Comment using your own words but please provide at least one reference for each comment.
Do a half page for discussion #1 and another half page for discussion #2 for a total of one page.
Provide the comment for each discussion separate.
Differential Diagnosis for GERD
Gastroesophageal reflux disease or GERD is characterized by
heartburn or burning pain that radiates up the esophagus usually within an hour
after eating. Other diseases that also have these symptoms and need to be
considered to help confirm the diagnosis of GERD include cholelithiasis, peptic
ulcer disease, gastritis, and angina (Freshman, 2017). The confirmed diagnosis
comes after a trial period of medication to treat GERD (Woo, 2017).
Treatment for GERD
The initial treatment for GERD is lifestyle modifications.
When patients come to see a provider to seek treatment for their heartburn
pain, they usually have already taken OTC antacids or H2Ras without improvement
of symptoms (Woo, 2017). The best pharmaceutical treatment for GERD is a
prescription dose of proton pump inhibitors (PPIs). PPI reduce acid
production and improve the symptoms of GERD (Freshman, 2017). All PPIs are
approved to treat GERD and initial dosing is determined by the patient’s
history of present illness to treat for symptomatic GERD or chronic GERD due to
an erosion of the esophagus. The type of PPI prescribe is determined by other
medications that the patient is taking or if they are unable to swallow pills
whole then they will be prescribed omeprazole, esomeprazole, and lansoprazole
where the capsules can be opened, and the granules can be added to a small
amount of apple sauce to swallow easier. The main treatment for GERD is for the
patient to take a PPI once a day for eight weeks. The medication should
be taken first thing in the morning 30 to 60 minutes before breakfast (Woo,
Labs and Tests to Confirm GERD
The physical exam and history of illness described by the patient
is the best evaluation to determine diagnosis followed by a trail of PPI for
eight weeks to determine if the symptoms are controlled. If the symptoms
are not controlled, then more testing will begin to check for other causes of
the heartburn pain. Endoscopy is the test that is used to diagnose problems
with the esophagus when red flags are present or initial treatment does not
work. The Endoscopy can determine if the patient has Barrett’s esophagus
or erosive esophagitis. A CBC, stool testing for occult blood and H.
pylori can also be done to rule out PUD or other bleeding that would cause a
low blood count (Freshman, 2017).
Discussion Question 1
What would you prescribe
pylori the treatment initiated after initial antacid therapy has failed is
listed below. (this patient has taken both over the counter famotidine or
Clarithromycin 500 mg BID for
Nexium 40mg BID for 14 days.
Amoxicillin 1000mg BID for 14 days.
Clarithromycin triple therapy
consisting of a PPI, clarithromycin, and amoxicillin or metronidazole for 14
days remains a recommended treatment in regions where H.
pylori clarithromycin resistance is known to be <15% and in
patients with no previous history of macrolide exposure for any reason.
(American College of Gastroenterology, 2017) Consideration should be given for
uninsured patient regarding cost of meds. Also consider patient’s younger age,
activity level and the fact that compliance may be less with increased number
of pills daily.
Education regarding need to take
prescribed medications until dosing is complete is needed, as complete
treatment may take 2-4 weeks. Patient should be educated regarding possible
side effects of medications to include nausea, diarrhea and change in taste.
How long would you prescribe
to Woo & Robinson (2017) states triple therapy is typically the first line
treatment and treatment is usually 10-14 days.
What other possible meds could
you prescribe to assist with the side effects from the medications prescribed?
A probiotic may help with any GI
distress associated with the use antibiotics. Another medication that may be
helpful is Zofran for possible nausea associated with the treatment regimen.
How would the treatment vary if
the patient has GERD instead?
Pharmacologically GERD is typically
treated with an antacid like a proton pump inhibitor. The nonpharmacological
interventions include diet modification, stress reduction, and ceasing usage of
NSAIDs. Diet modifications include smoking cessation, and alcohol consumption
discontinued or limited to small amounts of dilute alcohol, eat small meals
more frequently, and avoid foods that increase abdominal discomfort. (Chaudhari
Priyanka et al, 2016)
Discussion Question 2
GERD presents with mild epigastric
pain, and symptoms commonly worsen after meals, although the pain is
classically described as “burning” and may be located in the
substernal rather than epigastric area. Peptic ulcer disease (PUD) is defined
as epigastric pain that improves with meals is the hallmark of PUD. However, in
some cases, symptoms of PUD may worsen with meals. NSAID use is associated with
the development of PUD. Gastritis is the inflammation or irritation of the
stomach lining often causing sharp epigastric pain. This pain may be variably
worsened or improved with eating food. (Woo and Robinson, 2017) “Proton Pump
Inhibitors (PPIs) have been the mainstay of GERD management since omeprazole
was introduced 1989 and continue to be one of the top selling medication
classes.” (Almutairi et al, 2018) When GERD is severe surgical interventions
may be the nest option for management. According to Almutairi et al (2018) “the
main types of surgery are fundoplication and, for obese patients, gastric
bypass. Fundoplication is the standard surgical treatment for GERD.” Lifestyle
modifications include “avoiding: smoking, flat-lying body position while
sleeping, foods that irritate the gastric mucosa (e.g., spicy foods) or
stimulate acid production (e.g., alcohol), and foods that decrease lower
esophageal sphincter tone (e.g., fatty food, chocolate, and caffeine).” (Woo
& Robinson, 2017)
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