Rosen & Barkin's 5-Minute Emergency Medicine Consult (293 page)

• Nonspecific, may have some epigastric tenderness.
  
• Symptoms worsen with placing patient flat on the bed or Trendelenburg position
  

• Regurgitation is common in infants:
  
  • Incidence decreases from twice daily in 50% of those age 2 mo to 1% of 1-yr-olds.
    
• Signs:
  
  • Frequent vomiting, irritability, cough, crying, and malaise
    
  • Arching the body (hyperextension) at feeding and refusals of feedings
    
• Failure to thrive
  
• Formula intolerance
  
• Sepsis
  

• Differentiate GERD from more emergent conditions such as ischemic heart pain, esophageal perforation, or aortic pathology.
  
• Obtain typical history
  
• Perform thorough physical exam: Vital signs, head, ears, eyes, nose, throat (HEENT), chest and abdominal exams
  

No gold standard

• CBC:
  
  • Chronic anemia from esophagitis
    
• Stool testing for occult bleeding
  

• No routine Imaging
  
• Chest radiograph:
  
  • Evidence of esophageal perforation, hiatal hernia, aortic disease
    

• Diagnostic trial of antacid:
  
  • Those with persistent symptoms should be referred for endoscopy
    
  • 90% of GERD patients respond to proton pump inhibitor (PPI) therapy
    
• Barium esophagram for prominent dysphagia
  
• Esophageal pH monitoring:
  
  • Correlate symptoms to acid reflux
    
• Esophageal manometry (poor sensitivity):
  
  • Evaluate LES resting pressure and esophageal peristaltic contractions
    
• Esophagogastroduodenoscopy (EGD)—detects reflux esophagitis and complications (Barrett esophagus, hiatal hernia, stricture, ulcers, malignancy)
  

• Ischemic heart disease
  
• Asthma
  
• Peptic ulcer disease
  
• Gastritis
  
• Hepatitis/pancreatitis
  
• Esophageal perforation
  
• Esophageal foreign body
  
• Esophageal infection
  
• Cholecystitis/cholelithiasis
  
• Mesenteric ischemia
  

TREATMENT

• Esophageal pain may mimic angina
  
• Airway may need active control secondary to vomiting
  

• ABCs need to be evaluated
  
• IV fluid resuscitation for blood loss or shock
  

• Symptomatic relief:
  
  • Antacids
    
  • Antacids with viscous lidocaine
    
  • Sublingual nitroglycerine for esophageal spasm
    
  • Analgesics
    
• Lifestyle modifications:
  
  • Avoid late-night or heavy/fatty meals.
    
  • Minimize time in supine position after eating.
    
  • Elevation of head of bed
    
  • Weight loss
    
  • Eliminate smoking and alcohol intake
    
  • Avoid direct esophageal irritants such as citric juices and coffee
    
  • Avoid foods that decrease LES pressures such as fatty foods, chocolate, and coffee
    
  • Avoid drugs that lower LES tone
    
• PPIs:
  
  • More potent long-acting inhibitors of gastric acid secretion than H
    ₂
    -blockers
    
  • Faster healing than other drug therapies
    
  • More efficacious in severe GERD and frank esophagitis
    
• H
  ₂
  -blockers:
  
  • Effective for mild to moderate disease
    
  • Severe disease requires greater dosage than that used for peptic ulcer disease
    
• Antacids (Maalox, Mylanta):
  
  • Treatment of mild and infrequent reflux symptoms
    
  • Not effective for healing esophagitis
    
  • Alginic acid slurry floats on surface of gastric contents, providing mechanical barrier
    
• Sucralfate:
  
  • Binds to exposed proteins on surface of injured mucosa to form protective barrier
    
  • May also directly stimulate mucosal repair
    
• Metoclopramide (prokinetic drug):
  
  • Improves peristalsis
    
  • Accelerates gastric emptying
    
  • Increases LES pressure
    
• Drugs that modify TLESR
  
  • Baclofen
    
  • ADX10059
    
• Endoscopic therapy:
  
  • Suturing (plication), thermal injury, chemical injection
    
• Antireflux surgery (goal: Increase LES pressure):
  
  • Chronic reflux, younger patients, nonhealing ulceration, severe bleeding
    
  • Fundoplication can be more effective than medical therapy in selected cases
    
  • Currently newer incisionless procedure called transoral incisionless fundoplication available
    

• Reflux present in 30–50% of pregnancies
  
• Increased intra-abdominal pressure, hormonal fluctuations lead to increased TLESRs
  
• EGD reserved for severe presentations
  
• H
  ₂
  -blockers—1st-line therapy (longer safety record)
  
• PPIs—limited safety history in pregnancy
  

• Antacids: 30 mL + viscous lidocaine, 10 mL, PO q6h
  
• Cimetidine: 400 mg PO BID, 300 mg IM/IV q6–8h
  
• Esomeprazole: 20–40 mg PO daily
  
• Famotidine: 20 mg PO/IV BID (peds: 0.5–1 mg/kg/d div. q8–12h, max. 40 mg/d)
  
• Lansoprazole: 15–30 mg daily
  
• Metoclopramide: 10–15 mg PO/IV/IM q6h before meals and nightly at bedtime
  
• Nizatidine: 150 mg PO BID
  
• Omeprazole: 20–40 mg PO daily
  
• Pantoprazole: 40 mg PO/IV daily
  
• Rabeprazole: 20 mg PO daily
  
• Ranitidine: 150 mg (peds: 5–10 mg/kg q12h) PO BID or 300 mg PO nightly at bedtime
  
• Sucralfate: 1 g PO 1 hr before meals and nightly at bedtime
  

• Life style modifications:
  
  • Head of bed elevation
    
  • Dietary modification
    
  • Refraining from assuming a supine position after meals
    
  • Avoidance of tight-fitting garments
    
  • Promotion of salivation by either chewing gum
    
  • Restriction of alcohol use
    
  • Reduction of obesity
    
• Acid-suppressive medications:
  
  • PPI or H
    ₂
    blocker
    
• Treatment of
  H. pylori
  infections
  

• Prokinetic drugs (bethanechol, metoclopramide)
  
• Drugs that inhibit TLESRs (baclofen)
  

FOLLOW-UP

• Significant esophageal bleeding
  
• Uncontrolled reactive asthma
  
• Dehydration
  
• Starvation and failure to thrive
  

Uncomplicated GERD: Refer to patient’s primary care physician (PCP) or gastroenterologist for further evaluation.

Extraesophageal manifestations such as asthma, laryngitis.

Gastroenterologist for endoscopy in patients who require continuous maintenance medical therapy to rule out Barrett esophagus.

• GERD therapy should include lifestyle changes.
  
• In patients with worse than mild and intermittent GERD symptoms initiate acid-suppressive therapy.
  
• In patients with GERD and moderate to severe esophagitis, provide acid suppression with a PPI rather than H
  ₂
  blockers.
  
• Endoscopy for patients who fail chronic therapy (at least 8 wk).
  
• Antireflux surgery for patients on high doses of PPIs, specially in young patients who may require lifelong therapy.
  
• Complications of GERD
  
  • Esophagitis
    
  • Peptic stricture and Barrett metaplasia
    
  • Extraesophageal manifestations of reflux: Asthma, laryngitis, and cough.
    

• Cappell MS. Clinical presentation, diagnosis, and management of gastroesophageal reflux disease.
  Med Clin North Am
  . 2005;89(2):243–291.
  
• DeVault KR, Castell DO, American College of Gastroenterology. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease.
  Am J Gastroenterol
  . 2005;100:190–200.
  
• Diav-Citrin O, Arnon J, Shechtman S, et al. The safety of proton pump inhibitors in pregnancy: A multicentre prospective controlled study.
  Aliment Pharmacol Ther
  . 2005;21:269–275.
  
• Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease.
  Gastroenterology.
  2008;135:1392–1413.
  
• Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach.
  Arch Intern Med.
  2006;166:965–971.
  
• Nwokediuko SC. Current trends in the management of gastroesophageal reflux disease: A review.
  ISRN Gastroenterol.
  2012;2012:391631.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Gastritis
  
• Peptic Ulcer Disease
  

CODES