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  #1  
Old 06-04-2012
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GIT GERD Symptoms & Management

When do you start with PPI?
When do you perform 24-hr pH monitoring?
When do you decide to do endoscopy?

Solve this...
Your pt comes in with the typical GERD Sx... You prescribe PPI... 2 weeks later he comes back and reports no improvement in Sx. He denies any alarm Sx. What is your sequence in management of this pt?
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Old 06-04-2012
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When do you start with PPI?
Quote:
when patient has symptoms of GERD and no alarm symptoms
When do you perform 24-hr pH monitoring?
in atypical cases of GERD ! like chronic cough patients not resolving with anti-histamines and anti-asthma meds.
When do you decide to do endoscopy?
in alarm symptoms of GERD which are
  • weight loss significant over few months
  • patient is more than 45 years
  • positive family history of ca stomach
  • persistent vomiting
  • bloody vomiting
  • pallor
  • progressive dysphagia
  • palapable abdomen lump
  • scleral icterus
  • Fecal occult blood test positive

Solve this...
Your pt comes in with the typical GERD Sx... You prescribe PPI... 2 weeks later he comes back and reports no improvement in Sx. He denies any alarm Sx. What is your sequence in management of this pt?



failure to respond to PPI = endoscopy. i will scope the patient.

Last edited by tyagee; 06-04-2012 at 09:21 AM.
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Quote:
Originally Posted by tyagee View Post
Solve this...
Your pt comes in with the typical GERD Sx... You prescribe PPI... 2 weeks later he comes back and reports no improvement in Sx. He denies any alarm Sx. What is your sequence in management of this pt?



failure to respond to PPI = endoscopy. i will scope the patient.
Ok...the endoscopy comes back negative...what next?
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dx is non ulcer dyspepsia then.

PPI is ans to NUD.

what u say?
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Quote:
Originally Posted by tyagee View Post
dx is non ulcer dyspepsia then.

PPI is ans to NUD.

what u say?
Yeah here is where I am confused. I have a note in my MTB (probably from u world) saying that if endoscopy is negative, proceed with 24 hour pH monitoring to confirm the diagnosis of or rule out GERD... although non ulcer dyspepsia sounds like a reasonable diagnosis and the wise thing to do is to proceed with proton pump inhibitors, I'm still unsure if we should just jump to non ulcer dyspepsia as a diagnosis or try to completely rule out GERD as the diagnosis, even though the treatment is ultimately the same.
I don't think we'll have a problem if we're asked a treatment question, but the problem may arise if we're asked the next step in management question.
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Quote:
Originally Posted by usmledee View Post
Yeah here is where I am confused. I have a note in my MTB (probably from u world) saying that if endoscopy is negative, proceed with 24 hour pH monitoring to confirm the diagnosis of or rule out GERD... although non ulcer dyspepsia sounds like a reasonable diagnosis and the wise thing to do is to proceed with proton pump inhibitors, I'm still unsure if we should just jump to non ulcer dyspepsia as a diagnosis or try to completely rule out GERD as the diagnosis, even though the treatment is ultimately the same.
I don't think we'll have a problem if we're asked a treatment question, but the problem may arise if we're asked the next step in management question.
no, i am wrong. next step will be 24 hour pH monitor to completely rule out GERD !"completely". i think this shud be the ans.
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Quote:
Originally Posted by tyagee View Post
no, i am wrong. next step will be 24 hour pH monitor to completely rule out GERD !
Great..problem solved then..thanks.
So to sum it up… If the patient presents with typical symptoms of GERD, prescribed proton pump inhibitors. If the patient does not respond to proton pump inhibitors as treatment, performed an endoscopy. If the endoscopy shows negative findings, proceed with 24 hour pH monitoring to completely rule out GERD. If 24 hour pH monitoring is negative, diagnosis is non ulcer dyspepsia.
I would like to add one more thing… If the patient is diagnosed with dyspepsia and unresponsive to PPI's then we should perform serological testing for H. pylori. If it tests positive, then they should be treated.
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Quote:
There is no proven benefit of treating H. Pylori for non-ulcer dyspepsia.
Source : MTB 3 Page 173
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Quote:
Originally Posted by step1an View Post
Source : MTB 3 Page 173
My source is UW q id 3588. I also found this article. Testing of h.pylori is defendant on the age of the pt, absence of alarm Sx, and prevalence of h.pylori in the region.

http://www.bcguidelines.ca/guideline_dyspepsia.html


Management of Dyspepsia without alarm features:

Patients with mild or infrequent symptoms can be managed without further investigation using non-prescription acid reducing agents.1 Many medications can cause dyspeptic symptoms. A drug history including non-prescription medications is recommended.

For patients with more persistent symptoms, one of two approaches may be used:

Test and treat for H. pylori infection – see below: Management of H. pylori infection.

This approach is most appropriate for patients who have not been previously screened and is especially applicable in individuals who have an increased risk for H. pylori infection.

Individuals with dyspepsia who currently have an endoscopically or radiographically confirmed duodenal or gastric ulcer,6 or have had one within the past five years, should be tested for H. pylori infection (refer to Table 1). This does not apply to patients in whom successful eradication has been previously confirmed.

Empiric Therapy

This approach is most appropriate for patients who are unlikely to have H. pylori infection or who have previously tested negative for H. pylori. A 4-8 week course of treatment with a proton pump inhibitor (PPI) or H2-receptor antagonist (H2RA) may be prescribed.
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