Items in AFP with MESH term: Gastroesophageal Reflux
ABSTRACT: Gastroesophageal reflux is a common, self-limited process in infants that usually resolves by six to 12 months of age. Effective, conservative management involves thickened feedings, positional treatment, and parental reassurance. Gastroesophageal reflux disease (GERD) is a less common, more serious pathologic process that usually warrants medical management and diagnostic evaluation. Differential diagnosis includes upper gastrointestinal tract disorders; cow's milk allergy; and metabolic, infectious, renal, and central nervous system diseases. Pharmacologic management of GERD includes a prokinetic agent such as metoclopramide or cisapride and a histamine-receptor type 2 antagonist such as cimetidine or ranitidine when esophagitis is suspected. Although recent studies have supported the cautious use of cisapride in childhood GERD, the drug is currently not routinely available in the United States.
Proton Pump Inhibitors: An Update - Article
ABSTRACT: Since their introduction in the late 1980s, proton pump inhibitors have demonstrated gastric acid suppression superior to that of histamine H2-receptor blockers. Proton pump inhibitors have enabled improved treatment of various acid-peptic disorders, including gastroesophageal reflux disease, peptic ulcer disease, and nonsteroidal antiinflammatory drug-induced gastropathy. Proton pump inhibitors have minimal side effects and few significant drug interactions, and they are generally considered safe for long-term treatment. The proton pump inhibitors omeprazole, lansoprazole, rabeprazole, and the recently approved esomeprazole appear to have similar efficacy.
Diagnosing Night Sweats - Article
ABSTRACT: Night sweats are a common outpatient complaint, yet literature on the subject is scarce. Tuberculosis and lymphoma are diseases in which night sweats are a dominant symptom, but these are infrequently found to be the cause of night sweats in modern practice. While these diseases remain important diagnostic considerations in patients with night sweats, other diagnoses to consider include human immunodeficiency virus, gastroesophageal reflux disease, obstructive sleep apnea, hyperthyroidism, hypoglycemia, and several less common diseases. Antihypertensives, antipyretics, other medications, and drugs of abuse such as alcohol and heroin may cause night sweats. Serious causes of night sweats can be excluded with a thorough history, physical examination, and directed laboratory and radiographic studies. If a history and physical do not reveal a possible diagnosis, physicians should consider a purified protein derivative, complete blood count, human immunodeficiency virus test, thyroid-stimulating hormone test, erythrocyte sedimentation rate evaluation, chest radiograph, and possibly chest and abdominal computed tomographic scans and bone marrow biopsy.
ABSTRACT: The primary treatment goals in patients with gastroesophageal reflux disease are relief of symptoms, prevention of symptom relapse, healing of erosive esophagitis, and prevention of complications of esophagitis. In patients with reflux esophagitis, treatment is directed at acid suppression through the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and pharmacologic agents (a histamine H2-receptor antagonist [H2RA] taken on demand or a proton pump inhibitor IPPI] taken 30 to 60 minutes before the first meal of the day). The preferred empiric approach is step-up therapy (treat initially with an H2RA for eight weeks; if symptoms do not improve, change to a PPI) or step-down therapy (treat initially with a PPI; then titrate to the lowest effective medication type and dosage). In patients with erosive esophagitis identified on endoscopy, a PPI is the initial treatment of choice. Diagnostic testing should be reserved for patients who exhibit warning signs (i.e., weight loss, dysphagia, gastrointestinal bleeding) and patients who are at risk for complications of esophagitis (i.e., esophageal stricture formation, Barrett's esophagus, adenocarcinoma). Antireflux surgery, including open and laparoscopic versions of Nissen fundoplication, is an alternative treatment in patients who have chronic reflux with recalcitrant symptoms. Newer endoscopic modalities, including the Stretta and endocinch procedures, are less invasive and have fewer complications than antireflux surgery, but response rates are lower.
Barrett's Esophagus - Article
ABSTRACT: Gastroesophageal reflux disease (GERD) is a condition commonly managed in the primary care setting. Patients with GERD may develop reflux esophagitis as the esophagus repeatedly is exposed to acidic gastric contents. Over time, untreated reflux esophagitis may lead to chronic complications such as esophageal stricture or the development of Barrett's esophagus. Barrett's esophagus is a premalignant metaplastic process that typically involves the distal esophagus. Its presence is suspected by endoscopic evaluation of the esophagus, but the diagnosis is confirmed by histologic analysis of endoscopically biopsied tissue. Risk factors for Barrett's esophagus include GERD, white or Hispanic race, male sex, advancing age, smoking, and obesity. Although Barrett's esophagus rarely progresses to adenocarcinoma, optimal management is a matter of debate. Current treatment guidelines include relieving GERD symptoms with medical or surgical measures (similar to the treatment of GERD that is not associated with Barrett's esophagus) and surveillance endoscopy. Guidelines for surveillance endoscopy have been published; however, no studies have verified that any specific treatment or management strategy has decreased the rate of mortality from adenocarcinoma.
Update on Helicobacter pylori Treatment - Article
ABSTRACT: One half of the world's population has Helicobacter pylori infection, with an estimated prevalence of 30 percent in North America. Although it is unclear whether eradication of H. pylori improves symptoms in patients with nonulcer dyspepsia, there is strong evidence that eradication of this bacteria improves healing and reduces the risk of recurrence or rebleeding in patients with duodenal or gastric ulcer. A "test-and-treat" strategy is recommended for most patients with undifferentiated dyspepsia. With this approach, patients undergo a noninvasive test for H. pylori infection and, if positive, are treated with eradication therapy. This strategy reduces the need for antisecretory medications as well as the number of endoscopies. The urea breath test or stool antigen test is recommended. Until recently, the recommended duration of therapy for H. pylori eradication was 10 to 14 days. Shorter courses of treatment (i.e., one to five days) have demonstrated eradication rates of 89 to 95 percent with the potential for greater patient compliance. A one-day treatment course consists of bismuth subsalicylate, amoxicillin, and metronidazole, all given four times with a one-time dose of lansoprazole. In children with documented H. pylori infection, however, all regimens should continue to be prescribed for seven to 14 days until short-course treatment is studied and its effectiveness has been established in this population.
ABSTRACT: Gastroesophageal reflux disease (GERD) is a chronic, relapsing condition with associated morbidity and an adverse impact on quality of life. The disease is common, with an estimated lifetime prevalence of 25 to 35 percent in the U.S. population. GERD can usually be diagnosed based on the clinical presentation alone. In some patients, however, the diagnosis may require endoscopy and, rarely, ambulatory pH monitoring. Management includes lifestyle modifications and pharmacologic therapy; refractory disease requires surgery. The therapeutic goals are to control symptoms, heal esophagitis and maintain remission so that morbidity is decreased and quality of life is improved.
ABSTRACT: Gastroesophageal reflux disease (GERD) is the most common esophageal disease. Besides the typical presentation of heartburn and acid regurgitation, either alone or in combination, GERD can cause atypical symptoms. An estimated 20 to 60 percent of patients with GERD have head and neck symptoms without any appreciable heartburn. While the most common head and neck symptom is a globus sensation (a lump in the throat), the head and neck manifestations can be diverse and may be misleading in the initial work-up. Thus, a high index of suspicion is required. Laryngoscopy can confirm the diagnosis of laryngopharyngeal reflux. Erythema of the posterior larynx may be seen, and the true vocal cords may be edematous. Treatment should be initiated with a histamine H2 receptor blocker or proton pump inhibitor. Lifestyle changes are also beneficial. Untreated, GERD can lead to chronic laryngitis, dysphonia, chronic sore throat, chronic cough, constant throat clearing, granuloma of the true vocal cords and other problems.
Evaluation and Management of Dyspepsia - Article
ABSTRACT: Dyspepsia, often defined as chronic or recurrent discomfort centered in the upper abdomen, can be caused by a variety of conditions. Common etiologies include peptic ulcers and gastroesophageal reflux. Serious causes, such as gastric and pancreatic cancers, are rare but must also be considered. Symptoms of possible causes often overlap, which can make initial diagnosis difficult. In many patients, a definite cause is never established. The initial evaluation of patients with dyspepsia includes a thorough history and physical examination, with special attention given to elements that suggest the presence of serious disease. Endoscopy should be performed promptly in patients who have "alarm symptoms" such as melena or anorexia. Optimal management remains controversial in young patients who do not have alarm symptoms. Although management should be individualized, a cost-effective initial approach is to test for Helicobacter pylori and treat the infection if the test is positive. If the H. pylori test is negative, empiric therapy with a gastric acid suppressant or prokinetic agent is recommended. If symptoms persist or recur after six to eight weeks of empiric therapy, endoscopy should be performed.
ABSTRACT: Gastroesophageal reflux disease typically manifests as heartburn and regurgitation, but it may also present with atypical or extraesophageal symptoms, including asthma, chronic cough, laryngitis, hoarseness, chronic sore throat, dental erosions, and noncardiac chest pain. Diagnosing atypical manifestations of gastroesophageal reflux disease is often a challenge because heartburn and regurgitation may be absent, making it difficult to prove a cause-and-effect relationship. Upper endoscopy and 24-hour pH monitoring are insensitive and not useful for many patients as initial diagnostic modalities for evaluation of atypical symptoms. In patients with gastroesophageal reflux disease who have atypical or extraesophageal symptoms, aggressive acid suppression using proton pump inhibitors twice daily before meals for three to four months is the standard treatment, although some studies have failed to show a significant benefit in symptomatic improvement. If these symptoms improve or resolve, patients may step down to a minimal dose of antisecretory therapy over the following three to six months. Surgical intervention via Nissen fundoplication is an option for patients who are unresponsive to aggressive antisecretory therapy. However, long-term studies have shown that some patients still require antisecretory therapy and are more likely to develop dysphagia, rectal flatulence, and the inability to belch or vomit.