PANCE Blueprint GI and Nutrition (8%)

Patient will present as → a 38-year-old male with a 6-month history of heartburn and regurgitation, particularly after meals, drinking coffee, and lying down. He also complains of a chronic cough, especially at night. He is overweight and has a diet high in fatty foods. On examination, he is obese, and his abdominal examination is unremarkable. A trial of a proton pump inhibitor (PPI) is initiated, and he is counseled on lifestyle modifications, including weight loss, elevation of the head of the bed, and dietary changes to avoid trigger foods. He is advised to return if symptoms persist or worsen, in which case further diagnostic evaluation, such as an upper endoscopy, may be considered.

Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain

• Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia or cancer
• Gastroesophageal reflux disease (GERD) is common, occurring in 10 to 20% of adults. It also occurs frequently in infants, typically beginning at birth
• Factors contributing to reflux include weight gain, fatty foods, caffeinated or carbonated beverages, alcohol, tobacco smoking, and drugs

Drugs that lower LES pressure include anticholinergics, antihistamines, tricyclic antidepressants, Ca channel blockers, progesterone, and nitrates

• The PH Probe study is the gold standard for diagnosis
• The upper GI study is a study of anatomy, not for reflux
• A chronic cough can be an easily overlooked symptom of GERD
• Chronic GERD may predispose to Barrett's esophagus and cancer

"Once Barrett's esophagus has been identified, screening every 3 to 5 years by upper endoscopy is recommended to look for dysplasia or adenocarcinoma. There is an 11-fold increase in esophageal adenocarcinoma in a patient with Barrett's esophagus."

Patients with foul odor of breath and increasing symptoms think Zenker's Diverticulum, which is an outpouching of the hypopharynx resulting in regurgitation of solid foods – needs surgical repair.

Patients with typical symptoms of GERD may be given a trial of PPI therapy

• Patients who do not improve or have long-standing symptoms or symptoms of complications should be studied
• Endoscopy with cytologic washings and biopsy of abnormal areas is the test of choice
• Endoscopic biopsy is the only test that consistently detects the columnar mucosal changes of Barrett's esophagus. Patients with unremarkable endoscopy findings who have typical symptoms despite treatment with proton pump inhibitors should undergo 24-hour pH testing.
• The PH Probe study is the gold standard for diagnosis
• Any patient with symptoms of GERD accompanied by dysphagia, recurrent vomiting, weight loss, hematemesis, anemia, melena, or age > 50 should undergo endoscopy as these are considered high risk for the presence of an upper gastrointestinal malignancy

Management of uncomplicated GERD consists of elevating the head of the bed about 15 cm (6 in) and avoiding eating within 2 to 3 h of bedtime, strong stimulants of acid secretion (eg, coffee, alcohol), certain drugs (eg, anticholinergics), specific foods (eg, fats, chocolate), and smoking.

• Weight loss is recommended for overweight patients and those who have gained weight recently
• Drug therapy is stepwise:
  • For mild and intermittent symptoms, start with a low-dose histamine 2 receptor antagonist (H2RA) QD, then increase to BID if needed
  • Switch to a proton pump inhibitor if symptoms persist. Start low dose and increase to standard dose if needed
  • Once symptoms are controlled, treatment should be continued for at least eight weeks

** For severe or frequent symptoms → start with standard dos PPI once daily as initial treatment