Script BGD

Lifestyle Modifications
-Selective lifestyle changes should be part of the initial management plan and are esp. helpful in those with mild,
intermittent complaints.
 Avoidance of foods that are acidic and reduce LES pressure ( such as fatty foods, coffee and tea) - ( reducing
transient LES relaxations and reduces gastric acid stimulation
 Avoiding bedtime snacks ( this keeps the stomach empty at night, thereby decreasing nocturnal reflux episodes)
 Restricting alcohol and smoking
 Elevating the head of bed (reduces sleep disturbance from nighttime heartburn
 Weight reduction if overweight (this aims to reduce the incidence of reflux by the abdominal stress mechanism
-These maneuvers enhance esophageal acid clearance, decrease acid reflux related events, or ease heartburn symptoms
Pharmacologic Approach (the most clinically effective drugs for short- and long-term reflux treatment are acid
suppressive drugs)
 Inhibitors of Gastric Acid Secretion
 Proton Pump Inhibitors
 PPIs inhibit meal-stimulated and nocturnal acid secretion
 PPIs do not “cure” reflux disease, rather they treat GERD in an indirect way by decreasing the
number of acid reflux episodes.
 S/E:
 chronic acid suppression may be associated with an increased risk of enteric infections
(Clostridium difficile colitis)
 PPIs may affect the absorption of calcium, vitamin B 12, and iron.
 PPIs cause osteoporosis, they may interfere with insoluble calcium absorption or
possibly inhibit the osteoclastic proton transport system, potentially reducing
bone resorption.
 PPIs could retard the absorption of vitamin B 12 by decreasing gastric acidity,

reducing the release of cobalamin from dietary protein, thereby increasing
luminal cobalamin consumption.
 Dietary iron is primarily non-heme iron and requires acid for absorption
 FDA issued a warning regarding the potential for increased adverse

cardiovascular events in patients using PPIs and clopidogrel, especially
omeprazole, lansoprazole, and esomeprazole. The concern arose from the fact
that the antiplatelet activity of clopidogrel requires conversion from a prodrug to
an active metabolite by the CYP2C19 isoenzyme. This is the same pathway
required for metabolism of some PPIs. IT INHIBITS THE ANTI PLATELET EFFECT OF
CLOPIDOGREL
 Histamine 2 Receptor Antagonists
 are more effective in controlling nocturnal than meal-stimulated acid secretion
 * PPI’s superior efficacy compared with H2RAs on the basis of their ability to maintain an intragastric pH
greater than 4 from 10 to 14 hours daily compared with approximately 6 to 8 hours daily with the H2RAs
 * Complete healing of severe ulcerative esophagitis in more than 80% of patients taking PPIs, compared
with 51% on H2RAs
Surgical Intervention
 Laparoscopic Nissen Fundoplication
o Only surgical fundoplication corrects the physiologic factors contributing to GERD and potentially
eliminates the need for long-term medications. Antireflux surgery reduces acid and GER by increasing
basal LES pressure, decreasing tLESRs, and inhibiting complete LES relaxation. This is done by reducing
the hiatal hernia into the abdomen, reconstructing the diaphragmatic hiatus, and reinforcing the LES
Treatment of Esophageal Strictures
 Esophageal Dilation
o Dysphagia in patients with esophageal strictures and rings is related to stricture diameter and severity of
esophagitis. When the esophageal lumen diameter is less than 13 mm, dysphagia is common and
esophageal dilation is required.
Treatment of Barrett’s Esophagus
 Number of medical societies recommend regular endoscopic surveillance for patients with Barrett’s esophagus
 Endoscopic surveillance for Barrett’s esophagus can prevent deaths from esophageal adenocarcinoma seems
reasonable
 Mucosal neoplasms such as high-grade dysplasia and intramucosal carcinoma in Barrett’s esophagus traditionally
were treated with esophagectomy.
 2 general types of endoscopic therapies available for the treatment of Barrett’s esophagus: (1) endoscopic ablative
therapy, which uses heat (delivered by laser, electrocoagulation, argon plasma coagulation, or radiofrequency
energy), cold (cryotherapy) or photochemical energy to destroy the Barrett’s epithelium; and (2) endoscopic
mucosal resection (EMR), in which a diathermic snare or endoscopic knife is used to remove a segment of Barrett’s
epithelium, usually down to the submucosa.
CONCLUSION: Our group considers this case as a case of Benign Esophageal Stricture secondary to GERD because
of the following: the pt is a 60 yr old male with a history of regurgitation of sour material, GERD related chest pain
after eating that was relieved by omeprazole and a hx of dysphagia to solid foods.

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Lifestyle Modifications

 Inhibitors of Gastric Acid Secretion

 Proton Pump Inhibitors

 PPIs inhibit meal-stimulated and nocturnal acid secretion

 PPIs could retard the absorption of vitamin B 12 by decreasing gastric acidity,

 FDA issued a warning regarding the potential for increased adverse

 Histamine 2 Receptor Antagonists

 are more effective in controlling nocturnal than meal-stimulated acid secretion

 Laparoscopic Nissen Fundoplication

Treatment of Esophageal Strictures

Treatment of Barrett’s Esophagus

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