From: Subject: Best Dx/Best Rx: Gastroesophageal Reflux Disease Date: Wed, 3 Jun 2009 21:40:33 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0202_01C9E493.EC9D0A50" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0202_01C9E493.EC9D0A50 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0401.htm Best Dx/Best Rx: Gastroesophageal Reflux = Disease



Gastroesophageal Reflux=20 Disease

Mark Feldman, M.D.
University of Texas=20 Southwestern Medical School at Dallas

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features

  • Heartburn that radiates up chest and is = readily relieved=20 by antacids=20
  • Regurgitation of small quantities of sour- or=20 bitter-tasting gastric contents=20
  • Atypical (extraesophageal = presentations)=20
    • Chest pain=20
    • Hoarseness=20
    • Sore throat=20
    • Asthma=20
    • Chronic cough
3D""=20=20 bac= k to=20 top

Differential = Diagnosis

  • Angina pectoris=20
  • Myocardial infarction=20
  • Esophagitis due to infection=20
  • Esophageal motor disorder=20
  • Scleroderma=20
  • Aortic dissection (rare)
      3D""=20=20 bac= k to=20 top

      Best=20 Tests

      • Therapeutic trial of antacids, H2 = blockers,=20 or proton pump inhibitors (PPIs)=20
        • Initial test in patients with mild symptoms = or=20 symptoms of recent onset
      • Endoscopy=20
        • High specificity (> 95%), but low = sensitivity=20 (50%)=20
        • Reserve for the following:
          • Uncomplicated gastroesophageal reflux = disease (GERD)=20 that does not respond to empirical therapy=20
          • Patients with symptoms of complicated = GERD=20
            • Dysphagia=20
            • Weight loss/anorexia=20
            • Bleeding/anemia
          • Patients with long-standing symptoms = (particularly=20 if age > 50 yr) to rule out Barrett esophagus =
      • Esophageal pH monitoring=20
        • High sensitivity and specificity (both >=20 95%)=20
        • Useful for atypical or unresponsive = symptoms=20
      • Esophageal manometry=20
        • Useful for motor disorders and for = evaluation before=20 antireflux surgery
          3D""=20=20 bac= k to=20 top

          Best=20 Therapy

          Lifestyle Modifications = in=20 Treatment of GERD=20
          • Elimination of fatty foods and chocolate from=20 diet=20
          • Avoidance of tight, binding clothing=20
          • Avoidance of late (bedtime) snacks=20
          • Cessation of alcohol consumption=20
          • Cessation of smoking=20
          • Elevation of head of bed =
          Drug Treatment for GERD=20
          • Efficacy of antireflux drug therapy inversely = related to=20 underlying GERD severity
          PPIs=20
          • Treatment of choice for severe GERD (often in = double the=20 usual daily dose)=20
          • Usually first choice for treatment of mild to = moderate=20 GERD (in typical daily doses)=20
          • Efficacy rating 80%=96100%=20
          • Omeprazole=20
            • Dose: 20=9640 mg q.d.=20
            • Cost/mo: $40 (nonprescription) =
          • Esomeprazole=20
            • Dose: 40 mg q.d.=20
            • Cost/mo: $124
          • Lansoprazole=20
            • Dose: 30=9660 mg q.d.=20
            • Cost/mo: $248
          • Pantoprazole=20
            • Dose: 40=9680 mg q.d.=20
            • Cost/mo: $222
            H2 Receptor Blocking = Agents=20
            • Efficacy rating ~ 50%=20
            • Cimetidine=20
              • Dose: 400 mg q.i.d.=20
              • Cost/mo: $34 (nonprescription) =
            • Ranitidine=20
              • Dose: 150 mg b.i.d.=96q.i.d.=20
              • Cost/mo: $22 (nonprescription) =
            • Famotidine=20
              • Dose: 20=9640 mg b.i.d.=20
              • Cost/mo: $40=96$52 (nonprescription) =
            • Nizatidine=20
              • Dose: 150 mg b.i.d.=96q.i.d.=20
              • Cost/mo: $61=96$122 (prescription)=20
              Antacids (Particularly Those Containing = Alginic=20 Acid)=20
              • Efficacy satisfactory for mild and = intermittent=20 symptoms, but not for healing
              • Use as needed
                • Liquid dose: 15 ml q.i.d. (1 hr after meals = and at=20 bedtime)=20
                • Tablet dose: 2=964 tablets q.i.d. (1 hr = after meals and=20 at bedtime)
              Prokinetic=20 Agents=20
              • Metoclopramide=20
                • Efficacy satisfactory for mild and = intermittent=20 symptoms=20
                  • Dose: 10=9620 mg before meals=20
                  • Cost/mo: $30 =
                3D""=20=20 bac= k to=20 top

                Best References

                Emerenziani S, et al: Curr Opin Gastroenterol = 21:450, 2005=20 [PMID 15930987]

                Halstead LA: Drugs Today (Barc) 41(suppl B):19, = 2005 [PMID=20 16200228]

                Locke GR 3rd: Thorac Surg Clin 15:369, 2005 [PMID = 16104127]

                Pessaux P, et al: Arch Surg 140:946, 2005 [PMID=20 16230543]


                June 2006

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