GERD (Gastro-Esophageal Reflux Disease)

• Reflux can be physiologic if not cause symptoms/complication
• High prevalence, but need to be aware of differential diagnosis


• Clinical
  • Heartburn-retrosternal, postprandial
    • May mimic angina pectoralis
  • Regurgitation


• Diagnosis
  • Clinical


• Important differential diagnosis
  • Angina pectoris: heartburn
    • Helpful further investigation: EKG, EST
  • Upper GI tract malignancy
    • Helpful further investigation: EGD
    • Alarm features suggestive of malignancy
      • New onset of dyspepsia at age ≥ 60 yrs
      • GI bleeding (including occult blood)
      • IDA
      • Anorexia/unexplained weight loss
      • Dysphagia/Odynophagia
      • Persistent vomiting (Obstruction)
      • Family history of GI cancer in 1st-degree relative
  • Infectious esophagitis (HIV, ImCom)
    • Candida, CMV, HSV
  • Pill oesophagitis


• Management
  • Lifestyle and dietary modification
    • Weight loss
    • Elevation of head of the bed
    • งด “ของแสลง”
  • Medical (1st line in patients with typical GERD symptoms)
    • PPIs eg. Omeprazole >> effective in all severity
      • Standard dose duration = 8 weeks
    • Mild symptoms (use on demand)
      • H2RAs eg. Famotidine, Cimetidine (Ranitidine has been removed from the market due to carcinogenic risk)
      • Sucralfate: 1st line tx. in pregnancy (but H2RAs, PPIs is also considered safe)
      • Antacids
    • NO role of empiric H. pylori eradication

FAQs

• When to refer GERD patients for esophageal impedance-pH testing or esophageal manometry?
  • To prove that patient’s symptoms are truly due to GERD. (No other more serious conditions)
  • Before invasive GERD treatment such as Sx (in refractory cases).
• Other doctors have used prokinetic agents (e.g., metoclopramide) to treat GERD. Why don't you mention it?
  • Due to serious side effects and poor effectiveness, we suggest only using prokinetic agents in patients proven to have gastroparesis or other conditions with delayed gastric emptying time
  • ในประเทศไทยมีหลายกรณีพี่แพทย์ชนบทถูกชาวบ้านฟ้อง,ขับไล่ จากการฉีด metoclopramide ในห้องฉุกเฉินแล้วผู้ป่วยเกิด side effect เช่น EPS, Arrythmia
• “ของแสลง” คืออะไร
  • ของแสลงคือสิ่งที่ผู้ป่วยรับประทานแล้วอาจมีหรือไม่มีอาการขึ้นอยู่กับแต่ละบุคคลเช่นกาแฟ,น้ำอัดลม เป็นต้น