Effective Cures for GERD

The Acid Reflux Strategy

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The Acid Reflux Strategy Summary


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Patients With Atypical GERD

In patients presenting with extraesophageal GERD syndromes such as laryngitis or asthma, treatment with twice-daily PPI therapy for 2 months is probably warranted when there is a concomitant esophageal GERD syndrome. Patients with suspected reflux chest pain syndrome should receive twice-daily PPI therapy after cardiac causes have been excluded. Manometry and pH or impedance pH monitoring should be considered in patients who do not respond to PPI therapy.2 Maintenance therapy is generally indicated in patients with extraesophageal GERD syndromes and concomitant esophageal GERD syndromes but not with reflux chest pain syndrome alone. Stepdown therapy can be attempted based on symptom control. Pediatric Patients With GERD Gastroesophageal reflux occurs in approximately 18 of infants. As in adults, transient LES relaxations appear to be the most common cause.31 This is due to devel- opmental immaturity of the LES. Other causes include impaired luminal clearance of gastric acid,...

Stomach and Duodenum Dyspepsia

Chf Treatment Algorithm

Dyspepsia ( bad digestion ) accounts for approximately 5 of all visits to family practitioners and is the most common reason for referral to a gastroenterologist in the United States, accounting for 20 to 40 of consultations (Jones and Lacy, 2004). The term dyspepsia refers to episodic or recurrent pain or discomfort arising from the proximal GI tract related to meals and is associated with heartburn, reflux, regurgitation, indigestion, bloating, early satiety, and weight loss. The lack of a standardized definition affects accurate prevalence data, given the challenge of clearly defining dyspepsia as either functional or nonulcer dyspepsia ( 60 of cases), or that caused by structural or biochemical disease (40 ) (Dickerson and King, 2004). Regardless of cause, dyspepsia has a profoundly negative impact on patients' health-related quality of life (HRQOL) and results in significant economic burden. Nonulcer dyspepsia (NUD) is defined in patients who have undergone either formal...

Indigestion Its Easy to Be Queasy

Don't you just hate eating a meal and being reminded of it for several hours afterward The little candy mints aren't enough to stop the heartburn, gas, abdominal pain, and bloated or nauseous feeling that indigestion brings our way. Indigestion seems to be growing as a condition I know I see it more frequently in the office. Perhaps our modern lifestyle has something to do with it. Tips to End Indigestion You need hydrochloric acid (HCL) to digest food. Is your stomach making enough Swallow a tablespoon of lemon juice or vinegar (both are loaded with HCL). If your indigestion goes away you need more acid in your diet. If it's worse, you've got too Take a seat. Enjoying your meal while seated helps your body focus on digestion. Eating while standing or driving can increase indigestion. Cut out the aggravators. Reduce or eliminate alcohol, vinegar, caffeine, and refined, junk, spicy, or greasy foods, which can trigger indigestion. I see more indigestion every year as our lives race...


Derived from Greek roots meaning difficult digestion, dyspepsia has long served as a synonym for indigestion, one of the most common - and etiologically varied - of human miseries. It has also been regularly employed to label symptoms of diverse organic disorders, with the result that some gastroenterologists find the word uselessly elastic. Most practitioners, however, have reached a consensus to use dyspepsia to denote either the ailment of functional indigestion or the symptoms of peptic ulcer.

Functional Dyspepsia

Several essential oils have been used in the treatment of functional (nonulcer) dyspepsia. All of the published trials have concerned the commercial preparation known as Enteroplant , an enteric-coated capsule containing 90 mg of Mentha x piperita, and 50 mg of Carum carvi essential oils. Holtmann et al. (2001) were the first to investigate the effect of Enteroplant (twice daily) on disease-specific quality of life as measured by the Nepean Dyspepsia Index. All scores were significantly improved compared to the placebo. In 2002, the same team also demonstrated that patients suffering with severe pain or severe discomfort both responded significantly better in comparison with the placebo. Approximately 50 of patients suffering from functional dyspepsia are infected with Helicobacter pylori (Freidman, 1998). The Helicobacter status of 96 patients and the efficacy of Enteroplant were compared by May et al. (2003). They found that patients with Helicobacter pylori infection demonstrated a...


Nonpharmacologic recommendations for the treatment of heartburn during pregnancy do not differ from recommendations for nonpregnant patients. Small and frequent meals, remaining upright after eating, elevating the head of the bed, and avoiding foods known to decrease lower esophageal sphincter tone (such as chocolate, coffee, fatty foods, and peppermint) are recommended. Heartburn All the drugs used for heartburn during pregnancy are acceptable during lactation.19

Diagnosis of GERD

Hiatal Hernia Surgery Procedure

The most useful tool in the diagnosis of GERD is the clinical history, including both the presenting symptoms and associated risk factors. Patients presenting with uncomplicated, typical symptoms of reflux (heartburn and regurgitation) do not usually require invasive esophageal evaluation. These patients generally benefit from a trial of patient-specific lifestyle modifications and empiric acid-suppressing therapy.1 A clinical diagnosis of GERD is assumed in those responding to appropriate therapy. geal GERD syndrome who have not responded to an empiric trial of twice-daily pro- ton pump inhibitor (PPI) therapy. While controversial, some feel that screening for Barrett's esophagus should be performed in patients more than 50 years of age and those with longstanding heartburn. FIGURE 17-2. Therapeutic interventions in the management of gastroesophageal reflux disease. Pharmacologic interventions are targeted at improving defense mechanisms or decreasing aggressive factors. LES, lower...

The Symptoms of Pregnancy and Warning Signs of Cardiac Disease

Chest pain, the hallmark of coronary artery disease, is a common complaint during pregnancy. Fortunately, pregnant women are in an age group with a low risk of atherosclerotic coronary disease. More likely causes of chest pain include esophageal reflux (heartburn) or pressure on the rib cage. Typical angina pectoris, the type of chest pain caused by blocked coronary arteries, can be easily distinguished from other causes by history alone.

Upon completion of the chapter the reader will be able to

Explain the underlying causes of gastroesophageal reflux disease (GERD). 2. Differentiate among typical, atypical, and complicated symptoms of GERD. 4. Identify the desired therapeutic outcomes for patients with GERD. 5. Recommend appropriate lifestyle modifications and pharmacotherapy interventions for patients with GERD. 6. Discuss other nonpharmacologic interventions that may be appropriate for patients with GERD. 7. Formulate a monitoring plan to assess the effectiveness and safety of pharmacotherapy for GERD.

Patient Encounter Part 1

A 42-year-old man with a history of diabetes and hypertension presents complaining of heartburn. He reports a burning sensation in his upper chest and some regurgitation of sour-tasting material into his throat. The symptoms began about 1 month ago, occur about twice a week, and are associated with heavy meals and lying down after eating. He says that he smokes about one pack of cigarettes per day and drinks coffee and alcohol-containing beverages on most days. His weight is 116 kg (255 1b). What information is suggestive of GERD Does he have any factors contributing to GERD Patients with esophageal GERD syndromes who have failed twice-daily PPI therapy and have normal findings on endoscopy may benefit from manometry. Manometry helps to localize the LES for ambulatory pH monitoring, evaluates peristaltic Ambulatory pH monitoring objectively proves that symptoms are reflux related in patients with esophageal GERD syndromes not responding to twice-daily PPI therapy. Impedance monitoring...

Pharmacologic Therapy

Antacids are an appropriate component of treating mild GERD as they are clearly effective for immediate, symptomatic relief. They are often used concurrently with other acid-suppressing therapies. The histamine2-receptor antagonists (H2RAs) cimetidine, famotidine, nizatidine, and ranitidine decrease acid secretion by inhibiting the histamine2-receptors in gastric parietal cells. When given in divided doses, they are effective for patients with mild to moderate GERD.1 Standard doses provide symptomatic improvement in about 60 of patients after 12 weeks of therapy.1 Healing rates per endoscopy tend to be lower (50 ). Response to the H2RAs is dependent on (a) the severity of disease, (b) the dosage regimen used, and (c) the duration of therapy. For symptomatic relief of mild GERD, low-dose, nonprescription H2RAs may be beneficial. For patients not responding to patient-directed therapy with over-the-counter agents after 2 weeks, standard-dose acid-suppressing therapy is warranted....

Patient Care and Monitoring

Assess patient symptoms to determine if further diagnostic evaluation is necessary. Does the patient have any GERD-related complications such as difficulty in swallowing or unexplained weight loss 4. Instruct the patient to avoid foods that aggravate GERD symptoms. What causes GERD and what are things to avoid What are possible complications of GERD

Other Causative Factors

Dietary factors such as coffee, tea, cola, beer, and a highly spiced diet may cause dyspepsia, but they have not been shown to independently increase PUD risk. Although caffeine increases gastric acid secretion and alcohol ingestion causes acute gastritis, there is inconclusive evidence to confirm that either of these substances are independent risk factors for peptic ulcers.

Abnormalities of the Oral Region eTable 196 Swallowing Disorders

A constant sensation of a lump in the throat is known as globus hystericus and is not necessarily associated with the act of swallowing. This diagnosis can be made only by ruling out anatomic or motor abnormalities of the pharynx, larynx, or esophagus. From 23 to 60 of patients presenting with a globus sensation have GERD as the origin (Ahuja et al., 1999). eBox 19-7 online lists head and neck symptoms related to GERD versus gastroesophageal symptoms. about 50 of patients show a definitive abnormality with this test. Provocative testing with manometry involves infusion of edrophonium, esophageal balloon dilation, or acid perfusion into the esophagus. Recording esophageal pH in an ambulatory setting can indicate if acid reflux episodes are present at the same time as the patient's symptoms.

Clostridium Chauvoei

Duction. ' Exertion and acute indigestion may also be capable of initiating these events. In sheep, C. chauvoei infection more often presents as a wound infection resembling malignant edema or gas gangrene. Clinically, animals may display high fever, anorexia, and depression, often with lameness. Crepitant lesions may be detected in superficial areas, although many lesions are internal. However, sudden death, without display of clinical signs, is common. The common rancid-butter odor of the lesions results from bacterial production of butyric acid as an end-product. Peripheral areas of the resulting lesions are edematous and hemorrhagic, with evidence of myonecrosis, while the central areas of the lesions are typically dry and emphysematous. Microscopically, leukocytic infiltration is negligible, but degenerative changes occur in muscle fibers, and edema, emphysema, and hemorrhage are common.4'172'200

Chapter information

Contributing authors Doug Altman, Gerd Antes, Peter G0tzsche, Julian Higgins, Peter Jiini, Steff Lewis, David Moher, Andy Oxman, Ken Schulz, Jonathan Sterne and Simon Thompson. Acknowledgements The material in this chapter was developed by a working group consisting of Doug Altman (co-lead), Gerd Antes, Chris Cates, Mike Clarke, Jon Deeks, Peter G0tzsche, Julian Higgins (co-lead), Sally Hopewell, Peter Juni (core group), Steff Lewis, Philippa Middleton, David Moher (core group), Andy Oxman, Ken Schulz (core group), Nandi Siegfried, Jonathan Sterne Simon Thompson. We thank Hilda Bastian, Rachelle Buchbinder, Iain Chalmers, Miranda Cumpston, Sally Green, Peter Herbison, Victor Montori, Hannah Rothstein, Georgia Salanti, Guido Schwarzer, Ian Shrier, Jayne Tierney, Ian White and Paula Williamson for helpful comments. For details of the Cochrane Statistical Methods Group, see Chapter 9 (Box 9.8.a) and for the Cochrane Bias Methods Group, see Chapter 10 (Box 10.5.a).

Distribution and Incidence

Peptic ulcer dyspepsia is rare in people under the age of 20, but by age 30, 2 percent of the males and 0.5 percent of the females in a population have developed the condition. For men, the incidence increases steadily with age, reaching a peak of around 20 percent in the sixth decade of life. The incidence for women remains low, about 1 percent, until menopause, after which it climbs as rapidly as in men. A morbidity rate of nearly 14 percent has been re The prevalence of functional dyspepsia, by contrast, is uncertain. Having no distinct pathology, being neither communicable nor reportable, and only occasionally motivating its victims to seek medical help, it does not generate statistics. The widely shared clinical impression is that women are affected more than men, and people under the age of 40 more than those over age 40. Functional dyspepsia is also believed to be more prevalent in developed countries.

Epidemiology and Etiology

Although the most common, peptic ulcer is hardly the only organic source of dyspepsia. Esophagitis hiatus hernia gastritis carcinoma of the stomach, colon, or pancreas Crohn's disease disease of the biliary tract chronic nephritis or any of several other conditions, including pregnancy, can produce indigestion. In approximately half of the cases of dyspepsia, however, no lesion can be found, and symptoms arise from derangements of motor, secretory, or absorptive functions, especially delayed gastric motility, esophageal reflux, and hyperacidity. This functional indigestion has been related to physical stress (aerophagia, fatigue, dietary indiscretion) and, more commonly, to nervous stress. Anxiety, anger, frustration, and other indications of emotional turmoil can significantly impair digestive function in sensitive or tense individuals (a similar psychic component - chronic tension and repression of emotion - has been implicated in peptic ulcer). Because the symptoms of functional...

Clinical Manifestations

That most eminent of Victorian dyspeptics, Thomas Carlyle, likened his torment to a rat gnawing at the pit of the stomach. Dyspepsia's victims still complain of gastric pain, along with fullness or heaviness in the stomach, nausea and vomiting, belching, flatulence, and or acid eructations. Finally, dyspeptics may suffer heartburn, a caustic pain behind the sternum that sometimes climbs into the throat, resulting from esophageal reflux. Heartburn is the special affliction of those with sliding hiatus hernia when they bend or lie down.

History and Geography

So advised the author of the medieval Regimen Sanitatis Salernitanum, and no doubt his words were already age-old wisdom. Yet if indigestion has plagued the human race for as long as it has eaten, and no less hoary an expert than Hippocrates described its tortures, it was not until the nineteenth century that dyspepsia attained a prominent standing in pathology. Previously it was regarded as a too common but predictable and temporary discomfort brought on by immoderacy in diet. Alexander Pope's scolding couplets characterized pre-Victorian views (Davis 1966) The sources of intestinal turbulence came to appear more numerous during the early nineteenth century. The distrust of sensuality that marked the Victorian ethos more than once expressed itself in the blaming of physical decline on moral perversion. And because dyspepsia was so often found in patients guilty of some excess and just as often lacked any apparent organic basis, physicians found it easy to explain the condition on the...

Diagnostic Classification

Cific diagnoses, including a narrowly defined diagnosis of functional abdominal pain. In the remainder of this chapter, the specific Rome III diagnosis of functional abdominal pain will be spelled out and italicized to distinguish it from FAP in the more global, descriptive sense. The most widely used Rome III diagnoses associated with abdominal pain are listed in Table 18-1 and include irritable bowel syndrome (IBS), functional dyspepsia, childhood functional abdominal pain, childhood functional abdominal pain syndrome, and abdominal migraine (Rasquin et al. 2006). Baber et al. (2008) found that the Rome III criteria classified nearly 90 of youth with FAP, an improvement from the 68 classified using the previous Rome II criteria. In their study, 45 of youth with FAP met Rome III criteria for IBS, 23 for abdominal migraine, 15 for functional dyspepsia, 11 for functional abdominal pain, and 6 for functional abdominal pain syndrome. Nevertheless, despite the growing use and acceptance...

Evidence Based Treatment Approaches

Once an episode of CVS has started, over 50 of children will require intravenous rehydration to avoid dehydration and acidosis (Chow and Goldman 2007 Li and Misiewicz 2003). Supportive measures include placing the child in a quiet, less stimulating environment and avoiding bright lighting, along with the use of antiemetics such as on-dansetron and sedatives such as lorazepam (Chow and Goldman 2007 Li and Misiewicz 2003 Li et al. 2008). The off-label use of triptans such as suma-triptan has been suggested as potentially helpful in the management of acute CVS episodes when administered early. Antipsychotic medications such as prochlorperazine have been demonstrated to be efficacious in the management of acute migraine (Siow et al. 2005) and have shown promise in the management of intractable pediatric migraine (Kab-bouche et al. 2001), raising questions about their potential utility in CVS, but clinical experience has apparently been uninspiring (Li et al. 2008). The use of proton pump...

Noncarious Tooth Wear

Noncarious tooth wear is a common problem. Exposed dentin can result from acidic erosion, abrasion, and attrition, but most toothwear has erosion as the dominant etiological factor. Localized anterior toothwear of the upper anterior teeth is often caused by the consumption of erosive carbonated beverages, fruit juices, and citrus fruits. Regurgitated stomach acid in gas-troesophageal reflux disease, hiatus hernia, and esophagitis and vomiting in bulimia, alcoholism, and psychosomatic disorders can cause erosive tooth wear of the palatal surfaces of the anterior teeth. Drugs that tend to reduce the amount of saliva in the mouth, such as antidepressants, recreational drugs (LSD and Ecstasy, which is 3,4-methylene-dioxymethamphetamine), and diuretics, also diminish the buffering capacity available to neutralize dietary or stomach acids. Users of Ecstasy commonly complain of a dry mouth, and erosion from carbonated beverages is thought to be an important etiological factor. However, the...

What Practitioners Say It Does

Conditions that practitioners believe to be aided by aromatherapy include acne, anxiety, cold and flu, skin disorders, headaches, indigestion, premenstrual syndrome, muscle tension, and pain. Some aromatherapy advocates use body applications (massages and liniments) to treat physical problems, and inhalation methods to treat emotional problems.

Epidemiology and Social Impact of Gastrointestinal Disease

Although diseases of other organ systems (e.g., cardiovascular disease) may appear to be more dramatic illnesses with higher rates of morbidity and mortality, the overall impact of gastrointestinal (GI) disorders is often underestimated from both a biopsychosocial and a resource standpoint. Typically, diseases of the GI tract are misdiagnosed, mistreated, misunderstood, or missed altogether, ultimately leading to substantial psychological morbidity and tremendous direct and indirect expense. Digestive diseases cost an estimated 91 billion annually in U.S. health care costs, lost days from work, and premature deaths. More than 70 million Americans are diagnosed each year with disorders of the digestive tract, including gastroesophageal reflux disease, peptic ulcer disease, inflammatory bowel disease, GI cancers, motility

Cognitive Behavioral Therapy

CBT has the strongest empirical support when compared with other psychological treatment modalities. The results cross a wide variety of general medical conditions including irritable bowel disease, somatoform disorders, functional dyspepsia, inflammatory bowel disease, fibromyalgia syndrome, cystic fibrosis, juvenile rheumatoid arthritis, and polycystic ovary disease (Christian and D'Auria 2006 McQuaid and Nassau 1999 Rofey et al. 2008 Szi-gethy et al. 2004). CBT has been found useful for adverse effects of treatments (e.g., chemotherapy-induced nausea) and in decreasing maladaptive behavioral responses during medical procedures (Band and Weisz 1988).

Obstructive Sleep Apnea

Other common symptoms include irritability, impotence or reduced libido, and dry mouth. Symptoms of gastroesophageal reflux may be present if the repeated episodes of negative intrathoracic pressure associated with apneas lead to passage of gastric contents through the lower esophageal sphincter. Differential Diagnosis. Loud snoring with gasping or choking sounds, witnessed apneas, restless sleep, hypertension, and neck circumference greater than 16.5 inches are useful predictors of OSA, but a definitive diagnosis usually requires polysomnography. Among children, snoring or noisy breathing, daytime mouth breathing, and parental observation of apneas and struggles to breathe are suggestive symptoms. The absence of snoring and obesity does not rule out OSA in either adults or children. In patients with excessive daytime sleepiness, other diagnostic considerations include narcolepsy, idiopathic hypersomnia, periodic limb movement disorder (PLM), central sleep apnea, and the insufficient...

Nonsteroidal Anti Inflammatory Drugs

NSAIDs are one of the most widely used classes of medications in the United States, particularly in the elderly.4 More than 20,000 deaths and 100,000 hospitalizations occur in the United States per year as a direct result of adverse events related to NSAID use. Chronic NSAID ingestion leads to symptoms of nausea and dyspepsia in nearly half of the patients. Peptic ulceration occurs in up to 30 of patients who use NSAIDs (including aspirin) chronically, with GI bleeding or perforation occurring in 1.5 of patients who develop an ulcer. NSAID-related peptic ulcers usually occur in the stomach DU are much less common. NSAID-related dyspepsia

Abdominal and Intestinal Disorders

Among the discernible intestinal disorders are dyspepsia, acute diarrhea, and dysentery with some symptoms of the latter suggestive of amebic dysentery. Clearly discernible is cholera, or Vishuchika -the Ayurvedic term for cholera. The patient vomits, trembles, has continuous watery diarrhea, severe abdominal pain, and hiccoughs. In agonal stages there is tingling all over the body, and the patient loses consciousness and becomes cyanotic. The voice becomes weak, the muscles and joints become lax, and the eyes retract into the orbital cavity. In a

Patient Encounter 2

The fibric acid derivatives are generally well tolerated. The most common adverse effects include dyspepsia, abdominal pain, diarrhea, flatulence, rash, muscle pain, and fatigue (Table 12-9). Myopathy and rhabdomyolysis can occur, and the risk appears to increase with renal insufficiency or concurrent statin therapy. If a fibrate is used with a statin, fenofibrate is preferred because it appears to inhibit the glucuronidation of the statin hydroxy and moiety less than gemfibrozil, allowing greater renal clearance of the statins.2 ,42 A CK level should be checked before therapy is started and if symptoms occur. Liver dysfunction has been reported, and LFTs should be monitored. Fibrates increase cholesterol in the bile and have caused gallbladder and bile duct disorders, such as cholelithiasis and cholecystitis. Unlike niacin, these agents do not increase glucose or uric acid levels. Fibrates are contraindicated in patients with gallbladder disease, liver dysfunction, or severe kidney...

Coronary artery disease

ICannabwoid recepLor Coronary heart disease Comprehensive Ri mo nab ant Evaluation Study of Clinical Endpoints Cardiovascular disease Cytochrome P450 Gastroesophageal reflux disease Low-calorie diel Monoamine oxidase inhibitor National Institute of Health-National Heart Lung and Blood Institute Rimonabant in obesity Respirations per minute

Accreditation Commission for Acupuncture and Oriental Medicine AGAOM

Indigestion, 192-193 eight directions, 55-56 pulse, 13-15 tongue, 12-13 dianhea, 189-190 dysmenonhea, 167-170 ear infections, 142-144 eczema, 195-197 electro-acupuncture, treatments, 104 endometriosis, 177-179 facelifts, 197-199 fibromyalgia, 65-66 headaches, 59-61 healthful lifestyle tips, 251-252 herbal medicine, 47-49 HIV AIDS, 218-219 hypertension, 220-221 IBS, 186-187 indigestion, 191-193 infertility, 156-158 injuries, 101 insomnia, 225-227 jumper's knee, 88-89 knee pain, 87-88 licenses, 244 magnets, 45-46 Margaret Naeset, 75 medical histories, 14-15 menopause, 170-172 moxibustion, 41-42 nasal congestion, 126-127 acupressure, 4, 9-10, 19, 21-24, 27-29, 74, 86, 128-131, 239-241 acu-points, 5-7, 63-64, 238 allergies, 116-117 anxiety 210-211 arthritis, 78-79 asthma, 118-120 back pain, 82-85 bladder infections, 182-184 bronchitis, 121 bursitis, shoulders, 70-71 cancer, 151-153 carpal tunnel syndrome, 76-77 colds, 124-125 constipation, 188-189 dental pain, 62-64 diarrhea, 190...

Structure and Physiology

Stomach Quadrants

As food passes into the esophagus, an obstructing lesion can produce dysphagia, or difficulty swallowing. Gastroesophageal reflux can lead to heartburn. Upon entry of partially digested food into the stomach, the stomach relaxes. A failure of this relaxation may lead to early satiety or pain. The stomach functions as a food reservoir, secreting gastric juice and providing peristaltic activity with its muscular wall. Between 2 and 3 L of gastric juice is produced daily by the stomach lining and affects the digestion of proteins. The semifluid, creamy material produced by gastric digestion of food is called chyme. Secretion of gastric juice may produce pain if a gastric ulcer is present. Intermittent emptying of the stomach occurs when intragastric pressure overcomes the resistance of the pyloric sphincter. Emptying is normally complete within 6 hours after eating. Any obstruction to gastric emptying may produce vomiting.

Treatment of H pyloriAssociated Ulcers

Nsaids Ulcers

Approach to the patient presenting with ulcer-like symptoms. (GERD, gastroesophageal reflux disease HP Helicobacter pylori H2RA, histamine2-receptor antagonist NSAID, nonsteroidal anti-inflammatory drug NUD, nonulcer dyspepsia PPI, proton pump inhibitor.) (From Ref. 37.) FIGURE 18-3. Approach to the patient presenting with ulcer-like symptoms. (GERD, gastroesophageal reflux disease HP Helicobacter pylori H2RA, histamine2-receptor antagonist NSAID, nonsteroidal anti-inflammatory drug NUD, nonulcer dyspepsia PPI, proton pump inhibitor.) (From Ref. 37.)

Use Of Essential Oils Mainly As Chemical Agents And Not For Their Odor

The efficacy and safety of capsules containing peppermint oil (90 mg) and caraway oil (50 mg), when studied in a double-blind, placebo-controlled, multicenter trial in patients with nonulcer dyspepsia was shown by May et al. (1996). Intensity of pain was significantly improved for the experimental group compared with the placebo group after 4 weeks.

What do you do now

Autonomic functions are also often affected. Sweating, thermal regulation, and vasomotor control may differ on the two sides of the body. Cardiovascular abnormalities include tachycardia, orthostatic hypotension without cardiac rate acceleration, and intermittent bradycardia. Gastrointestinal autonomic dysfunction includes decreased esophageal motility, gastroesophageal reflux, and gastric retention.

Levocarnitinein Libido

Dosage of, 320, 321-322, 323, 335t, 336t drug interactions of, 321-322 in GERD, 320, 321-322, 323 in Helicobacter pylori eradication, 3351 in peptic ulcer disease, 336t Lanthanum in allergic rhinitis, 1049-1050 in cirrhosis, 394 in constipation, 373 in erectile dysfunction, 885 in GERD, 317, 319, 320t in hyperlipidemia, 234, 236t, 240, 958 in hypertension, 58-59, 59t, 957-958 in ischemic heart disease, 117-118 in musculoskeletal disorders, 1027-1028 in osteoarthritis, 1000 in Parkinson's disease, 557 in urinary incontinence, 914 Lifting, in enuresis, 9231 Lifting techniques, 1028 Ligament, 1020, 1020 physical characteristics of, 177t Low-density lipoprotein cholesterol, 120, 230 goals for, 120, 151, 236, 755-756 optimal level for, 230 oxidation of, 125 Lower esophageal sphincter pressure, in GERD, 316, 317t Lower respiratory tract, normal flora of, 1157 Lower respiratory tract infection, 1189-1201 Lower urinary tract symptoms, 809

Parallel Diagnostic Inquiry

Before reaching this point, the physician needs a different mode of diagnostic pursuit. For example, a patient presents with several days of intermittent, heavy chest pain. The physician might test for angina pectoris, then for other cardiac causes, then for gastroesophageal reflux disease (GERD), while looking for pleuritic explanations and perhaps ruling out costochondritis. If all these tests are negative, the physician might initiate an exploration of psychological or psychosocial factors that could be responsible. After an exhaustive focus on various physical explanations for this pain, the patient might question the physician's competency. With no explanation for the chest pain, the patient also may think the physician is saying, in effect, It must all be in your head. It is not good practice to complete a physical workup for a symptom with no explanation. By that time, the physician could have elaborated a set of psychosocial connections to the symptoms. By pursuing a strategy...

Pharmacologic Treatment

The adverse effects of oral bisphosphonates are their inherent toxicity to epithelial cells lining the gastrointestinal tract. The results are irritation of the esophagus, acid eructation, nausea, and heartburn. Patients with a significant background of gastrointestinal intolerance, therefore, are not suitable for prescribing oral formulations. However, clinicians may improve patients' tolerance by giving oral bisphosphonates in small doses and slowly increasing the dosage until full dose is achieved. This will lead to better compliance even with individuals who have a past history of dyspepsia. The other potential complication is osteonecrosis of the jaw. Osteonecrosis of the jaw is defined as exposed bone in the musculofacial region that fails to heal within 8 weeks after identification by a health care provider. The group of patients who carry the greatest risk for developing this complication are those with multiple myeloma or metastatic carcinoma of the skeleton who are being...

What if my testosterone level is low What are the risks and benefits of testosterone therapy

HA in 16 , flushing in 10 , dyspepsia in 7 , visual disturbance in 3 , priapism uncommon. NAION (nonarteritic anterior ischemic optic neuropathy) and hearing loss have been reported in individuals taking PDE 5 inhibitors, but a causal relationship has not been identified. The risk factors for NAION are similar to those for ED, such as age 50 yr, HT, increased cholesterol, and DM. HA 15 , flushing 11 , dyspepsia 4 .

Composition of Refluxate

The composition, pH, and volume of the refluxate are other factors associated with gastroesophageal reflux. Duodeno-gastric reflux esophagitis or alkaline esophagitis refers to esophagitis induced by the reflux of bilious and pancreatic fluid. Although bile acids have both a direct irritant effect on the esophageal mucosa and an indirect effect of increasing hydrogen ion permeability of the mucosa, symptoms are more often related to acid reflux than to bile reflux. The percentage of time that esophageal pH is below 4 is greater for patients with severe disease than for those with mild disease. The pathophysiology of GERD is a complex process. It is difficult to determine which occurs first gastroesophageal reflux leading to defective peristalsis with delayed clearing or an incompetent LES pressure leading to gastroesophageal reflux. Understanding factors associated with the development of GERD is essential to providing effective treatment (Fig. 17-2).

Cholelithiasis and Cholecystitis

Asicite Raio

In the approach to the patient with symptomatic gallstones, clinicians should effectively rule out other potential causes of RUQ and epigastric abdominal pain, distinguishing biliary from nonbiliary etiologies as the primary source of disease (see Table 38-1). A gallstone blocking the cystic duct or common bile duct (CBD choledocholithiasis) results in acute biliary colic, which can evolve into acute suppu-rative cholecystitis or cholangitis. The onset of pain from biliary colic is rarely related to meals or the type of food consumed, contrary to popular opinion. Many patients with postprandial abdominal pain believe that they have gallbladder disease, but many of them suffer from dyspepsia or GERD. One meta-analysis found that heartburn, flatulence, regurgitation, and fatty food intolerance were not associated with gallstones, but that epigastric pain, nausea, and vomiting were associated with a higher odds ratio of having gallstones (Kragg et al., 1995).

Causes And Outcomes Of Sexual Harassment

Sexual harassment harms those targeted,29,30 and this harm may persist for years after the harassment has ended.5 Many studies have documented the extensive physical and emotional costs for those who have been harassed. It is believed that costs to emotional well-being are directly related to harassment, whereas the physical health consequences are by-products of the increased psychological distress associated with sexual harassment.20 More specifically, sexual harassment has been linked to gastrointestinal (heartburn, diarrhea, stomach pains), musculoskeletal (headaches pain in joints, muscles, back, and neck), and cardiovascular symptoms (chest pain, tachycardia), headache, eyestrain, skin problems,24,31 and chronic diseases, such as hypertension, neurological disorders, diabetes, cardiovascular diseases, and so on.32

Patient Encounter 1 Part 1 Patient History

A 74-year-old Caucasian woman with a history of chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease (GERD) presents to the clinic for follow-up. She reports intermittent daytime and nighttime sweating that comes on suddenly. She reports soaking her bed sheets when this occurs. She had a hysterectomy at age 20 and has never taken estrogen replacement. She reports good relief of reflux symptoms on her current regimen. She started taking a calcium supplement approximately 2 years ago on the suggestion of her friend because she has never gotten much calcium in her diet. She states she does not like milk and never drank it even as a child. She occasionally eats some dairy products such as cheese and ice cream approximately once a week. PMH COPD GERD S P total abdominal hysterectomy and bilateral salpingoo-phorectomy at age 20 nicotine dependence

Infantile Regurgitation

In the infant with recurrent vomiting, a thorough history and physical examination are often sufficient to establish a diagnosis of uncomplicated gastroesophageal reflux disease (GERD), labeling the infant as the happy spitter. Diagnostic evaluation is indicated if there are signs of poor weight gain, GI obstruction, excessive crying and irritability, disturbed sleep, or feeding or respiratory problems suggesting suspected asthma or recurrent pneumonia. In the infant with uncomplicated GERD, parental education, reassurance, and anticipatory guidance are recommended no specific intervention is necessary because the process is usually self-limited. Thickened formula and a trial of a hypoallergenic formula are the best treatment options. A trial of time-limited acid-suppression therapy, usually with histamine-2 receptor antagonists (H2RAs), is useful in determining if GERD is causing vomiting and regurgitation. If symptoms worsen or do not improve by 18 to 24 months of age, reevaluation...

Determined Digestion What Goes Down Can Stay Down

Avoid cold or raw foods, which may overtax the digestive system. Toddlers quickly develop a taste for fatty, greasy foods like chips, fried foods, or peanut butter. Cutting out these items, despite the protests, will often resolve the vomiting and indigestion challenges.

Chromosomal Anomalies

In addition to the typical phenotypic features of the syndrome, associated congenital cardiac and gastrointestinal abnormalities may be present. A third to a half of patients with Down's syndrome have congenital cardiac defects, of which one third are endocardial cushion defects, and the remainder are ventricular septal defects. Tetralogy of Fallot and atrial septal defects also occur, and there is an increased incidence of moyamoya disease. More than half of patients have bilateral hearing loss, of which many cases are attributable to anomalies of the inner and middle ear. Malformations of the gastrointestinal tract, including intestinal atresia and imperforate anus, occur in about 5 to 7 percent of patients, and there is a reported increased incidence of Hirschsprung's disease. Although abnormalities of T-lymphocyte function have been reported, no specific relationship of these to the infection rate has been established. Other associated abnormalities include gastroesophageal...

Nonsurgical treatment of OA

Ence in effect on OA pain between the different members of this class of compounds or between those compounds that inhibit both cyclooxygenase-i and -2, or are selective for cyclooxygenase-2 (COX-2) 8i . Several of the non-selective inhibitors have been in use for many years, such as diclofenac, ibuprofen and naproxen, and some are available OTC. The adverse effects of this class of compounds are significant and well known, affecting the gastrointestinal lining (dyspepsia, gastritis, gastrointestinal bleeding), kidney function, nervous system and thrombocyte function (clot inhibition). The risk of serious gastrointestinal bleeding, sometimes leading to death, varies significantly between different members of the class, and those mentioned above constitute a low-risk group within the class 93,94 . The risk of adverse effects increases with age. The patient should use the lowest effective dose for the shortest time needed.

Functional Assessment

Patients respond to different classes of NSAIDs for unknown reasons, and no NSAID appears superior to others in efficacy. Treatment is largely empiric. Most clinicians start with a low dose and titrate upward if needed. An adequate trial of an NSAID requires that the patient take a maximum dose for 3 weeks before changing to a different NSAID, although many patients will expect a change in medication before this. It is usually best to switch to an NSAID from a different class. There is no benefit to combining nonsalicy-late NSAIDs. All COX-1 NSAIDs can cause dyspepsia and GI toxicity, interfere with platelet function, and prolong bleeding times. Other common side effects include renal toxicity and central nervous system (CNS) symptoms such as drowsiness, dizziness, and confusion. A 2004 Cochrane review of NSAIDs for lower back pain concluded that the various types of NSAIDs (e.g., COX-2 inhibitors) are equally effective, and selection of an NSAID for OA should be based on relative...

Gastrointestinal Physiology And Antacid Therapy

Changes in smooth muscle tone occur early in pregnancy as a result of an increase in progesterone. This leads to a decrease in the tone of the lower oesophageal sphincter and, combined with the increased abdominal mass, results in an increased possibility of regurgitation and pulmonary aspiration of gastric contents. The pH of the gastric contents is lower, and therefore there is an increased incidence of heartburn in pregnancy. Gastric emptying is not delayed during pregnancy but is delayed in labour, especially by pain, anxiety and opioids.

Patient Encounter Part 2 The Medical History Physical Exam and Diagnostic Tests

ROS (-) skin rash (-) nasal congestion, drainage (-) chest pain, paroxysmal nocturnal dyspnea, orthopnea (+) shortness of breath, cough, intermittent wheezing (-) hemoptysis (-) heartburn, reflux symptoms, N V D, change in appetite, change in bowel habits (-) joint pain or swelling (-) pedal edema

Nutritional Deficiencies and Disorders

In North Africa where the child between 1 and 3 years old is weaned abruptly and then given a diet of carbohydrates familiar in family fare, the young may not be able to tolerate the change, which may then cause dyspepsia, infantile diarrhea, lowered resistance to infectious diseases, and kwashiorkor. Nomadic tribespeople of the Sahara south of the Atlas mountains, however, wean the infant over a 6-month period, introducing it gradually first to camel's milk and then to cereals.

Miscellaneous Diseases

While visiting a drugstore in Seoul with his interpreter, Woods (see the first section of this chapter) examined many roots and herbs that were all said to be good for the stomach This suggests, of course, that digestive disorders were common. Gastritis seemed to be the major disease in the category of stomach diseases, although Avison thought that common complaints of chronic indigestion included many cases of stomach ulcers.

Clinical Manifestations and Pathology

A distended abdomen and pronounced, sharply pointed shoulder blades ( pot belly and angel wings in the American South) were once thought to identify children with hookworm disease, although the same features often accompany malnutrition as well. In pregnant women, hookworm infection increases the likelihood of fetal morbidity. Victims of hookworm anemia, regardless of age or sex, may be chronically sluggish, listless, and easily tired, symptoms that prompted a facetious American newspaper reporter early in the twentieth century to dub hookworm the germ of laziness. Dropsy, dizziness or giddiness, indigestion, shortness of breath, tachycardia, and in very extreme cases congestive heart failure have also all been associated with advanced hookworm disease. Hookworm sufferers will sometimes eat dirt, chalk, or clay as well.

Past Medical History

As with the adult, the past medical history should include details of any hospitalizations, injuries, and surgeries, as well as any medications taken on a regular basis. Ask, ''Does your child have any chronic health problems '' Common chronic health problems in children include asthma, seizure disorders, eczema, recurrent ear infections or urinary tract infections, sickle cell disease, cystic fibrosis, diabetes, gastroesophageal reflux disease, and cerebral palsy. If the child was born before term, ask about late effects of preterm birth, such as chronic lung disease, nutritional problems, developmental difficulties, and sensory deficits.

Hypertrophic Pyloric Stenosis Clinical Summary

Hypertrophic pyloric stenosis (HPS) is characterized by progressive postprandial, nonbilious vomiting that steadily increases in frequency and amount due to hypertrophy of the pyloric musculature and edema of the pyloric canal, producing gastric outlet obstruction. It is usually diagnosed in infants from birth to 5 months, most commonly at 2 to 8 weeks of life. The vomiting may become forceful and is then described as projectile (although this pattern is not always present). There is a familial tendency, and white males are more frequently affected. During the physical examination, peristaltic waves may be observed traveling from the left upper to right upper quadrants. The hypertrophy of the antral and pyloric musculature produces the olive to palpation (best palpated in the epigastrium or right upper quadrant after emptying the stomach with a nasogastric tube). As a result of persistent vomiting, hypochloremic, hypokalemic metabolic alkalosis with varying degrees of dehydration and...

Gastrointestinal Effects of Pneumoperitoneum

The mechanism(s) of decreased ileus with laparoscopic surgery remain(s) unclear. Another concern with abdominal laparoscopy has been gastroesophageal reflux. Despite the increased intra-abdominal pressures associated with insufflation, there has been no increased incidence of gastroesophageal reflux and regurgitation in patients undergoing laparoscopic procedures (19). However, the combination of elevated intra-abdominal pressures from the pneumoperitoneum, morbid obesity, and the application of the Trendelenburg position can increase the likelihood of regurgitation and aspiration of gastric contents. To avoid reflux, high-risk patients may be premedicated with 10 mg of intravenous metoclopramide. Also, administration of H2 blockers can reduce gastric acidity and the associated morbidity if aspiration of gastric contents should occur. Finally, a cuffed endotracheal tube should prevent aspiration of stomach contents.

Black Hairy Tongue Clinical Summary

Black hairy tongue (BHT) represents a benign reactive process characterized by hyperplasia and dark pigmentation of the tongue's filiform papillae. The elongated filiform papillae may reach up to 2 cm in length and vary in actual degree of pigmentation from light tan to black. Predisposing factors may include excessive smoking, gastroesophageal reflux, poor oral hygiene, chemotherapy, and the use of broad-spectrum oral antibiotics. Pigment from consumed food, beverages, and tobacco products stains the entrapped food debris and desquamated papillary keratin. Some antibiotics may alter normal oral microflora and promote the growth of chromogenic organisms, also contributing to the tongue's discoloration. The darkly pigmented filament-like papillae give the tongue a black, hairy appearance. Males are more often affected than females this condition very rarely occurs in children. Alteration of taste perception and fetid breath may be a consequence of BHT.

Laparoscopic Partial Nephrectomy Greater or Lesser Than One Day Duration of Hospital Stay Predictor

Multiple logistic regression analysis (Table 6) identified congeorine heart failure, parenchymal tumor, and tumor abutting the collecting system to be independent significant predictors of a duration of hospital stay greater than one day. This analysis identified the appropriate weighting for characteristics in the design of a linear regression prediction algorithm. The following parameters were utilized in the model hypertension, gas-tic esophageal reflux disease, anxiety, hematuria (micro or gross), diabetes mellitus, CRI, gout, congestive heart failure, Crohn's disease, transabdominal approach, solitary kidney, Gastro-esophageal reflux disease

GI symptoms abdominal pain cramps and diarrhea

Initial reports found that up to half of all marathon runners have occasional loose stools or three or more bowel movements per day. Furthermore, the urge to defecate, abdominal cramping and increased flatulence are common lower GI symptoms of runners. A small percentage of marathoners report bloody bowel movements with running. Upper GI symptoms such as heartburn are not infrequent, particularly during running. Other upper tract symptoms include increased eructations, abdominal pain, nausea and vom-

Relevant pharmacology

The main pathways for pharmacological control of gastric acid secretion are shown in Fig. 9.32. The synthesis of antagonists to the H2 histamine receptors provided the first revolution in the treatment of gastric ulcers (the second revolution being the discovery that eradication of Helicobacter pylori infection results in long-term ulcer remission). H2 antagonists such as cime-tidine and ranitidine can antagonise acid secretion initiated not only by histamine, but also by gastrin and acetylcholine, and thus decrease both basal secretion of HC1 and secretion stimulated by food intake. They promote healing of duodenal ulcers, and are also useful in the treatment of heartburn chapter 9 and dyspepsia due to excess acid secretion. The main advantage of the H2

Irritable Bowel Syndrome

You can also try alternative remedies such as taking enteric-coated capsules of peppermint oil three times a day between meals (skip this one if you have heartburn), or explore yoga, meditation, or hypnosis to lessen stress and anxiety, which can sometimes wind up in your gut. Also, for women who notice IBS flare-ups around the time of menstruation, take evening primrose oil or black cohosh.

Gastrointestinal tract

Gastrointestinal disorders are the commonest of these unwanted effects. They include dyspepsia (or oesophageal irritation) and gastric erosions, which may present with bleeding or perforation. Piroxicam reportedly causes most symptomatic bleeding perhaps because of its long half-life and cumulation in the elderly. Naproxen and diclofenac are less often implicated and ibuprofen is said to be the safest in this respect, although when equi-anti-inflammatory doses are used, endoscopic evidence of increased safety is absent. Erosions or ulcers are caused by uninhibited acid secretion, reduced mucus and bicarbonate secretion, reduced mucosal blood flow and biochemical bridging of the mucus barrier allowing the hydrogen ions to enter the mucosal cells.

Gastrointestinal System

Maldigestion due to pancreatic enzyme insufficiency is present in about 85 to 90 of CF patients.5 Thick pancreatic secretions and cellular debris obstruct the pancreatic ducts and lead to fibrosis. Volume and concentration of pancreatic enzymes and bicarbonate are reduced, leading to maldigestion of fat and protein and subsequent malabsorption of fat-soluble vitamins (A, D, E, and K). Maldigestion is characterized by abdominal distention, steatorrhea, flatulence, and malnourish-ment despite voracious intake. Maldigestion is progressive and may develop later in a previously pancreatic sufficient patient. Other complications may include gastroesophageal reflux, dysmotility, salivary dysfunction, intussusception, volvulus, atresia, rectal prolapse, and complications related to corrective surgery for meconium ileus.6

Constipation Ready Set No Go

Constipation is a frequent GI complaint, especially among women, children, and those over age 65. Again, we don't talk about it, but it can lead to various maladies, including bad breath, body odor, depression, headaches, hemorrhoids, indigestion, insomnia, gas, and fatigue.

Heart Attack Myocardial Infarction

Although heart attack symptoms are usually clear, heart attack victims may not experience any angina and may just not feel well. In some cases, patients report a sudden onset of heartburn and shortness of breath. These are often explained away as merely indigestion and only later will the actual cause become clear. Sometimes heart attacks are even discovered long after they have occurred, and, in retrospect, patients recall no symptoms at all.

Laparoscopic Radical Simple Nephrectomy Models

Planned adrenalectomy, planned lymph node dissection, gastro-esophageal reflux disease, hypertension, smoking, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease, coronary artery disease, hematuria (micro or gross), kidney stones, obstructive sleep apnea, congestive heart failure, cerebrovascular accident, polycystic kidney disease depression, fibromyalgia, liver cirrhosis, bleeding disorders, planned transperitoneal versus retroperitoneal approach, side of nephrectomy, tumor size, nodal involvement, renal vein involvement, body mass index, American Society of Anesthesiology grade, planned specimen extraction incision and duration of hospital stay (in days).

Infancy through Adolescence

Although malnutrition is still a problem in the United States, inappropriate nutrition, especially calorie-nutrient imbalance leading to overweight and obesity, has become commonplace. Recent NHANES studies demonstrate that the prevalence of overweight (BMI 95 ) in girls 2 to 19 years old increased from 13.8 in 1999-2000 to 16 in 2003-2004, and the prevalence of overweight in boys 2 to 19 years old increased from 14 to 18.2 (Ogden et al., 2006). Increased pediatric BMI is associated with high blood pressure, sleep apnea, asthma, polycystic ovarian syndrome, type 2 diabetes, gastroesophageal reflux, and orthopedic problems (Benson et al., 2009). A nationwide survey of more than 6000 children and adolescents found that at least 30 consumed fast food on a typical day. These children consumed more total fat, total carbohydrate, more added sugars and sugar-sweetened beverages, less milk, and fewer fruits and nonstarchy vegetables than children who did not eat fast food (Bowman, 2004). The...

Pure Cholinergic or Adrenergic Disorders

Its clinical features include insensitivity to pain and temperature, absence of tears, hypoactive corneal and tendon reflexes, and absence of fungiform papillae of the tongue. Patients with familial dysautonomia have poor suck and feeding responses, esophageal reflux with vomiting and aspiration, uncoordinated swallowing, episodic hyperhidrosis, vasomotor instability, postural hypotension, hypertensive crises, supersensitivity to cholinergic and adrenergic agents, and absent histamine flare. 39

Nonpharmacologic Therapy

Nonpharmacologic treatment of GERD includes patient-specific lifestyle modifications, antireflux surgery, or endoscopic therapies. Although most patients do not respond to lifestyle changes alone, the importance of maintaining these lifestyle changes throughout the course of GERD therapy should be stressed to selected patients on a routine basis. The most common lifestyle changes that a patient should be educated about include (a) losing weight and (b) elevating the head of the bed if symptoms are worse when recumbent. Elevating the head of the bed about 6 to 10 in. (15-25 cm) with an undermattress foam wedge (not just elevating Other lifestyle modifications should be considered based on the circumstances of the individual patient. These include (a) eating smaller meals and avoiding meals 3 hours before sleeping, (b) avoiding foods or medications that exacerbate GERD, (c) smoking cessation, and (d) avoiding alcohol. factors that may exacerbate GERD symptoms (see Table 17-1). ' '...

Causes of Erectile Dysfunction

The side effects reported with Viagra are usually mild to moderate in nature. These include a flushing sensation, indigestion, nasal congestion, some alteration in vision, diarrhea, and headache. Viagra should not be used by men with coronary artery disease who are taking medicine containing nitrates. Nitrates are found in many prescription medicines used to treat chest pain, or angina, due to coronary artery disease. These medicines include nitroglycerin sprays, ointments, pastes, or tablets that are swallowed, chewed, or dissolved in the mouth. Nitrodur, Imdur, and

Can You Spoil a Child

Way, not to worry about spoiling in that period but to do what works. Experienced parents come to that decision by themselves they just say, This baby is a fusser and needs more settling time. Another reason for not worrying about spoiling in the first three or four months is that it is fairly easy to cure. Yon say to the baby (he doesn't understand the words but he gets the tone) I think you are getting spoiled. Your doctor says you probably don't have much indigestion or tension by this age and that it's all right to let you fuss for a little while when you've recently been fed. You and I know-that you are not hungry. I'll be right in the next room.' You say this not angrily but in an affectionate, reassuring tone. Hug him, lav him down and walk briskly to the living room. Your cheerful, self-confident manner reassures him that there is nothing seriously wrong and that you haven't stopped loving him. 106-7, 120-21, 127 indigestion, 140 infection (s), 9-10. 19


Compression of the lungs, stomach, intestines, and bladder can cause symptoms such as mild breathlessness, heartburn, and a need to pass urine frequently. Compression of the lungs, stomach, intestines, and bladder can cause symptoms such as mild breathlessness, heartburn, and a need to pass urine frequently.

What It Is

To the dismay of the related National Institutes of Health (NIH) programs and patient advocacy groups, such as those that seek to protect patients with Alzheimer's disease, mental illness, cancer other diseases, many dietary supplements claim to reduce or cure problems such as depression, sleep disorders, diminishing memory, indigestion, arthritis and cancer. Still others promise to achieve antiaging effects, rejuvenation, and the elimination of toxins from the body. Literally thousands of dietary supplements, nutritional aids, and similar products are widely promoted and generally available to the public. Their promises are rarely substantiated in fact.

General Application

Numerous cardiothoracic, general surgical, gynecologic and urologic procedures have been attempted either in animate laboratories or clinically (Fig. 11) (122-133). Most of these studies have been case reports with series only available for evaluation of outcomes in cardiac surgery. A case report of computer-assisted robotic Heller myotomy in a 76-year-old female with progressive dysphagia was performed in Columbus, Ohio (123). The da Vinci system was utilized using four operative cannulas (5 mm liver retractor, two 10 mm working ports in the patient's midline and left midclavicular line, and one 5 mm port in the left anterior axillary line). An assistant surgeon stayed at the patient's bedside and controlled retraction and changed instruments on the robotic arm. The total operative time was 160 minutes and she was discharged the following day. Another case report again utilized the da Vinci system to perform a Nissen fundoplica-tion on a 56-year-old female with longstanding...


VA function of the stomach is the production of hydrochloric acid. If the cardiac sphincter fails to contain the acidic chyme produced by the stomach, the acid moves into the esophagus, irritating its mucosal lining and causing gastro-esophageal reflux disease (GERD). The irritation presents as an uncomfortable, perhaps burning sensation in the region of the esophagus, deep to the heart. As a result, this condition is also referred to as heart burn.

Vocal Cord Nodules

Vocal cord nodules result from long-term vocal overuse or abuse. Nodules are typically seen as symmetric raised areas at the anterior aspect of each vocal cord. These occur more often in women, boys, lecturers, coaches, and professional singers. The most common symptom is hoarseness and a persistent raspy voice. Smoking, allergies, and GERD tend to aggravate the condition and can prevent healing. Nodules are always bilateral and classically occur at the junction of the anterior one third and posterior two thirds of the vocal cords (Fig. 19-7). Nodules must be distinguished from polyps, which are smooth and often unilateral, and granulomas, which tend to be located more posteriorly on the vocal cord. Treatment is initially conservative. The patient is referred for voice therapy, which consists of counseling, vocal reeducation, relative voice rest, and psychotherapeutic rehabilitation. Most patients respond after several sessions of voice therapy, but satisfactory improvement can take...

Medical Overview

As discussed previously, pediatric feeding disorders often accompany general medical conditions. For example, feeding disorders are often associated with digestive problems and may suggest a gastrointestinal disorder (Manikam and Perman 2000). Gastrointestinal difficulties can impact feeding on a number of levels, including the intake, retention, digestion, absorption, and elimination of food (Man-ikam and Perman 2000). Ultimately, discomfort and decreased appetite related to digestive problems can lead to food refusal and escape behaviors, which in turn may lead to more severe feeding issues. For example, children with gastroesophageal reflux disease may experience pain or discomfort during or after feedings as a result of esophagitis. This discomfort, coupled with an interruption of normal oral feeding as a result of surgical treatment to address related reflux, increases the likelihood of feeding problems (Linscheid et al. 2003 Mathisen et al. 1999).


In classifying feeding disorders, one important distinction should be noted. The termsfeeding disorder and failure to thrive are often used interchangeably to describe infants and young children who exhibit impaired growth (Chatoor 2002). However, failure to thrive is a purely descriptive term and may not adequately capture the causes of growth failure, because multiple pathways can lead to growth failure (Gold-bloom 1987). Similarly, failure to thrive may result from multiple etiologies (e.g., oral-motor dysfunction, choking, gastroesophageal reflux) however, as Chatoor (2002) argued, not all feeding disorders lead to growth failure, and not every child with growth failure has a feeding disorder. Ultimately, the use of different nomenclature can have a significant impact on both clinical decisions (e.g., identifying evidence-based treatments for feeding problems) and research (e.g., comparing results across studies).

Treatment modalities

Bisphosphonates include alendronate and risedronate, both oral agents, and zolendronic acid and pamidronate, given intravenously. These agents have been shown to be extremely efficacious in high-turnover osteoporosis 43 . Bone turnover is rapidly decreased within 6 weeks with the oral agents and within 3 days with the intravenous drugs. They increase bone mass at all measurable sites and decrease fracture incidence by 50 , including in the spine and the hip 7, 18, 57 . Bisphosphonates' mechanism of action involves interposition between osteoclasts and How-ship's lacunae, thus interfering with resorption. The drug is then ingested by the osteoclast and disrupts cellular membrane synthesis pathways, leading to the osteoclasts' premature death 80 . Reported side effects of oral bis-phosphonates include esophagitis and indigestion, but the once weekly regimen appears to be better tolerated and just as efficacious as daily dosing 65, 38 . Intravenous therapies, while not tested...

Stomach Pain

Chronic use of some medications, particularly some of the NSAIDs, can irritate the stomach and other areas of the gastrointestinal tract or may actually damage the mucous lining of the gastrointestinal system. In this case, medications to treat and prevent ulcers may be used, such as sucralfate, which helps form a coating that helps protect the ulcer from acids of the stomach. Other medications, classically used to treat ulcers or GERD (gastroesophageal reflux disease), a severe form of heartburn, that reduce or eliminate acid production such as Tagamet, Zantac, Aciphex, Prilosec, Prevacid, and Protonix are often considered as well.


Peak bone development occurs throughout adolescence, with smaller bone gain during the 20s and less calcium needed at this age. Bone loss starts with menopause for women, which increases the need for calcium and vitamin D to prevent bone loss. High dietary intake of calcium does not seem to present any risk previous concern about kidney stone formation with increased calcium intake appears to be unfounded (Curhan et al., 1997). Side effects of high calcium supplement intake include constipation and dyspepsia, and calcium supplementation with more than 2000 mg day of vitamin D may lead to soft tissue calcification.


Dosage For therapeutic purposes, chew one fresh clove daily. (For breath purposes, you might want to follow it up with an Altoid, one of those curiously strong mints ) There are also enteric-coated garlic-powder supplements, but note that the supplement should provide at least 5,000 mg of allicin daily. Consumption of large quantities (five or more cloves daily) can result in heartburn, flatulence, and related gastrointestinal problems.


Use Ginger might relieve motion sickness, nausea from morning sickness, and indigestion or an upset stomach. It has an overall calming effect on the digestive system because it increases the secretion of digestive juices, including saliva, neutralizing stomach acids, and toxins.

Oh My Aching Heart

Contrary to the name, heartburn is actually a burning sensation in your lower esophagus that is usually accompanied by a sour taste. Although this dreadful feeling can happen at any time during your pregnancy, it's most common toward the last few months, when your baby is rapidly growing and exerting pressure on your stomach and uterus. What's more, during pregnancy, the valve between your stomach and esophagus can become relaxed, making it easy for the food to occasionally reverse directions. Some simple remedies to ease heartburn Keep a log and track some foods that might be triggering your heartburn. Some common culprits include regular and decaf coffee, colas, spicy foods, greasy fried foods, chocolate, citrus fruits and juices, and tomato-based products.

Antimony and Bismuth

Restricted to gastrointestinal therapy. Since the 1970s, two Bi(III) compounds have been most commonly used worldwide bismuth subsalicylate (BSS) for the prevention and treatment of diarrhea and dyspepsia, and colloidal bismuth subcitrate (CBS Figure 10.16) for the treatment of peptic ulcers. Most ulcers are associated with the bacterium, Helicobacter pylori. In the 1990s, a new Bi(III)-containing drug was developed, ranitidine bismuth citrate (RBC), which combines the antisecretory action of ranitidine with the bactericidal properties of bismuth. Although the use of bismuth containing drugs for years was declining, they are now again becoming increasingly popular as combination pharmaceuticals due to developed antibiotics resistance by H. pylori.


Patients with psychogenic seizures frequently present to neurologists or epilepsy monitoring units having been diagnosed with epilepsy and treated with anticonvulsants. Seizures may be difficult to differentiate from frontal lobe seizures characterized by violent motor activity and sexual automatisms. Malingering and physiological nonepileptic events such as cerebral hypoperfusion, hypoxia, hypoglycemia, electrolyte disturbances, alcohol and drugs effects, migraine, gastroesophageal reflux, parasomnias, and movement disorders including paroxysmal dyskinesias may produce similar symptoms.

Stable Angina

Mpi Myocaridal

Aspirin resistance has been reported recently and can be present in approximately 25 of patients. Also, aspirin hypersensitivity is common and primarily related to GI side effects. Aspirin's side effects (e.g., bleeding, dyspepsia) can be reduced without compromising its effectiveness with the use of enteric-coated aspirin.

Aspiration pneumonia

Pneumonia in stroke patients is most often caused by dysphagia and secondary aspiration. In up to 70 of stroke patients the cough and swallow reflexes are impaired and oropharyngeal or gastric content may gain access to the lungs 37 . In the lungs, bacteria can initiate an infectious process. Major risk factors for aspiration pneumonia are older age, stroke, altered mental state, poor oral hygiene, and gastroesophageal reflux disease (for review see Shige-mitsu and Afshar 38 ).

Clinical History

Obtaining a detailed clinical history is especially important when diagnosing a sleep disturbance because routine physical examination is often not revealing during the waking hours. From the history, age of onset, duration and progression of the sleep complaint, and the general classification of the type of sleep disturbance is usually obtained. The International Classification of Sleep Disorders categorizes sleep disturbances as (1) dyssomnias or disorders that result in insomnia or excessive sleepiness (2) parasomnias or disorders of arousal, partial arousal, or sleep stage transition and (3) sleep disorders associated with medical or psychiatric disorders. The dyssomnias include the intrinsic sleep disorders arising from bodily malfunctions such as psychophysiological insomnia, obstructive and central sleep apnea, restless legs syndrome (RLS), and periodic limb movement disorder (PLMD). Examples of parasomnias include sleep walking, sleep terrors, sleep talking, nightmares, REM...

Daniel Frisbie

Amplitude Setpoint Tapping Mode

Since their invention in the 1980s, STM and AFM have provided scientists with exquisitely detailed snapshots of a wide variety of structural and chemical phenomena occurring on surfaces. The impact of STM on our understanding of surface chemistry and physics was apparent immediately. In 1986, Gerd Binnig and Heinrich Rohrer were awarded the Nobel Prize for their invention of the STM only 5 years earlier. The success of STM and AFM has led to the proliferation of scanning probe technology in all aspects of science and industry. New scanning probe microscopies have been developed that allow high-resolution imaging of a large spectrum of sample characteristics in addition to topography, including frictional properties, local electric and magnetic domains, thermal behavior, optical absorption, fluorescence, and birefringence. SPMs are now valued not just as imaging instruments, but as important analysis and metrology tools for examining a range of material properties on nanometer length...

Helicobacter pylori

A spiral, urease-producing bacterium, Helicobacter pylori is associated with almost 90 of duodenal ulcers. Testing is indicated in patients with either active or previously documented peptic ulcer disease, in the evaluation of dyspepsia who have no alarm features, and for patients with a history of gastric MALT (mucosa-associated lymphoid tissue) lymphoma (MALToma) (Chey and Wong, 2007). Several tests can be performed during endoscopy. Rapid urease testing of a biopsy specimen has sensitivity over 90 and specificity over 95 , with results available within 1 to 24 hours. The sensitivity of rapid urease tests is reduced by drugs that treat Serologic tests for immunoglobulin G (IgG) antibody to H. pylori are helpful in determining previous infection and have sensitivity of approximately 88 but specificity of only 70 to 80 . Even though titers may decline slowly after eradication of the organism with antibiotics, these tests have limited use in evaluation of the effectiveness of...

Esophageal Clearance

Many patients with GERD produce normal amounts of acid, but the acid produced spends too much time in contact with the esophageal mucosa. The contact time is dependent on the rate at which the esophagus clears the noxious material, as well as the frequency of reflux. The esophagus is cleared by primary peristalsis in response to swallowing, or by secondary peristalsis in response to esophageal distention and gravitational effects. Table 17-1 Foods and Medications That May Worsen GERD Symptoms GFRD, gastroesophageal reflux disease LES, lower esophageal sphincter NSAIDs, nonsteroidal anti-inflammatory drugs. Adapted from Williams DB, Schade RR. Gastroesophageal reflux disease. In DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy A Pathophysiologic Approach, 7th ed. New York McGraw-Hill, 2008 556, with permission. Swallowing contributes to esophageal clearance by increasing salivary flow. Saliva contains bicarbonate that buffers the residual gastric material on the surface of...


Laryngomalacia is the most common cause of chronic stri-dor in neonates and is characterized by high-pitched inspira-tory stridor that can be intensified with agitation, feeding, and placement in the supine position. The disorder is caused by immaturity of the laryngeal cartilages and is typically seen on examination as an omega-shaped epiglottis and floppy ary-epiglottic folds that partially obstruct the laryngeal inlet on inspiration. The key to the diagnosis lies in the history and typical findings on flexible fiberoptic laryngoscopy. Airway flu-oroscopy provides a dynamic evaluation of the laryngotracheal complex and often shows a component of tracheomalacia as well (laryngotracheomalacia). Treatment is rarely needed, because the problem is self-limiting and resolves by 18 months of age. Gastroesophageal reflux is extremely common, because the increased pressure gradient needed for adequate ventilation causes an increase in acid reflux into the esophagus. This exacerbates the...

Patient Encounter

Heart Failure Pharmacotherapy

TS is a 78-year-old white female admitted to a hospice program for palliative care. The patient has a primary diagnosis of breast cancer with metastases to the lung and bone. TS has a past medical history that includes chronic heart failure (CHF), hypothyroidism, osteoporosis, and gastroesophageal reflux disease (GERD). She has no known drug allergies. The patient's chief complaint upon admission is pain that is rated 5 on the pain scale (0-10), nausea and vomiting, depression, and constipation. She describes her pain as an aching pain in the areas of her bone metastases. The pain increases with movement. She also has a constant deep pain in her left chest area but it is not as severe. TS is currently bedbound.


The safety and efficacy of orlistat have not been determined beyond 4 years of use. Minimal systemic effects exist because orlistat acts locally in the GI tract. Thus, common side effects reported include oily spotting, flatus with discharge, fecal ur3g9ency, fatty oily stools, oily evacuation, increased defecation, and fecal incontinence.3 Other adverse events include bloating, abdominal pain, dyspepsia, nausea, vomiting, diarrhea, and headache.45


Pharyngitis is an acute throat infection caused by viruses or bacteria. Other conditions, such as gastroesophageal reflux, postnasal drip, or allergies, also can cause sore throat and must be distinguished from infectious causes. Acute pharyngitis is responsible for 1 to 2 of adult physician visits and 6 to 8 of pediatric visits but gen-

Mucosal Resistance

The esophageal mucosa and submucosa consist of mucus-secreting glands that contain bicarbonate. Bicarbonate moving from the blood to the lumen can neutralize acidic refluxate in the esophagus. A decrease in this normal defense mechanism can potentially lead to erosions in the esophagus. When the mucosa is repeatedly exposed to the refluxate in GERD, or if there is a defect in the normal mucosal defenses, hydro-genions diffuse into the mucosa, leading to the cellular acidification and necrosis that ultimately cause esophagitis.4

LES Pressure

Mechanisms by which defective LES pressure may cause gastroesophageal reflux are threefold. First, and probably most important, reflux may occur after spontaneous transient LES relaxations that are not associated with swallowing.5 Esophageal distention, vomiting, belching, and retching can cause relaxation of the LES. These transient relaxations may play an important role in intermittent nonerosive reflux.6 Transient decreases in sphincter pressure are responsible for approximately 65 of the reflux episodes in patients with GERD.

Gastric Emptying

Gastric volume is related to the amount of material ingested, rate of gastric secretion, rate of gastric emptying, and amount and frequency of duodenal reflux into the stomach. Delayed gastric emptying can lead to increased gastric volume and can contribute to reflux. Factors that increase gastric volume and or decrease gastric emptying, such as smoking and high-fat meals, are often associated with gastroesophageal reflux. This partially explains the prevalence of postprandial gastroesophageal reflux.

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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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