  Likewise, no case should be self-diagnosed because of a magazine article or a friend’s story.

Case Study:  Patient faces Denial, Takes the First Steps

Case Study in GERD shows a dangerous tendency to self-diagnose.

It is true that most patients with GERD can be successfully treated with medications and lifestyle changes.  However, self-diagnosis of GERD can be medically dangerous because the symptoms of GERD can indicate more serious digestive problems.

In a recent interview, DDC Orlando’s Dr. Sanjay Reddy stated, “Chronic heartburn and acid reflux can mean more than “just” GERD.  Gastro Esophageal Reflux Disease itself can be the body’s way of sending alarm signals to indicate more serious problems.”  This is exactly the reason your primary doctor might refer you to Digestive Disease Consultants of Orlando.  With a careful examination, case history and state-of-the-art testing, we can interpret the alarm signals from your body.  We need to know if your GERD symptoms are just dyspepsia, like most patients.   Or if we should investigate more serious possibilities.

Perhaps, like our case study, Elena, you do not know about all the other possibilities such as Barrett’s Esophagus or the beginnings of esophageal cancer.  In the mind and experience of a patient, the symptoms of those diseases might seem like a straight-forward case of GERD.

At DDC Orlando, when patients exhibit GERD symptoms, doctors work to discern and monitor your risk of a condition that can result in cancer without proper treatment. GERD is not always simply dyspepsia.  In the words of experts, “It is essential for individuals who suffer persistent heartburn or other chronic and recurrent symptoms of GERD to seek an accurate diagnosis , to work with their physician, and to receive the most effective treatment available.”

Case Study:  Elena’s Denial and Excuses for Avoiding Diagnosis

Doctor explains GERD to DDC Orlando Patient

Toughness:  Her parents raised her to be strong.  Years of conditioning to be tough had taught her to grin and bear it.  So she developed a high tolerance for pain when her throat burned or her chest ached.  She avoided the doctor and months stretched into years.  Like many people who deal daily with acid reflux, she blamed it on dyspepsia.

She was in denial that there could be anything more severe than indigestion interrupting her life.  She refused to let GERD take more than a few moments of her time.  This mind-set worked for a while, but as in many case studies, symptoms grew very severe.  Finally, it became obvious to Elena that the over-the-counter antacids did not have the power to treat her illness.

Timidity:   Elena could not be considered an introverted person.  However, she had a deep-seated shyness about discussing bodily functions.  Even admitting her diarrhea embarrassed her.  Additionally, her friends had told her horror stories about the type of testing her condition might require. ( Rest assured, DDC Orlando will be addressing that issue in the near future. )

Case Study:  Elena and the Lifestyle Changes—Her Baby-Steps

After a few more attacks l ike the one at her Birthday dinner , our case study patient’s family became concerned. Elena’s  husband hugged her as he said, “Three trips to the emergency room in two months?  Hon, something’s wrong.  I took the liberty of making you an appointment.  Keep it or change it, but you can’t go on like this.”

She kept the appointment with her primary care doctor.  Based on her description of her reflux and heartburn symptoms, he diagnosed GERD.  He immediately suggested life-style and dietary changes. (She thought, “Tell me something I don’t know.  I’ve already started changing my life. I know some of my triggers .  I am keeping a food diary.)

He also wrote prescriptions for stronger medications than over-the-counter antacids and booked her for a re-check in six weeks.  She smiled weakly when the doctor gave her several brochures about GERD lifestyle changes.  Our case study dreaded trying to lose her extra 38 pounds of body weight.

Case Study Quiz:  Find the Anti-GERD Lifestyle Changes in Elena’s Story Below!

We challenge you to find the lifestyle changes woven into the following case-study scenario:

Elena drove home slowly and fought sadness because now GERD was a real medical diagnosis .  As she picked up her prescriptions at the pharmacy, she hated the idea of depending on her new pills to control it.  Then she desperately wanted a cigarette, but she had quit two weeks ago because she knew they were a trigger.  They literally hurt her throat and chest.  She smiled grimly.  A good strong cup of coffee would improve her mood, she thought.  But it wasn’t worth the choking hot lava in the throat, the reflux.  Caffeine was another one of the first triggers she discovered .  She had not had a cup in three weeks, since her last trip to the emergency room.

Case Study Scenario:  GERD vs. Family life

Upon her return home, Elena’s 6-year-old daughter Ashleigh met her at the door,

“Mommy, Mommy, Daddy turned your bed into a slide,” she shrilled.

We re-join patient Elena’s story of her diagnosis of GERD.  To enrich your understanding, we suggest you read or review the introduction of her case study in our one of our previous blogs.   Before the dramatic episode on her birthday , which resulted in an emergency room visit, Elena had never seriously discussed her chronic heartburn and reflux with her primary physician.  Her knowledge of the condition came from conversations with friends and a few magazine articles.

Case Study:  The Patient’s Top Three Excuses for Avoiding a Discussion of GERD

Time:   Elena is a busy mom of three with her own part-time real estate job.  Our case study patient, Elena, had a hectic life and a full schedule.  She declared, “I just don’t have time to go see the doctor every time I have a belly ache or heartburn.”

Case Study Patient With GERD finds hope with family support.

Elena could see the head of the bed had been raised  on pretty polished wooden blocks.  Our case study patient started to smile.  Her husband, still holding an electric drill from his bed-tilting project, strode into the room and hugged her.

14-year-old Lisa popped her head around the kitchen doorway, “Hi, Mom!  I made Baked Parmesan Chicken Breasts for dinner.  You’ll love them. They’re crispy even without skin!” Elena’s 9-year-old son, Mike chimed in, “And Dad made me eat the rest of those cookies so you wouldn’t be tempted !”  Elena laughed, hugged, and stopped feeling sad. “Yeah,” added Mike, as if to explain the cookies, “We read all about Gerdie on the Internet.” … And that is how our DDC Orlando GERD case study patient named her condition! 

Please join us at this blog next week for all the answers to the above case study quiz .  You’ll find out more about Elena’s lifestyle changes.  Also, learn why, six weeks after diet, medication and lifestyle changes, she ended up in the emergency room again with GERD symptoms.

Case Studies

CR, a 44-year-old man, comes to the pharmacy looking for a remedy for his heartburn. He reports that his heartburn has been bothering him for the past few weeks, and he complains of an acidic taste in his mouth and a burning feeling in his throat about twice a week. CR does not complain of any other related symptoms, such as pain when swallowing. CR has a box of omeprazole (Prilosec) in his hand. He asks if it would be the best product to help alleviate his symptoms.

As the pharmacist, how would you respond?

EF is a 30-year-old woman who comes to the pharmacy with dry, demarcated lesions in linear streaks, with some vesicles, on her hands, arms, and face. She says she was gardening yesterday for a few hours and must have touched poison ivy. EF says she tried to hide it with makeup to go to work this morning, but it only made it worse. She exclaims, “I cannot stand the itching anymore.” Upon questioning, you find out that she has had similar lesions before, but they were less extensive and not as bothersome. EF asks if there is pharmacy product that could help. She has no significant medical history and is not taking any prescription or OTC medications.

As the pharmacist, what would you recommend?

Case 1: Based on his reported symptoms, CR likely suffers from mild/ episodic gastroesophageal reflux disease (GERD), so he is a candidate for self-treatment. OTC proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, and esomeprazole are appropriate for self-treatment of GERD for up to 14 days. However, before you recommend these products, you should educate CR that OTC omeprazole, lansoprazole, and esomeprazole are not intended for immediate relief of heartburn. These drugs have a slow onset but a long duration of action, and CR may have to take one of these drugs for 1 to 4 days before he feels better. CR should be cautioned to speak to his doctor if his symptoms do not resolve after 2 weeks or his heartburn worsens.

Alternatively, CR could try a histamine2 (H2)-receptor antagonist such as ranitidine, cimetidine, famotidine, or nizatidine. H2-receptor antagonists have a different mechanism of action than PPIs and provide relief of heartburn more quickly than PPIs. H2-receptor antagonists can be taken prophylactically before meals to prevent GERD.

CR might also consider taking an antacid, including calcium carbonate, sodium bicarbonate, magnesium hydroxide/aluminum hydroxide, or bismuth subsalicylate. These agents have the fastest onset of action, but they provide only symptomatic relief of heartburn and have the shortest duration of action.

Case 2: Allergic contact dermatitis is an inflammatory skin reaction to a foreign substance, such as urushiol in the sap of the poison ivy plant. Sensitized patients can develop clinical symptoms such as erythema, intense itching, and formation of plaques and vesicles within 4 to 96 hours after exposure to an allergen.

EF appears to have severe contact dermatitis. She is not a candidate for self-treatment because of the facial involvement of her dermatitis and the presence of vesicles and intense itching. If left untreated, allergic contact dermatitis resolves within 1 to 3 weeks; however, it can cause significant discomfort. EF should be referred to her primary care provider to obtain a prescription for an oral corticosteroid, such as prednisone to decrease itching, and perhaps a high-potency topical corticosteroid such as clobetasol propionate 0.05% cream, which is generally not applied to the face. A 21-day course of oral prednisone (starting at 1 mg/kg/day and tapered over 3 weeks) is appropriate and can significantly reduce symptoms, including itching.

EF should be told to keep the area clean and to avoid scratching and using makeup, as they can irritate the skin. In addition, nonpharmacologic treatments, including the application of cold compresses, can be recommended. EF might try using astringents such as aluminum acetate (Burrow’s solution) or calamine to reduce inflammation and promote drying, and healing of the lesions.

Read the answers

function showAnswer() {document.getElementById("answer").style.display = 'block';document.getElementById("link").style.display = 'none';}

Dr. Coleman is professor of pharmacy practice, as well as codirector and methods chief at Hartford Hospital Evidence-Based Practice Center, at the University of Connecticut School of Pharmacy.

Pharmacists Can Educate Patients on Summer Health Tips

Expanding Roles, New Approaches for Pharmacists in Managing Graft-Vs-Host Disease

Enhancing Pharmacy Practice: Accessible and Affordable Continuing Education for Technicians

Addressing Challenges When Implementing Bispecific Antibodies in Diverse Settings

Condition Watch, June 2024

Enhancing Cancer Care: SOGI Data Collection for Sexual and Gender Minority Patients Remains Critical

2 Commerce Drive Cranbury, NJ 08512

609-716-7777

GERD Case Study 2024 Questions And Answers NEW Version A... - $21.95 Add to Cart

GERD Case Study 2024 Questions And Answers NEW Version A+

Preview 1 out of 5 pages

Generating Your Document

Purchase the document to get the full access instantly

•   3 Million+ Study Documents
•   100% Money Back Guarantee
•   Immediate Download Access

Report Copyright Violation

Exam Details

Add To Cart

Add To Wishlist

• Trusted by 800,000+ Students
• 24/7 Money Back Guarantee
• Download is directly available

Specifications

Institution Eastern Arizona College

Study Nursing

Course GERD Case Study 2024 Questions And Answers NEW Version A+

Document Details

Language English

Subject Health Care

Updated On Jun 29,2024

Number of Pages 5

Written 2023-2024

Seller Details

1.7K documents uploaded

10 documents sold

Member since 9 months

Reviews received

Recommended documents

NAPSRx Final Exam Solutio...

Focused Exam: Abdominal P...

HLTH 501 FINAL EXAM | Com...

BUS 660 Forecasting Case ...

Final Applied Lab Project...

What students are saying about us.

DocMerit is a great platform to get and share study resources, especially the resource contributed by past students.

Northwestern University Karen

I find DocMerit to be authentic, easy to use and a community with quality notes and study tips. Now is my chance to help others.

University Of Arizona Anna Maria

One of the most useful resource available is 24/7 access to study guides and notes. It helped me a lot to clear my final semester exams.

Devry University David Smith

DocMerit is super useful, because you study and make money at the same time! You even benefit from summaries made a couple of years ago.

Liberty University Mike T

• Follow us on
• Copyright © 2024 | All rights reserved

Register a free account