Gastroesophageal Reflux Disease

C.M., a 58-year-old male, presents with his wife to the clinic for an
emergency room follow up. His wife has noticed over the past several
weeks that his voice is changing, and he seems to be clearing his throat
frequently. He is up frequently at night complaining of a burning
sensation, and he prefers to sleep in the recliner chair. He also
mentioned that he suffers from heartburn 3 times per week. She notes
that he does not like her spicy meatballs like he once did and complains
of burning in his chest on occasion. This worries his wife because her
husband has a history of heart disease & has been a smoker for the past
10 years. The most recent episode of chest discomfort led them to the
emergency room although a cardiac cause for his symptoms was ruled
out, the patient was notified that it might be related to his obesity as his
BMI is 35.

PMH: Hypertension, Coronary artery disease s/p MI with stent

placement 10 months ago, Hyperlipidemia, Depression

Medications:
QUESTIONS
1. What are the signs and symptoms consistent with GERD?
 Heartburn

 Sore throat or a burning sensation in the throat.

 Chronic cough

 Regurgitation
2. What are the precipitating factors in this case?
 Obesity

 Smoking

 Deity factor

3. Does this patient have any alarming symptoms?

Yes, this patient has some alarming symptoms:

 Chronic cough with voice changes (potential sign of aspiration or damage to the
vocal cords).
 Frequent regurgitation or burning in the chest: May indicate worsening or
untreated GERD.
 Heart disease history: Given the patient's background of coronary artery disease
(CAD), chest discomfort should always raise concerns for a cardiac event,
though it has been ruled out in this case.
 Potential esophageal damage: Although not yet diagnosed, his GERD symptoms
could progress to complications like esophagitis or even Barrett’s esophagus.

4. Has this patient developed any complications due to GERD?

 Esophagitis

 Barrett’s esophagus

 Esophageal stricture

 Laryngopharyngeal reflux (LPR)

 5. How can you diagnose GERD?
 Clinical history and symptoms

 Trial of PPI therapy

 Upper endoscopy

 Ambulatory pH monitoring

 Esophageal manometry

6. What are the goals of therapy in this patient?

 Relieve symptoms (heartburn, regurgitation, cough, hoarseness).

 Promote healing of esophageal mucosa

 Prevent complications such as esophageal stricture, Barrett’s esophagus, and

cancer.

 Improve quality of life and reduce the need for frequent ER visits or
hospitalizations.

 Control reflux through both pharmacological and non-pharmacological

interventions.

7. What non-pharmacological therapy should be used for this

patient?
 Weight loss

 Elevating the head of the bed

 Avoiding large meals

 Avoiding eating close to bedtime: At least 2-3 hours before lying down.

 Avoiding trigger foods: Spicy foods, chocolate, citrus, caffeine, alcohol, and fatty
foods can all exacerbate GERD.

 Smoking cessation
 8. What is the most appropriate pharmacological therapy for this
patient?
Proton pump inhibitors (PPIs): Medications like omeprazole, esomeprazole, or
lansoprazole to decrease gastric acid production and promote healing of the
esophagus. Once daily before breakfast.

9. What are the counseling tips that should be given to the patient
regarding his pharmacological therapy?
Don’t stop medications abruptly

After 4 weeks, the patient returns to the clinic worried about having
continuous epigastric pain & frequently coughing up blood lately. He is
wondering if these symptoms are indicative of progression of symptoms
or side effects of one of the medications he is taking. He wants to know
your recommendation about his current situation.

1. In your opinion, what should be recommended for this patient?

Endoscopy
 Peptic Ulcer Disease
Case
Chief Complain: “My stomach has been hurting really bad for the past
month or so. It seems to get worse at night.”

HPI: Justine Ward is a 67-year-old woman who presents to her primary

care physician with complaints of episodic epigastric pain for the past 6
weeks. Her pain is non-radiating. It is sometimes worse with meals, but
sometimes eating helps improve the pain. She has been experiencing
occasional nausea, bloating, and heartburn. She denies any change in
color or frequency of bowel movements. She does not have a history of
PUD or GI bleeding. She mentions that she has been having frequent
headaches for the past month and has been taking naproxen sodium one
to two times daily.

PMH: CAD × 1 year (s/p Taxus stents × 2), Hypothyroidism × 22 years,

Hyperlipidemia × 10 years, Lactose intolerance × 47 years,
Postmenopausal; LMP ~13 years ago

SH: She is married and has raised three children; she is not employed
outside the home. She has never smoked and drinks one to two glasses
of wine most days of the week.

Meds:
Plavix 75 mg PO daily
Lisinopril 5 mg PO daily
Aspirin 325 mg PO daily
Synthyroid 125 mcg PO daily
Simvastatin 40 mg PO daily
MVI tablet PO daily
Tums 500 mg PO PRN stomach pain
Naproxen sodium 220 mg PO PRN headaches
Lactaid one tablet PO PRN dairy product consumption
VS: BP 110/72 left arm (seated), P 99, RR 16 reg, T 37.2°C, Wt 68 kg,
Ht 5′3″

Abd: Soft; mild epigastric tenderness; (+) BS; no splenomegaly or

masses; liver size normal

Rect: Nontender; stool heme (+)

Labs: All lab values are within the normal ranges except for the
following
 Low Hgb 10.1 g/dL (12.1-15.1 g/dL)
 Low Hct 30% (36.1-44.3%)
 Low MCV 72 um3 (80-97.6 um3).

QUESTIONS
1. Identify this patient’s drug therapy problems.
 Use of Naproxen (NSAID) in the presence of PUD risk: The patient is using naproxen
for headache relief. NSAIDs can irritate the gastrointestinal tract and exacerbate or
contribute to the development of peptic ulcer disease (PUD), especially in a patient
with a history of ulcer or who is at risk for GI bleeding.

 Use of aspirin and Plavix (dual antiplatelet therapy): She is on aspirin (325 mg) and
Plavix (75 mg) as part of secondary prevention for coronary artery disease (CAD).
Dual antiplatelet therapy increases the risk of GI bleeding, especially in the presence
of an ulcer.

 Inappropriate use of Tums (calcium carbonate): The patient uses Tums as needed
for stomach pain. While it provides short-term relief, it can also worsen the problem
by increasing acid production after the rebound effect.

 Anemia and low MCV: The patient has low hemoglobin (Hgb) and hematocrit (Hct)
levels, as well as a low mean corpuscular volume (MCV), which suggests possible
iron deficiency anemia. This could be exacerbated by chronic blood loss from the
ulcer or NSAID use.

 Potential for drug interactions: The patient is on multiple medications, including

Plavix, aspirin, statins, and Synthroid. There could be interactions (e.g., between
Plavix and aspirin, which increases bleeding risk).
 2. What information (signs, symptoms, diagnostic tests, and
laboratory values) indicates the presence of PUD?
 Epigastric pain

 Nausea, bloating, and heartburn

 Stool heme positive

 Anemia: The low hemoglobin (Hgb 10.1 g/dL) and hematocrit (Hct 30%)
suggest chronic blood loss, potentially from the ulcer.

 Low MCV: Indicates microcytic anemia, likely from iron deficiency, which can
result from chronic blood loss.

 EGD findings: The endoscopy revealed a 5.5-mm superficial ulcer in the

superior duodenum, with inflammation, indicating the presence of PUD.

Justine’s PCP referred her for a non-emergent EGD, which revealed a

5.5-mm superficial ulcer in the superior duodenum. The ulcer base was
clear without evidence of active bleeding. In addition, inflammation of
the duodenum was detected and biopsied.

3. What are your treatment goals for treating this patient’s PUD?
 Alleviate symptoms.

 Promote ulcer healing

 Prevent complications

 Address anemia

 Eradicate H. pylori (if confirmed

 Minimize drug-related risks

4. Considering the patient’s presentation, what non-pharmacologic

 alternatives are available to treat her PUD?
 Dietary changes

 Frequent small meals

 Avoid NSAIDs

 Elevate head of bed

 Stress management

 Smoking cessation

5. In the absence of information about the presence of H. pylori,

what pharmacologic alternatives are available to treat duodenal
ulcers?
Proton pump inhibitors (PPIs): Medications like omeprazole,
esomeprazole, or pantoprazole are the first-line treatment for duodenal
ulcers to reduce gastric acid secretion and promote healing.

6. Based on the patient’s presentation and the current medical

assessment, design a pharmacotherapeutic regimen to treat her
duodenal ulcer, anemia, and frequent headaches.
1. For PUD:
o Proton pump inhibitor (PPI): Omeprazole 20 mg PO daily for 4-8 weeks (to
heal the ulcer and reduce acid production).
o H2 antagonist (if needed for additional acid control): Famotidine 20 mg PO at
bedtime.
o Discontinue naproxen: Recommend switching to an alternative pain
management strategy (e.g., acetaminophen) or an appropriate NSAID with a
lower GI risk (e.g., celecoxib, if absolutely necessary and with a PPI).
o Stop Tums: Advise against frequent use of antacids, as it may mask symptoms
without addressing the underlying problem.
2. For Anemia:
 oIron supplementation: Ferrous sulfate 325 mg PO daily (if iron deficiency
anemia is confirmed) to replenish iron stores and treat the low hemoglobin.
o Monitor hemoglobin levels over the next few weeks to assess the response to
iron therapy.
3. For Headaches:
o Discontinue naproxen due to the risk of exacerbating PUD and bleeding.
o Acetaminophen (if she requires pain relief for headaches), 500 mg every 4-6
hours as needed, but not exceeding 3,000 mg per day.

7. What information should be provided to the patient to ensure

successful therapy, enhance compliance, and minimize adverse
effects?
 Adherence to PPI therapy

 Avoidance of NSAIDs

 Iron supplementation

 Dietary recommendations: Suggest avoiding irritant foods and eating smaller,

more frequent meals.

 Monitoring for side effects: Advise the patient to report any worsening pain,
unusual fatigue, or signs of GI bleeding (e.g., black tarry stools, coffee-ground
vomit).

 Follow-up

At the time of the EGD, a biopsy of the duodenal mucosa was taken and
indicated the presence of inflammation and abundant H. pylori-like
organisms.

8. What is the significance of finding H. pylori in the duodenal

biopsy?
H. pylori eradication improves healing rates of ulcers and reduces the
risk of complications such as GI bleeding, perforation, and gastric
cancer.
 9. Based on this new information, how would you modify your goals
for treating this patient’s PUD?
 Eradicate H. pylori

 Promote ulcer healing

 Prevent recurrence.

 Monitor for eradication.

10. What pharmacotherapeutic alternatives are available to achieve

the new goal?
 PPI: Continue omeprazole 20 mg PO daily.

 Antibiotics: Clarithromycin 500 mg PO twice daily. Amoxicillin 1,000 mg PO

twice daily (or metronidazole 500 mg twice daily if allergic to penicillin).

11. Design a pharmacotherapeutic regimen for this patient’s ulcer

that will accomplish the new treatment goals.
 Omeprazole 20 mg PO daily (for acid suppression)

 Clarithromycin 500 mg PO twice daily

 Amoxicillin 1,000 mg PO twice daily

 Continue iron supplementation (ferrous sulfate) to address anemia

12. How should the PUD therapy you recommended be monitored

for efficacy and adverse effects?
 Symptom improvement

 Follow-up EGD

 Check H. pylori eradication

 Monitor hemoglobin

 Monitor for adverse effects

 13. What information should be provided to the patient about her
therapy?
 Duration of treatment: Explain that she will need to take the PPI and
antibiotics for 10-14 days to eradicate H. pylori and heal the ulcer.

 Side effects: Warn her about possible side effects of antibiotics (e.g.,
diarrhea, taste disturbances, or nausea).

 Compliance with iron therapy: Discuss the importance of taking iron as

prescribed for anemia and potential side effects like constipation.

 Dietary modifications: Reinforce avoiding irritating foods, large meals, and

alcohol.

 Follow-up care: Emphasize the need for follow-up to ensure treatment

success.

14. How should her frequent headaches now be treated?

Discontinue naproxen: Replace naproxen with acetaminophen (500 mg every 4-6
hours as needed) for headache relief.