So what is your next step of
management with GERD, GERD, GERD?
Do not change or do not
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.
What does this mean?
Stay away from tobacco.
Do not drink alcohol, and by that because
you’re having a patient that has reflux issues.
Maybe there’s a history of this
going on, quite a bit in fact.
When you go to bed at night, do not remain in a supine
position because that would then facilitate the reflux.
So try to create an angle for yourself
when you’re sleeping so that you
prevent the reflux from taking place,
maybe an angulation of 6 to 8 inches.
Next , when you eat, do
not make this into a race.
So you probably… if you have GERD you probably
not competing with Kobayashi or Kabashi,
forget the individual but anyhow, the hotdog
winner who’s always… you know what I mean?
That’s amazing to me.
I get sick just watching it but anyhow, point being is
do not, do not swallow your food in a
hurried, hurried fashion.
Chew, chew, chew and slowly
get it through esophagus.
Avoid meals that lower lower
esophageal sphincter pressures.
if at all required.
I’ll show you procedure coming up, mean to
say that at some point, if you find that
there is GERD, lifestyle modification,
anti-reflux type of surgery might be indicated.
And pro-kinetic agents, especially
if you’re worried about the reflux
being caused by diabetic neuropathy resulting in gastroparesis.
So that would be the cause of why the reflux is taking
place because you can’t move forward, so therefore
pro-kinetics are just metochlorpramide, would then assist
you and maybe perhaps even correct the GERD issues.
Reduction of the reflux is the
objective for this section.
Reduction of acid: In the first steps of management,
you do everything in your power to reduce the reflux.
Number two, along with it, beyond the lifestyle modification,
this doesn’t seem to be working or it’s not effective enough.
Then you become a little
bit more aggressive.
The histamine blocker that you’re going to use here
will be an H2 blocker, part of ranitidine, cimetidine.
These are H2 blockers so that you prevent hopefully
some of this acid from being secreted into the stomach.
Needs at least 6 weeks of therapy.
PPIs would be even better - Proton Pump Inhibitor;
and by that you should be thinking about the parietal cell,
in the fundus or the body, you’re thinking about
the apical luminal membrane which is facing the lumen.
On that membrane, you have what’s
known as a hydrogen-potassium pump.
So that’s the pump that PPIs - Prevacid,
Prilosec, Nexium (the purple pill).
Now it… all of this is available
over the counter isn’t it?
But it takes a little bit of time for it to work, but
PPIs in fact are better acid regulators than are H2 blockers.
Once you get through
Once you start getting past your medication, mean to say that
all of this doesn’t seem to truly be effective for your patient.
And your patient is still exhibiting symptoms
of GERD, then you’ll have to do surgery.
On your left, before surgery,
reflux taking place.
On the right, after surgery, you’ll notice here
that there is ligation taking place in which
literally you secure the distal esophagus so
that you do not have reflux taking place.
So there are many mo-… many, many, many
ways in which we could properly regulate
and control our reflux but it begins with
reflux control with lifestyle modification.