0071643192.pdf

■ If the patient is unresponsiveto therapy or has alarm symptoms(dysphagia,
odynophagia, weight loss, anemia, long-standing symptoms, blood in stool,
age >50), proceed as follows:
■ Barium esophagography: Has a limited role but can identify strictures
■ Upper endoscopy with biopsy: Standard workup in the presence of
alarm symptoms;normal in >50% of patients with GERD (most have
nonerosive reflux disease) or may reveal endoscopic esophagitis grades 1
(mild) to 4 (severe erosions, strictures, Barrett esophagus); strictures
can be dilated
■ Ambulatory esophageal pH monitoring: The gold standard, but often
unnecessary; indicated for correlating symptoms with pH parameters
when endoscopy is normal and (1) symptoms are unresponsive to med-
ical therapy, (2) antireflux surgery is being considered, or (3) there are
atypical symptoms (eg, chest pain, cough, wheezing)

TREATMENT

See Table 11.1.

■ Behavioral modification: Elevate the head of the bed 6 inches; stop
tobacco and alcohol use. Advise patients to eat smaller meals, reduce fat
intake, lose weight, avoid recumbency after eating, and avoid certain foods
(eg, mint, chocolate, coffee, tea, carbonated drinks, citrus, and tomato
juice). This is effective in 25% of cases.

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

TABLE 11.1. Treatment of GERD/Peptic Ulcer Disease

AGENT MECHANISM EXAMPLE

Antacid Neutralizes gastric acid Calcium carbonate, aluminum hydroxide, magnesium

hydroxide

Histamine antagonist Inhibits gastric acid secretions Cimetidine, ranitidine, famotidine, nizatidine

(H-2 blocker)

Proton pump inhibitor Inhibits H+/K+ATPase enzyme in Omeprazole, lansoprazole, pantoprazole

parietal cells, prevents acid release

Misoprostol Prostaglandin E analog, prevents Misprostol

NSAID-induced ulcers only

Sucralfate Binds to ulcer site Sucralfate

Bismuth Diminishes pepsin activity, used Bismuth subsalicylate

with triple therapy for Helicobacter

pylorieradication

H. pylorieradication 95% of duodenal ulcers and 70% Amoxicillin, clarithromycin, omeprazole or bismuth,

of gastric ulcers are due to H. pylori, tetracycline, metronizadole, omeprazole; other PPIs

Gram-negative, spiral-shaped acceptable to substitute for omeprazole

organism; eradication with triple

therapy treatment for 10–14 days