Heartburn resident survival guide: Difference between revisions
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{{WikiDoc CMG}}; {{AE}} {{Jose}}<br /> | {{WikiDoc CMG}}; {{AE}} {{Jose}}<br /> | ||
==Overview== | ==Overview== | ||
[[Heartburn]] is the feeling of burning or pressure inside the [[chest]], normally located behind the [[breastbone]], which can last for several hours and may worsen after food ingestion. Some patients may also have a peculiar acid taste in the back of the [[throat]] accompanied with excessive [[salivation]], regurgitating gas and [[bloating]].<ref name="pmid31935049">{{cite journal| author=| title=Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management | journal=National Institute for Health and Care Excellence: Clinical Guidelines | year= 2019 | volume= | issue= | pages= | pmid=31935049 | doi= | pmc= | url= }} </ref> The most common cause of [[heartburn]] is [[gastroesophageal reflux disease]] (GERD), in which the [[lower esophageal sphincter]] allows for gastric content to reflux into the [[esophagus]]. This may cause atypical symptoms which includes: [[coughing]], [[wheezing]] or [[asthma]]-like symptoms, [[hoarseness]], [[sore throat]], dental erosions or [[Gingiva|gum]] disease, discomfort in the ears and nose. [[Heartburn]] is a symptom though, and it can have other causes besides [[GERD]], such as [[esophagitis]] (infections, [[eosinophilic]]) and [[esophageal cancer]]. It can also be mistaken by [[chest pain]] and presented in life-threatening diseases such as [[acute coronary syndromes]], [[aortic dissection]] and [[pericarditis]]. | [[Heartburn]] is the feeling of burning or pressure inside the [[chest]], normally located behind the [[breastbone]], which can last for several hours and may worsen after food [[ingestion]]. Some patients may also have a peculiar acid taste in the back of the [[throat]] accompanied with excessive [[salivation]], regurgitating gas and [[bloating]].<ref name="pmid31935049">{{cite journal| author=| title=Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management | journal=National Institute for Health and Care Excellence: Clinical Guidelines | year= 2019 | volume= | issue= | pages= | pmid=31935049 | doi= | pmc= | url= }} </ref> The most common cause of [[heartburn]] is [[gastroesophageal reflux disease]] ([[GERD]]), in which the [[lower esophageal sphincter]] allows for [[gastric]] content to reflux into the [[esophagus]]. This may cause atypical [[symptoms]] which includes: [[coughing]], [[wheezing]] or [[asthma]]-like [[symptoms]], [[hoarseness]], [[sore throat]], dental erosions or [[Gingiva|gum]] disease, discomfort in the [[ears]] and [[nose]]. [[Heartburn]] is a symptom though, and it can have other causes besides [[GERD]], such as [[esophagitis]] ([[infections]], [[eosinophilic]]) and [[esophageal cancer]]. It can also be mistaken by [[chest pain]] and presented in life-threatening [[diseases]] such as [[acute coronary syndromes]], [[aortic dissection]] and [[pericarditis]]. | ||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
[[Heartburn]] can be expressed by the patient as a type of [[chest pain]]. While evaluating [[heartburn]], it is mandatory to differentiate it from [[cardiac]] [[chest pain]]. | [[Heartburn]] can be expressed by the [[patient]] as a type of [[chest pain]]. While evaluating [[heartburn]], it is mandatory to differentiate it from [[cardiac]] [[chest pain]]. | ||
Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated. | Life-threatening causes include [[conditions]] that may result in death or permanent [[disability]] within 24 hours if left untreated. | ||
*[[Acute coronary syndromes]] | *[[Acute coronary syndromes]] | ||
| Line 38: | Line 38: | ||
|- | |- | ||
|Burning [[chest pain]], begins at the [[breastbone]] | |Burning [[chest pain]], begins at the [[breastbone]] | ||
|Tightness, pressure, squeezing, stabbing or dull pain, most often in the center | |Tightness, pressure, squeezing, stabbing or dull [[pain]], most often in the center | ||
|- | |- | ||
|Pain that radiates towards the [[throat]] | |[[Pain]] that radiates towards the [[throat]] | ||
|Pain radiates to the [[shoulders]], [[neck]] or arms | |[[Pain]] radiates to the [[shoulders]], [[neck]] or arms | ||
|- | |- | ||
|Sensation of food coming back to the [[Mouth (human)|mouth]] | |Sensation of food coming back to the [[Mouth (human)|mouth]] | ||
|Irregular or rapid [[heartbeat]] | |Irregular or rapid [[heartbeat]] | ||
|- | |- | ||
|Acid taste in the back of the [[throat]] | |[[Acid]] taste in the back of the [[throat]] | ||
|Cold [[sweat]] or [[clammy]] skin | |Cold [[sweat]] or [[clammy]] skin | ||
|- | |- | ||
|Pain worsens when patient lie down or bend over | |[[Pain]] worsens when [[patient]] lie down or bend over | ||
|Lightheadedness, [[weakness]], [[dizziness]], [[nausea]], indigestion or vomiting | |[[Lightheadedness]], [[weakness]], [[dizziness]], [[nausea]], [[indigestion]] or [[vomiting]] | ||
|- | |- | ||
|Appears after large or spicy meal | |Appears after large or spicy meal | ||
| Line 56: | Line 56: | ||
|- | |- | ||
| | | | ||
|Symptoms appears with physical exertion or extreme [[stress]] | |[[Symptoms]] appears with physical exertion or extreme [[stress]] | ||
|} | |} | ||
===Common Causes=== | ===Common Causes=== | ||
*[[Gastroesophageal reflux disease]] (GERD) | *[[Gastroesophageal reflux disease]] ([[GERD]]) | ||
*Eosinophillic [[esophagitis]] | *Eosinophillic [[esophagitis]] | ||
*[[Malignancy]] | *[[Malignancy]] | ||
| Line 72: | Line 72: | ||
The diagnosis of [[GERD]] is made based on: | The diagnosis of [[GERD]] is made based on: | ||
*Symptom presentation | *[[Symptoms|Symptom]] presentation | ||
*Response to antisecretory therapy | *Response to antisecretory therapy | ||
*Objective testing with [[endoscopy]] | *Objective testing with [[endoscopy]] | ||
*Ambulatory reflux monitoring | *Ambulatory [[reflux]] monitoring<ref name="pmid23419381" /> | ||
<br> | <br> | ||
| Line 119: | Line 119: | ||
Perform [[upper endoscopy]] to detect [[esophageal adenocarcinoma]] and [[Barret’s esophagus]]. Surveillance examinations should occur not more frequently than once every 3 to 5 years. If the [[patient]] presents with [[Barret's Esophagus|Barret's]] [[esophagus]] or [[dysplasia]], more frequent intervals are indicated. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref> | Perform [[upper endoscopy]] to detect [[esophageal adenocarcinoma]] and [[Barret’s esophagus]]. Surveillance examinations should occur not more frequently than once every 3 to 5 years. If the [[patient]] presents with [[Barret's Esophagus|Barret's]] [[esophagus]] or [[dysplasia]], more frequent intervals are indicated. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref> | ||
Screening for [[H. Pylori]] is not recommended routinely on [[GERD]]. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref> | [[Screening]] for [[H. Pylori]] is not recommended routinely on [[GERD]]. <ref name="urlwww.worldgastroenterology.org">{{cite web |url=https://www.worldgastroenterology.org/UserFiles/file/WDHD-2015-handbook-final.pdf |title=www.worldgastroenterology.org |format= |work= |accessdate=}}</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
|+Diagnostic Testing for GERD <ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381 }} </ref> <ref name="pmid28631728">{{cite journal| author=Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N| title=ACG and CAG Clinical Guideline: Management of Dyspepsia. | journal=Am J Gastroenterol | year= 2017 | volume= 112 | issue= 7 | pages= 988-1013 | pmid=28631728 | doi=10.1038/ajg.2017.154 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28631728 }} </ref> | |+[[Diagnostic]] Testing for [[GERD]] <ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381 }} </ref> <ref name="pmid28631728">{{cite journal| author=Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N| title=ACG and CAG Clinical Guideline: Management of Dyspepsia. | journal=Am J Gastroenterol | year= 2017 | volume= 112 | issue= 7 | pages= 988-1013 | pmid=28631728 | doi=10.1038/ajg.2017.154 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28631728 }} </ref> | ||
! align="center" style="background: #4479BA; color: #FFFFFF " |Test | ! align="center" style="background: #4479BA; color: #FFFFFF " |Test | ||
! align="center" style="background: #4479BA; color: #FFFFFF " |Indication | ! align="center" style="background: #4479BA; color: #FFFFFF " |Indication | ||
| Line 139: | Line 139: | ||
|- | |- | ||
|[[Esophageal]] [[biopsy]] | |[[Esophageal]] [[biopsy]] | ||
|Exclude non-GERD causes | |Exclude non-[[GERD]] causes | ||
| | | | ||
|- | |- | ||
| Line 146: | Line 146: | ||
|Rule out [[achalasia]]/[[scleroderma]]-like esophagus pre-op | |Rule out [[achalasia]]/[[scleroderma]]-like esophagus pre-op | ||
|- | |- | ||
|Ambulatory reflux monitoring | |Ambulatory [[reflux]] monitoring | ||
|Preoperatively for non-erosive disease, refractory [[GERD]] [[symptoms]] or [[GERD]] [[diagnosis]] in question | |Preoperatively for non-erosive disease, refractory [[GERD]] [[symptoms]] or [[GERD]] [[diagnosis]] in question | ||
|Correlate [[symptoms]] with reflux, document abnormal acid exposure or reflux frequency | |Correlate [[symptoms]] with reflux, document abnormal [[acid]] exposure or [[reflux]] frequency | ||
|} | |} | ||
==Treatment== | ==Treatment== | ||
Shown below is an algorithm summarizing the treatment of refractory [[GERD]] according the the American Journal of Gastroenterology guidelines.<ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381 }} </ref> | Shown below is an algorithm summarizing the treatment of [[refractory]] [[GERD]] according the the American Journal of Gastroenterology guidelines.<ref name="pmid23419381">{{cite journal| author=Katz PO, Gerson LB, Vela MF| title=Guidelines for the diagnosis and management of gastroesophageal reflux disease. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 3 | pages= 308-28; quiz 329 | pmid=23419381 | doi=10.1038/ajg.2012.444 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23419381 }} </ref> | ||
Lifestyle modifications are indicated for all [[patients]] and include: | Lifestyle modifications are indicated for all [[patients]] and include: | ||
*Dietary changes (reduce ingestion of [[chocolate]], [[caffeine]], [[alcohol]], acidic and/or spicy foods - low degree of evidence, but there are reports of improvements with elimination); | *Dietary changes (reduce ingestion of [[chocolate]], [[caffeine]], [[alcohol]], acidic and/or spicy foods - low degree of evidence, but there are reports of improvements with elimination); | ||
*[[Weight loss]] for overweight patients or patients that have had recent weight gain; | *[[Weight loss]] for [[overweight]] [[patients]] or [[patients]] that have had recent [[weight gain]]; | ||
*Head of bed elevation and avoidance of meals 2–3 h before bedtime if nocturnal symptoms.<ref name="pmid23419381" /> | *Head of bed elevation and avoidance of meals 2–3 h before bedtime if [[nocturnal]] [[symptoms]].<ref name="pmid23419381" /> | ||
{| class="wikitable" | {| class="wikitable" | ||
|+Medications used in GERD | |+[[Medications]] used in [[GERD]] | ||
! align="center" style="background: #4479BA; color: #FFFFFF " |Medication | ! align="center" style="background: #4479BA; color: #FFFFFF " |Medication | ||
! align="center" style="background: #4479BA; color: #FFFFFF " |Indication | ! align="center" style="background: #4479BA; color: #FFFFFF " |Indication | ||
| Line 167: | Line 167: | ||
|- | |- | ||
|[[Proton pump inhibitor|PPI]] therapy | |[[Proton pump inhibitor|PPI]] therapy | ||
|All [[patients]] without contraindications | |All [[patients]] without [[contraindications]] | ||
|Use the lowest effective dose, safe during [[pregnancy]] | |Use the lowest effective dose, safe during [[pregnancy]] | ||
|- | |- | ||
|[[H2-receptor antagonist]] | |[[H2-receptor antagonist]] | ||
|May be used as a complement to [[PPI|PPIs]] or as maintenance option in patients without erosive disease | |May be used as a complement to [[PPI|PPIs]] or as maintenance option in [[patients]] without erosive [[disease]] | ||
|Beware [[tachyphylaxis]] after several weeks of usage | |Beware [[tachyphylaxis]] after several weeks of usage | ||
|- | |- | ||
| Line 180: | Line 180: | ||
|[[Sucralfate]] | |[[Sucralfate]] | ||
|[[Pregnant]] women | |[[Pregnant]] women | ||
|No role in non-pregnant patients | |No role in non-pregnant [[patients]] | ||
|} | |} | ||
<br /> | <br /> | ||
| Line 187: | Line 187: | ||
* | * | ||
*Differentiate [[heartburn]] from cardiac [[chest pain]] | *Differentiate [[heartburn]] from [[cardiac]] [[chest pain]]. | ||
*Consider a twice daily dosing in patients with night-time symptoms, variable schedules, and/or [[sleep disturbance]] | *Consider a twice daily dosing in [[Patient|patients]] with night-time [[symptoms]], variable schedules, and/or [[sleep disturbance]]. | ||
*Advise the [[patient]] to cease eating [[chocolate]], [[caffeine]], spicy foods, [[citrus]] or carbonated beverages | *Advise the [[patient]] to cease eating [[chocolate]], [[caffeine]], spicy foods, [[citrus]] or carbonated beverages. | ||
*Strongly recommend [[weight loss]] if patient's BMI is higher than 25 or recent [[weight gain]] | *Strongly recommend [[weight loss]] if [[patient]]'s [[BMI]] is higher than 25 or recent [[weight gain]]. | ||
*Recommend head of bed elevation if [[nocturnal]] [[GERD]] | *Recommend head of bed elevation if [[nocturnal]] [[GERD]]. | ||
*Advise against late evening meals | *Advise against late evening meals. | ||
*Promote [[alcohol]] and [[tobacco]] cessation. | *Promote [[alcohol]] and [[tobacco]] cessation. | ||
*If there is an alarm [[Symptoms|symptom]] such as [[dysphagia]]. | *If there is an alarm [[Symptoms|symptom]] such as [[dysphagia]]. | ||
Revision as of 17:45, 28 August 2020
| Heartburn Resident Survival Guide Microchapters |
|---|
| Overview |
| Causes |
| Diagnosis |
| Treatment |
| Do's |
| Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]
Overview
Heartburn is the feeling of burning or pressure inside the chest, normally located behind the breastbone, which can last for several hours and may worsen after food ingestion. Some patients may also have a peculiar acid taste in the back of the throat accompanied with excessive salivation, regurgitating gas and bloating.[1] The most common cause of heartburn is gastroesophageal reflux disease (GERD), in which the lower esophageal sphincter allows for gastric content to reflux into the esophagus. This may cause atypical symptoms which includes: coughing, wheezing or asthma-like symptoms, hoarseness, sore throat, dental erosions or gum disease, discomfort in the ears and nose. Heartburn is a symptom though, and it can have other causes besides GERD, such as esophagitis (infections, eosinophilic) and esophageal cancer. It can also be mistaken by chest pain and presented in life-threatening diseases such as acute coronary syndromes, aortic dissection and pericarditis.
Causes
Life Threatening Causes
Heartburn can be expressed by the patient as a type of chest pain. While evaluating heartburn, it is mandatory to differentiate it from cardiac chest pain.
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
| Heartburn (GERD) | Angina or Heart Attack |
|---|---|
| Burning chest pain, begins at the breastbone | Tightness, pressure, squeezing, stabbing or dull pain, most often in the center |
| Pain that radiates towards the throat | Pain radiates to the shoulders, neck or arms |
| Sensation of food coming back to the mouth | Irregular or rapid heartbeat |
| Acid taste in the back of the throat | Cold sweat or clammy skin |
| Pain worsens when patient lie down or bend over | Lightheadedness, weakness, dizziness, nausea, indigestion or vomiting |
| Appears after large or spicy meal | Shortness of breath |
| Symptoms appears with physical exertion or extreme stress |
Common Causes
- Gastroesophageal reflux disease (GERD)
- Eosinophillic esophagitis
- Malignancy
- Achalasia
- Peptic ulcer disease[4]
Diagnosis
Below is shown a compendium of information summarizing the diagnosis of gastroesophageal reflux disease (GERD) according the the American Journal of Gastroenterology guidelines.[4]
The diagnosis of GERD is made based on:
- Symptom presentation
- Response to antisecretory therapy
- Objective testing with endoscopy
- Ambulatory reflux monitoring[4]
| Classic symptoms of GERD (heartburn and regurgitation) | If there are warning signs*: upper endoscopy during the initial evaluation | ||||||||||||||||||
| PPI 8-week trial | |||||||||||||||||||
| If better: GERD probable | If refractory, proceed to refractory GERD algorithm | ||||||||||||||||||
* Dysphagia, bleeding, anemia, weight loss and recurrent vomiting are considered warning signs and should be investigated with upper endoscopy.
Shown below is an algorithm summarizing the treatment of refractory GERD according the the American Journal of Gastroenterology guidelines.[4]
| Treat GERD: Start a 8-week course of PPI | If there are warning signs*: upper endoscopy during the initial evaluation | ||||||||||||||||||||||||||||||||||||
| Refractory GERD | |||||||||||||||||||||||||||||||||||||
| Optimize PPI therapy | |||||||||||||||||||||||||||||||||||||
| No response: Exclude other etiologies | |||||||||||||||||||||||||||||||||||||
| Typical symptoms: Upper endoscopy | Atypical symptoms: Referral to ENT, pulmonary, allergy specialist | ||||||||||||||||||||||||||||||||||||
| Abnormal: (eosinophilic esophagitis, erosive esophagitis, other) Specific treatment | NORMAL | Abnormal: (ENT, pulmonary, or allergic disorder) Specific treatment | |||||||||||||||||||||||||||||||||||
| REFLUX MONITORING | |||||||||||||||||||||||||||||||||||||
| Low pre test probability of GERD | High pre test probability of GERD | ||||||||||||||||||||||||||||||||||||
| Test off medication with pH or impedance-pH | Test on medication with impedance-pH | ||||||||||||||||||||||||||||||||||||
- High Risk: Men >50 years with chronic gastroesophageal reflux disease symptoms (>5 years), AND:
- Nocturnal reflux symptoms
- Hiatal hernia
- Elevated body mass index
- Tobacco use
- Intra-abdominal distribution of fat
Perform upper endoscopy to detect esophageal adenocarcinoma and Barret’s esophagus. Surveillance examinations should occur not more frequently than once every 3 to 5 years. If the patient presents with Barret's esophagus or dysplasia, more frequent intervals are indicated. [5]
Screening for H. Pylori is not recommended routinely on GERD. [5]
| Test | Indication | Recommendation |
|---|---|---|
| Proton Pump Inhibitor (PPI) trial | Classic symptoms, no warning/alarm symptoms | If negative does not rule out GERD |
| Barium swallow | Use for evaluating dysphagia | Only useful for complications (stricture, ring) |
| Endoscopy | Use if alarm symptoms, chest pain or high risk* patients | Consider early for elderly, high risk for Barret’s, non-cardiac chest pain, patients unresponsive to PPI |
| Esophageal biopsy | Exclude non-GERD causes | |
| Esophageal manometry | Pre operative evaluation for surgery | Rule out achalasia/scleroderma-like esophagus pre-op |
| Ambulatory reflux monitoring | Preoperatively for non-erosive disease, refractory GERD symptoms or GERD diagnosis in question | Correlate symptoms with reflux, document abnormal acid exposure or reflux frequency |
Treatment
Shown below is an algorithm summarizing the treatment of refractory GERD according the the American Journal of Gastroenterology guidelines.[4]
Lifestyle modifications are indicated for all patients and include:
- Dietary changes (reduce ingestion of chocolate, caffeine, alcohol, acidic and/or spicy foods - low degree of evidence, but there are reports of improvements with elimination);
- Weight loss for overweight patients or patients that have had recent weight gain;
- Head of bed elevation and avoidance of meals 2–3 h before bedtime if nocturnal symptoms.[4]
| Medication | Indication | Recommendation |
|---|---|---|
| PPI therapy | All patients without contraindications | Use the lowest effective dose, safe during pregnancy |
| H2-receptor antagonist | May be used as a complement to PPIs or as maintenance option in patients without erosive disease | Beware tachyphylaxis after several weeks of usage |
| Prokinetic therapy and/or baclofen | Used if symptoms do not improve | Undergo diagnostic evaluation first |
| Sucralfate | Pregnant women | No role in non-pregnant patients |
Do's
- Differentiate heartburn from cardiac chest pain.
- Consider a twice daily dosing in patients with night-time symptoms, variable schedules, and/or sleep disturbance.
- Advise the patient to cease eating chocolate, caffeine, spicy foods, citrus or carbonated beverages.
- Strongly recommend weight loss if patient's BMI is higher than 25 or recent weight gain.
- Recommend head of bed elevation if nocturnal GERD.
- Advise against late evening meals.
- Promote alcohol and tobacco cessation.
- If there is an alarm symptom such as dysphagia.
- If there's no response with such measures and initial 8-week PPI treatment, refer patient to a specialist.
Don'ts
- Do not request an upper endoscopy for every patient complaining of GERD;
- Do not request manometry or ambulatory GERD monitoring routinely.
References
- ↑ "Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management". National Institute for Health and Care Excellence: Clinical Guidelines. 2019. PMID 31935049.
- ↑ "Heartburn vs. heart attack - Harvard Health".
- ↑ Bösner S, Haasenritter J, Becker A, Hani MA, Keller H, Sönnichsen AC; et al. (2009). "Heartburn or angina? Differentiating gastrointestinal disease in primary care patients presenting with chest pain: a cross sectional diagnostic study". Int Arch Med. 2: 40. doi:10.1186/1755-7682-2-40. PMC 2799444. PMID 20003376.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Katz PO, Gerson LB, Vela MF (2013). "Guidelines for the diagnosis and management of gastroesophageal reflux disease". Am J Gastroenterol. 108 (3): 308–28, quiz 329. doi:10.1038/ajg.2012.444. PMID 23419381.
- ↑ 5.0 5.1 "www.worldgastroenterology.org" (PDF).
- ↑ Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N (2017). "ACG and CAG Clinical Guideline: Management of Dyspepsia". Am J Gastroenterol. 112 (7): 988–1013. doi:10.1038/ajg.2017.154. PMID 28631728.