Differential Diagnosis for GERD

Differential Diagnosis for GERD

Discussion #1

Differential Diagnosis for GERD

 

Gastroesophageal reflux disease or GERD is characterized by heartburn or burning pain that radiates up the esophagus usually within an hour after eating.  Other diseases that also have these symptoms and need to be considered to help confirm the diagnosis of GERD include cholelithiasis, peptic ulcer disease, gastritis, and angina (Freshman, 2017). The confirmed diagnosis comes after a trial period of medication to treat GERD (Woo, 2017).

 

Treatment for GERD

 

The initial treatment for GERD is lifestyle modifications.  When patients come to see a provider to seek treatment for their heartburn pain, they usually have already taken OTC antacids or H2Ras without improvement of symptoms (Woo, 2017).  The best pharmaceutical treatment for GERD is a prescription dose of proton pump inhibitors (PPIs).  PPI reduce acid production and improve the symptoms of GERD (Freshman, 2017). All PPIs are approved to treat GERD and initial dosing is determined by the patient’s history of present illness to treat for symptomatic GERD or chronic GERD due to an erosion of the esophagus. The type of PPI prescribe is determined by other medications that the patient is taking or if they are unable to swallow pills whole then they will be prescribed omeprazole, esomeprazole, and lansoprazole where the capsules can be opened, and the granules can be added to a small amount of apple sauce to swallow easier. The main treatment for GERD is for the patient to take a PPI once a day for eight weeks.  The medication should be taken first thing in the morning 30 to 60 minutes before breakfast (Woo, 2017).

 

Labs and Tests to Confirm GERD

 

The physical exam and history of illness described by the patient is the best evaluation to determine diagnosis followed by a trail of PPI for eight weeks to determine if the symptoms are controlled.  If the symptoms are not controlled, then more testing will begin to check for other causes of the heartburn pain. Endoscopy is the test that is used to diagnose problems with the esophagus when red flags are present or initial treatment does not work.  The Endoscopy can determine if the patient has Barrett’s esophagus or erosive esophagitis.  A CBC, stool testing for occult blood and H. pylori can also be done to rule out PUD or other bleeding that would cause a low blood count (Freshman, 2017).

Discussion #2

Discussion Question 1

What would you prescribe initially?

For H pylori the treatment initiated after initial antacid therapy has failed is listed below. (this patient has taken both over the counter famotidine or ranitidine)

Clarithromycin 500 mg BID for 14 days.

Nexium 40mg BID for 14 days.

Amoxicillin 1000mg BID for 14 days.

Clarithromycin triple therapy consisting of a PPI, clarithromycin, and amoxicillin or metronidazole for 14 days remains a recommended treatment in regions where H. pylori clarithromycin resistance is known to be <15% and in patients with no previous history of macrolide exposure for any reason.  (American College of Gastroenterology, 2017) Consideration should be given for uninsured patient regarding cost of meds. Also consider patient’s younger age, activity level and the fact that compliance may be less with increased number of pills daily.

Education regarding need to take prescribed medications until dosing is complete is needed, as complete treatment may take 2-4 weeks. Patient should be educated regarding possible side effects of medications to include nausea, diarrhea and change in taste.

How long would you prescribe these medications?

According to Woo & Robinson (2017) states triple therapy is typically the first line treatment and treatment is usually 10-14 days.

What other possible meds could you prescribe to assist with the side effects from the medications prescribed?

A probiotic may help with any GI distress associated with the use antibiotics. Another medication that may be helpful is Zofran for possible nausea associated with the treatment regimen.

How would the treatment vary if the patient has GERD instead?

Pharmacologically GERD is typically treated with an antacid like a proton pump inhibitor. The nonpharmacological interventions include diet modification, stress reduction, and ceasing usage of NSAIDs. Diet modifications include smoking cessation, and alcohol consumption discontinued or limited to small amounts of dilute alcohol, eat small meals more frequently, and avoid foods that increase abdominal discomfort. (Chaudhari Priyanka et al, 2016)

Discussion Question 2

GERD presents with mild epigastric pain, and symptoms commonly worsen after meals, although the pain is classically described as “burning” and may be located in the substernal rather than epigastric area. Peptic ulcer disease (PUD) is defined as epigastric pain that improves with meals is the hallmark of PUD. However, in some cases, symptoms of PUD may worsen with meals. NSAID use is associated with the development of PUD. Gastritis is the inflammation or irritation of the stomach lining often causing sharp epigastric pain. This pain may be variably worsened or improved with eating food. (Woo and Robinson, 2017) “Proton Pump Inhibitors (PPIs) have been the mainstay of GERD management since omeprazole was introduced 1989 and continue to be one of the top selling medication classes.” (Almutairi et al, 2018) When GERD is severe surgical interventions may be the nest option for management. According to Almutairi et al (2018) “the main types of surgery are fundoplication and, for obese patients, gastric bypass. Fundoplication is the standard surgical treatment for GERD.” Lifestyle modifications include “avoiding: smoking, flat-lying body position while sleeping, foods that irritate the gastric mucosa (e.g., spicy foods) or stimulate acid production (e.g., alcohol), and foods that decrease lower esophageal sphincter tone (e.g., fatty food, chocolate, and caffeine).” (Woo & Robinson, 2017)

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