Gastroesophageal reflux disease (GERD)

“Heartburn”—substernal chest discomfort/pain with a burning quality.

Difficulty swallowing and/or pain on swallowing (if associated with esophagitis).

“Water brash”—sour or bitter taste in the mouth.

Nocturnal cough (due to aspiration), asthma exacerbation, hoarseness of voice (due to vocal cord involvement).

Increased risk of aspiration pneumonia.

Precipitated by alcohol, caffeine, medications (such as anticholinergics, benzodiazepines), cigarette smoking, large meals, caffeine, fatty foods, and supine position.

Often a clinical diagnosis.

24-h pH monitoring.

In the presence of dysphagia, odynophagia, early satiety, weight loss, or bleeding, and atypical symptoms (e.g., cough, asthma, hoarseness, chest pain), refer early for endoscopic evaluation.

Conservative measures:

Smoking and alcohol cessation.

Elevate head of bed at least 6 in.

Small, frequent meals while avoiding late meals.

Avoidance of medications and substances that may cause precipitation of symptoms (e.g. caffeine, fatty and spicy foods).

Medications: After failure of lifestyle changes for 3 weeks and with complicated cases.

H₂ blockers: May require long-term maintenance with half of acute treatment doses. Acute treatment doses are as follows:

Famotidine (Pepcid) 40 mg p.o. at bedtime or 20 mg p.o. twice daily.

Ranitidine (Zantac) 300 mg p.o. at bedtime or 150 mg p.o. twice daily.

Side effects—Altered mental status, depression, constipation, diarrhea, headache, and thrombocytopenia in elderly patients.

Caution with using cimetidine in psychiatric populations as it can cause delirium, and increase blood levels of valproic acid, selective serotonin reuptake inhibitors, carbamazepine, and tricyclics.

Symptoms persisting despite a 6-week trial of acute treatment doses with H2 blockers require treatment with proton pump inhibitors.

Proton pump inhibitors: May require longterm maintenance with full acute treatment doses daily. Acute treatment doses are as follows:

Omeprazole (Prilosec) 40 mg p.o. daily.

Has been reported to lower serum levels of clozapine.

Lansoprazole (Prevacid) 30 mg p.o. daily.

Pantoprazole (Protonix) 40 mg p.o. daily.

Side effects—gastrointestinal upset, headaches, vitamin B₁₂ deficiency with chronic use.

For complicated and/or refractory cases refer to medicine/gastroenterology.

Peptic ulcer disease (PUD)

Can be asymptomatic.

Epigastric abdominal pain (e.g., burning, tightness).

Anorexia (especially with gastric involvement).

Pain relieved by food (duodenal) and worsened by food (gastric).

Nausea and vomiting.

Upper GI bleed.

Precipitated by NSAIDs, stress-related mucosal disease, alcohol, H. pylori infection.

Helicobacter pylori is causative agent for majority of ulcers.

Testing for H. pylori may entail urea breath test, serology, EGD^a + rapid urease, biopsy and histology.

EGD is indicated if gastrointestinal tract (GI) bleed and/or neoplasia is suspected.

Conservative measures:

Smoking and alcohol cessation.

Discontinuation of NSAIDs including aspirin.

Avoidance of precipitating dietary substances, including spicy food.

Stress management techniques.

Medications:

H. pylori-associated PUD—treat with anti-H. pylori regimen ×10-14 d followed by maintenance with proton pump inhibitor/H₂ blocker × 4-8 weeks.

Non-ulcer dyspepsia—trial of proton pump inhibitor.

Acid suppressive treatment—maintenance treatment with proton pump inhibitor/H₂ blocker ×4-8 weeks, with continued treatment for complicated cases. Continue maintenance with H₂ blockers at half of acute treatment doses or proton pump inhibitors at full acute treatment doses.

Refer to medicine for management in the event of evidence of GI bleed, perforation.

^a EGD, esophagogastroduodenoscopy.