Prof_Marcos A. power point and narrated document see rubric

Hello my name is Blah blah blah and I will be presenting the clinical practice guideline on the diagnosis and management of Gastroesophageal reflux disease also known as GERD.

Disease and Background

Incidence: GERD can occur at any age, but the incidence increases after age 50 and common in older adults (Dunphy, Winland-Brown, Porter, & Thomas, 2011). In 2005, the incidence of GERD was approximately 5 per 1000 persons-years in the overall US populations (El-Serag, Sweet, Winchester & Dent, 2014).

Prevalence: Epidemiologic estimates of the prevalence of GERD are based primarily on the typical symptoms of heartburn and regurgitation (Katz, Gerson, & Vela, 2013). The prevalence is increasing worldwide and it is the most prevalent gastrointestinal disorder in the United States.

The prevalence of GERD ranged from 18.1-27.8% of the population of North America. Research suggests that Caucasians patients tend to have more severe manifestations and complications (Dalbir, & Fass, 2018).

Pathophysiology: Esophageal reflux occurs when the gastric volume or the intra-abdominal pressure is elevated. It can also occur when the sphincter tone of the lower esophageal sphincter (LES) is decreased or when the LES undergoes inappropriate relaxation. Gravity, saliva, and peristalsis work together to return refluxed content back to the stomach (Dunphy, Winland-Brown, Porter, & Thomas, 2011). With repeated exposure to gastric acid, the esophagus and esophageal mucosa becomes inflamed and irritated causing an inflammatory response. The esophagus then cannot eliminate the refluxed material causing a prolonged exposure of gastric content to the esophageal mucosa (Dunphy, Winland-Brown, Porter, & Thomas, 2011). 

Clinical Presentation:

Subjective: The most typical symptom of GERD is heartburn, ranging from mild to severe and regurgitation. Other associated symptoms include water brash (reflux salivation), dysphagia, sour taste in the mouth in the morning, odynophagia, belching, coughing, hoarseness, and wheezing that usually occurs at night (Dunphy, Winland-Brown, Porter, & Thomas, 2011). Chest pain in the retrosternal or substernal area may also occur, which will then need further evaluation to rule out cardiac origin. Factors that usually make symptoms worse include reclining after eating, eating a large meal, alcohol, chocolate caffeine, nicotine, fatty food, and spicy food ingestion, wearing constrictive clothing, heavy lifting, straining, or working in a bent over position is involved to help determine a diagnosis of GERD (Dunphy, Winland-Brown, Porter, & Thomas, 2011). 

Objective: The physical exam is usually normal for patients with GERD. The only sign may be a stool positive for occult blood on a rectal exam resulting from microhemmorrhages in the irritated esophageal epithelium (Dunphy, Winland-Brown, Porter, & Thomas, 2011).

Publication and Applicability in Primary Care

The evidenced based clinical practice guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease from the American Journal of Gastroenterology was developed by the American College of Gastroenterology and released in March of 2013 with no revisions. The authors are Katz, P. O., Gerson, L. B., and Vela, M. F. The organization or group that developed the clinical practice guidelines is the Nature Publishing Group. These clinical practice guidelines is applicable to primary care in order to properly diagnosis and manage GERD and reduce related complications such as erosive esophagitis, stricture, and Barrett’s esophagus (Katz, Gerson, & Vela, 2013).

Key Action Statements & Body of Evidence

5 recommendations applicable in primary care are:

1. A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation and are the most reliable for making a presumptive diagnosis based on history alone. Empiric medical therapy with a PPI is the recommended approach to confirm GERD when it is suspected in patients with typical symptoms. This is a strong recommendation, moderate level of evidence (Katz, Gerson, & Vela, 2013).

2. A cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation. Non-cardiac chest pain is and associated symptom with the presence of GERD, therefore, cardiac etiology should be ruled out. This is a strong recommendation, moderate level of evidence (Katz, Gerson, & Vela, 2013).

3. Weight loss is recommended for GERD patients who are overweight or have had recent weight gain. This is a conditional recommendation, moderate level of evidence. GERD and obesity have a definite correlation with body mass index, waist circumference, and weight gain (Katz, Gerson, & Vela, 2013). Weight gain with a normal BMI has been associated with new onset of GERD symptoms. It has been shown that there has been a reduction in GERD symptoms with weight loss (Katz, Gerson, & Vela, 2013).

4. Barium radiographs should not be preformed to diagnose GERD. Although barium radiographs detect esophagitis, the sensitivity of this test is very low and is not recommended as a diagnostic test without dysphagia. This is a strong recommendation, high level of evidence (Katz, Gerson, & Vela, 2013).

5. Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications (Katz, Gerson, & Vela, 2013). The vast majority of patients with heartburn and regurgitation will not have erosions limiting upper endoscopy as an initial diagnosis test for patients with suspected GERD. (Katz, Gerson, & Vela, 2013). This is a strong recommendation, moderate level of evidence.

These statements are applicable to primary care in which present key evidence supporting the recommendations.

Application in Clinical Rotation

W.S. is a 57-year-old Caucasian obese female who came in on 10/11/18 with chief complaint of intermittent epigastric pain and heartburn x 2 weeks. It progressively worsens after eating, smoking, and drinking coffee. Standing up helps. She tried OTC Tums, which temporarily relieved the discomfort. Discomfort is 4/10 now after eating breakfast and 8/10 at worse.

W.S has a past medical history of HTN. She takes lisinpril 10 mg PO daily for hypertension. She has no past surgical history. No allergies. She is married with 2 grown kids and works full time. She states she is not very active and does not engage in much physical activity or daily exercise due to her busy schedule. She states she occasionally smokes cigarettes but is trying to quit completely and drinks alcohol occasionally.

She is 5’6” and weights 180 lbs which considers her overweight with a BMI of 29.05. BP 135/65, HR 70, T 36.5, R 18. Abdomen soft, nontender, BS active. Otherwise, normal physical exam.

The patient was diagnosed based on the presenting symptom of heartburn, weight, lifestyle, and aggravating factors. The patient was prescribed to take omeprazole 20 mg PO daily and follow up in 2 weeks. Treatment was based on familiarity and it being an over the counter medication. Comparing these actions to the CPG guidelines, Proton pump inhibitors (PPI’s) are considered the most effective medical treatment for GERD. There are seven proton pump inhibitors (PPI’s). Four are over the counter, omeprazole, lansoprazole, esomeprazole, and omeprazole-sodium bicarbonate. Rabeprazole, pantoprazole, and dexlansoprazole are available only by prescription (Dalbir, & Fass, 2018). Esomeprazole showed an 8% increase in probability of GERD symptom relief at 4 weeks of taking (Katz, Gerson, & Vela, 2013). A meta-analysis of these concluded that the newer PPI’s were similar in efficacy in terms of heartburn control, healing esophageal erosions and the relapse rates of GERD (Dalbir, & Fass, 2018).

The patient was educated on importance of healthy diet, daily exercise, and weight management. According to the CPG guidelines, weight loss is recommended for GERD patients who are overweight or have had recent weight gain in order to reduce the symptoms of GERD (Katz, Gerson, & Vela, 2013).

Reference

Dalbir, S. S., & Fass, R. (2018). Current trends in the management of gastroesophageal reflux disease. Gut and Liver 12(1), 7-16.

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis Company.

El-Serag, H. B., Sweet, S., Winchester, C. C., & Dent, J. (2014). Update on the epidemiology of gastro-oesophageal reflux disease: A systemic review. Gut 63(6), 871-880.

Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology, 108(3), 308-328.