Setting: office
CC: “Heartburn”
HPI: A 27-year-old man with several months of epigastric discomfort and a burning sensation in his chest comes to see you at your office. He says that the discomfort is worse after he lies down for a while. He often has a bad taste in his mouth like “I am sucking on a handful of coins.”
PMHX:
Recurrent pharyngitis
Hoarseness
Chronic cough
Acid hits the back of the throat causing pain.
Twenty-five percent of patients with chronic cough have reflux disease.
Acid hits the carina causing cough.
Medications:
Multiple short courses of antibiotics for pharyngitis and cough
Cimetidine intermittently
What physical finding is characteristic of gastroesophageal reflux disease (GERD)?
a. Epigastric tenderness
b. None
c. Loss of dental enamel
d. Parotid gland enlargement
Answer b. None
GERD is entirely a symptom complex. There is no physical finding. Loss of dental enamel and parotid gland enlargement are from vomiting in anorexia or bulimia, not GERD.
PE: normal
Abdomen: nontender epigastric area
GERD is often misdiagnosed as:
• Pharyngitis
• Laryngitis
• Bronchitis
Acid hits the vocal cords causing hoarseness.
Initial Orders:
PPI, such as omeprazole
Why is cimetidine only effective in two-thirds of patients?
a. Incomplete inhibition of parietal cell
b. Increase in gastrin production
c. Tachyphylaxis (it wears off)
d. Helicobacter pylori
Answer a. Incomplete inhibition of parietal cell
Histamine is one of three stimulants to the production of acid at the parietal cell of the stomach. Because histamine potentiates the effect of acetylcholine from the vagus nerve as well as the effect of gastrin, there is a 60% to 70% reduction in acid production. At least one-third of patients will not have their acid production controlled by an H2-blocker such as cimetidine, ranitidine, or famotidine.
The patient returns the following week. He has only partial improvement in his symptoms. The bad taste in his mouth persists.
Which cranial nerve is responsible for the bad taste in his mouth?
a. V
b. VII
c. VIII
d. IX
e. XII
Answer d. IX
Acid hits the back of the tongue producing a bitter taste that is often described as “metallic.” Cranial nerve IX (glossopharyngeal) and X (vagus) transport the sense of taste from the back of the tongue. The bitter taste receptors and perception are at the back of the tongue to inhibit the likelihood of aspiration into the airway. Sweet taste receptors are at the anterior portion of the tongue and are controlled by the facial nerve, cranial nerve VII.
After several more weeks of return visits, it is clear that the PPI is not completely controlling the patient’s symptoms.
GERD should be controlled by PPIs in 95% of patients.
Failure of PPI = Confirm the Diagnosis
What should you do to confirm the diagnosis?
a. Double the dose of the PPI.
b. Do an endoscopy.
c. Do a 24-hour pH monitor.
d. Put in an NG tube for acid output.
Answer c. Do a 24-hour pH monitor.
The most accurate test of GERD is the 24-hour pH monitor. Because PPIs are amazingly effective at 95% symptom control, the failure of PPI treatment means there is a 20:1 chance that the diagnosis is not really GERD. Endoscopy can show Barrett esophagus and erosive esophagitis, but you cannot tell that acid is refluxing by endoscopy alone.
Substances that dilate the LES
• Nicotine
• Alcohol
• Caffeine
• Chocolate
• Peppermint
The 24-hour pH monitor confirms the presence of GERD. The patient continues to be bothered by symptoms of heartburn. You are planning a surgical or endoscopic procedure to tighten the LES.
What test should you do prior to a Nissen fundoplication or other LES-tightening procedure?
a. Esophageal manometry
b. Chest CT
c. Nuclear gastric emptying test
Answer a. Esophageal manometry
You have to be sure the ability of the esophagus to contract is normal prior to an LES-narrowing procedure. If you tighten the LES, and esophageal contractility is inadequate, you will create a blockade like achalasia.
Nuclear gastric emptying using barium-soaked bread tests for diabetic gastroparesis.
After the procedure, symptoms resolve for 2 years. There is a recurrence of GERD-like symptoms and PPIs are now given regularly. PPIs control the symptoms. Upper endoscopy shows columnar metaplasia.
What is the management?
a. Distal esophagectomy
b. Endoscopic mucosal resection
c. PPIs and repeat endoscopy in 2 to 3 years
d. Repeat surgical tightening
Answer c. PPIs and repeat endoscopy in 2 to 3 years
Barrett esophagus or columnar metaplasia of the distal esophagus is managed by doing surveillance endoscopy every 2 to 3 years.
• Patients with Barrett esophagus have a 0.5% per year chance of esophageal cancer.
• Patients with low-grade dysplasia need repeat endoscopy every 6 months.
• Patients with high-grade dysplasia need endoscopic mucosal resection.
Most patients with GERD do not progress to Barrett esophagus and only a very few go on to cancer.