Fast Five Quiz: Stress-Related Conditions

George D. Harris, MD, MS


September 26, 2019

Lifestyle modifications are the first line of management in pregnant women with GERD. Lifestyle modifications include the following:

  • Losing weight (if overweight)

  • Avoiding alcohol, chocolate, citrus juice, and tomato-based products (2005 guidelines from the American College of Gastroenterology also suggest avoiding peppermint, coffee, and possibly the onion family)

  • Avoiding large meals

  • Waiting 3 hours after a meal before lying down

  • Elevating the head of the bed by 8 inches

H2-receptor antagonists are the first-line agents for patients with mild to moderate symptoms and grade I-II esophagitis. Options include ranitidine, cimetidine, famotidine, and nizatidine.

PPIs are the most powerful medications available for treating GERD. These agents should be used only when this condition has been objectively documented. They have few adverse effects. However, data have shown that PPIs can interfere with calcium homeostasis and aggravate cardiac conduction defects. Long-term use of these agents has also been associated with bone fractures in postmenopausal women, chronic renal disease, acute renal disease, community-acquired pneumonia, and Clostridium difficile intestinal infection.

Prokinetic agents are somewhat effective, but only in patients with mild symptoms; other patients usually require additional acid-suppressing medications, such as PPIs. Long-term use of prokinetic agents may have serious, even potentially fatal, complications and should be discouraged.

The most commonly performed operation today in both children and adults with GERD is the Nissen fundoplication, which is a 360° transabdominal fundoplication. Indications for fundoplication include the following:

  • Patients with symptoms that are not completely controlled by PPI therapy can be considered for surgery; surgery can also be considered in patients with well-controlled GERD who desire definitive, one-time treatment

  • The presence of Barrett esophagus is an indication for surgery (whether acid suppression improves the outcome or prevents the progression of Barrett esophagus remains unknown, but most authorities recommend complete acid suppression in patients with histologically proven Barrett esophagus)

  • The presence of extraesophageal manifestations of GERD may indicate the need for surgery; these include (1) respiratory manifestations (eg, cough, wheezing, aspiration); (2) ear, nose, and throat manifestations (eg, hoarseness, sore throat, otitis media); and (3) dental manifestations (eg, enamel erosion)

  • Young patients

  • Poor patient compliance with regard to medications

  • Postmenopausal women with osteoporosis

  • Patients with cardiac conduction defects

  • Cost of medical therapy

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