Treatment. So what is your next step of management
with GERD, GERD, GERD? Do not change or do not
administer medication. That is not your first step.
Conservatively you check to see, in the stem of a
question, in your vignette and with your patient,
as to whether or not they have already started to
implement lifestyle modifications. You want to try
to avoid those agents that would further relax
your lower esophagal sphincter. In a condition
where that is indeed the pathology. For example,
avoiding tobacco and alcohol. When going to bed at
night, you'd recommend to keep the head elevated
by approximately 6 to 8 inches so that you prevent
reflux from taking place. Same concept in terms of meals.
When the stomach is full, you do not want to lie
down immediately for the fact that you may then facilitate
reflux. Avoiding meds that lower, lower esophageal
sphincter pressure. Anti-reflux surgery/endoscopic devices
should be avoided if at all possible in a patient
suffering from GERD. And pro-kinetic agents useful for
gastroparesis may also be avoided in a patient with
GERD. After lifestyle modifications, if we start getting into
realm of, well more moderate type of symptoms of
GERD, then you start thinking about using H2 blockers.
H2 blockers include drugs such as ranitidine, famotidine.
And then PPIs would be if the symptoms of the patient
were much more severe. Proton pump inhibitors. Need
at least 6 weeks of therapy to find any type of
decrease in the symptoms of the patient. Let's say
that we have refractory cases and you have gone through
the hierarchy of management of GERD; Including the
fact that, once again, remember we start with
lifestyle modifications. Next, start using H2 blockers
if the severity is increasing. And if it's
much more severe, it's frequent, and you are even
worried about erosion and such, then you start
thinking about using PPI. And don't forget that it
may, especially in the antral region of the stomach
you might have H. pylori that's involved and
therefore giving rise to something called gastritis.
Chronic type b. Chronic type b type of gastritis.
Therefore at that point H. pylori eradication
would be recommended. Surgically, what you want to
do is, if the lower esophageal sphincter is not
responding, you'll take the fundus of the stomach;
But before the surgery you'll notice that
everthing is weak here. And then you'll take the
fundus of the stomach and then you will wrap this around
the lower esophageal sphincter. In other words, you're
making this much more tight. And you're making it
much more difficult for reflux from taking place.
Not only would you then take the fundus of the stomach
and wrap it around it to tighten, or in other words
create a sphincter surgically. But then you would go
back and re-estimate the actual lower esophageal
sphincter to make sure that everything is in proper order
to prevent reflux from taking place.
So there are many, many, many, many ways in which
we could properly regulate and control our reflux
but it begins with reflux control
with lifestyle modification.