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Heartburn and Acid Reflux Cure Program Overview

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Heartburn Nausea and Constipation

During pregnancy, high progesterone levels relax muscular tone and slow down peristalsis in the digestive tract.14 This can be beneficial in that slower food transit times allow for increased nutrient absorption from foods. Absorption efficiency of iron, calcium, and vitamin B12 increases during pregnancy. However, reduced muscle tone can also cause problems. In the lower esophagus, it allows gastric reflux, causing irritation and discomfort (heartburn). Reflux can be minimized by eating multiple small meals. Meals should not be eaten immediately prior to physical activity or exercise. Also, because reflux is usually worse when lying down, elevating the head of the bed and not eating or drinking within 3 hours of bedtime can be helpful.14

Hiatal Hernia And Gastroesophageal Reflux

Diaphragm Crura

The overall management of patients who present with dysphagia or heartburn must include, of course, a cardiovascular history and examination since the suspicion of ischemic cardiac disease or other myocardial dysfunction must always be in mind. The esophageal problems that may result in dysphagia or heartburn can include carcinoma, gastroesophageal reflux or motility disorders (including achalasia or diffuse esophageal spasm). The preoperative evaluation of patients who present with suspected esophageal motility disease or gastroesophageal reflux should always include esophagoscopy (with biopsy if necessary) a 24-hour pH probe study and manometry. An upper GI study may be helpful on occasion, The 24-hour pH probe monitor determines with high sensitivity and specificity the presence of gastroesophageal reflux. This is much more difficult to evaluate using the upper GI barium swallow. An upper GI barium swallow which reveals a hiatal hernia is not at all synonymous with gastroesophageal...

Dyspepsia

Dyspepsia is not a condition, but rather a set of symptoms of which upper abdominal pain or discomfort is the predominant complaint. In cross-sectional surveys, the prevalence of dyspepsia (3,14,23-26) has ranged from 3 to 44 . Why this large variation The first consideration is whether the study included the symptom of heartburn in the definition of dyspepsia. Heartburn is experienced by 20 of the population weekly and 40 annually (27). There is significant overlap between upper abdominal symptoms and heartburn (23,27), and clinical studies have shown that many people with dyspepsia have reflux even in the absence of heartburn (28). If heartburn is ignored, the surveys suggest that 15 to 20 of the population experience dyspepsia over the course of a year. The second issue is whether patients who have symptoms of IBS in addition to their symptoms of dyspepsia are included. Approximately 30 of people with dyspepsia will also report IBS symptoms (3). Exclusion of people with IBS will...

Nonulcer Dyspepsia

Many patients with nonulcer dyspepsia have abnormalities of gastric emptying and increased pain perception in the gastrointestinal tract, suggesting that the condition is part of the spectrum of irritable bowel syndrome (see Chapter 32). Patients with predominant epigastric pain or reflux symptoms may improve with simple antacids taken as needed. More severe symptoms may require antisecretory drugs, particularly a proton pump inhibitor, although the response rate is lower (40-50 ) than in patients with documented pathology. Where the main symptom is bloating, a prokinetic agent (metoclopramide or domperidone, see below) is preferred. The incidence of Helicobacter pylori colonisation in patients with nonulcer dyspepsia is not significantly different from that in the general population and eradication of the organism provides, at best, only one-quarter of patients with prolonged symptomatic improvement (a proportion that is similar to the placebo response for this condition).

Noncardiac Chest Pain Functional Chest Pain

Noncardiac chest pain (NCCP) is defined by the absence of significant stenoses in the major epicardial coronary arteries. Each year, about 450,000 people with chest pain have normal coronary angiograms (35). Despite the high number of people suffering from NCCP, little is known about the epidemiology or natural history of chest pain in the community. Moreover, little population-based data have been published to date that help characterize NCCP in the community. The prevalence of NCCP has been estimated to be 23 based on self-report only (27). The prevalence in the community is similar by gender (25,27,36) but a higher female-tomale ratio is seen in tertiary care referral centers (37). It has been observed that there is significant overlap between NCCP and frequent gastroesophageal reflux symptoms.

Abdominal Pain for Life

Dyspepsia and dyspepsia subgroups a population-based study. Gastroenterology 1992 102(4 Pt 1) 1259. 16. Agreus L et al. Irritable bowel syndrome and dyspepsia in the general population overlap and lack of stability over time. Gastroenterology 1995 109 671. 23. Jones R et al. Dyspepsia in England and Scotland. Gut 1990 31(4) 401. 26. Kay L, Jorgensen T. Epidemiology of upper dyspepsia in a random population. Scand J Gastroenterol 1994 29 1. 27. Locke GR III et al. Prevalence and clinical spectrum of gastroesophageal reflux a population-based study in Olmsted County, Minnesota. Gastroenterology 1997 112 1448. 28. Klauser A et al. What is behind dyspepsia . Dig Dis Sci 1993 38(1) 147. 29. Bytzer P, Hansen J, Schaffalitzky de Muckadell O. Empirical H2-blocker therapy or prompt endos-copy in management of dyspepsia. Lancet 1994 343 811. 30. Castillo J et al. Overlap of IBS and dyspepsia how much is explained by upper abdominal pain associated with bowel habit ....

Peripheral Sensitization And Visceral Pain Syndromes

The current understanding of mechanisms of peripheral sensitization is largely derived from studies examining the effects of injury or inflammation on visceral afferents. Most patients with chronic visceral pain, such as irritable bowel syndrome, nonulcer dyspepsia or interstitial cystitis, do not have signs of inflammation, raising questions about the relevance of these findings. While the definition of such functional diseases excludes active inflammation, up

Helicobacter Pylori H Pylori

An increased incidence of GERD has been linked to the decrease in H. pylori infection produced by the current trend of eradication therapy. H. pylori may have a protective role by either reducing achlorhydria induced by PPIs or by increasing the activity of PPIs by increasing the formation of the active metab

Silent Myocardial Infarction Woman at Risk

At the same time as Joe is being evaluated in the ED, Lindsey Walters, a 62-year-old woman from Dr. Jordan's office, enters the ED by ambulance. Her husband says she fell down some stairs at their home and injured her right leg. He also reveals that Lindsey had some chest pain and discomfort in her left arm a couple of days ago, but did not let him call her physician. She thought she might have some indigestion and so brushed away her husband's concerns. The ED team taking care of Lindsey finds her semiconscious but responsive to their questions. They order a chemistry metabolic profile, a CBC, and right leg x-rays to determine what may be wrong with Lindsey. The treating physician also requests cardiac markers on Lindsey.

Diagnosis And Staging Of Gastric Malt Lymphoma

The most common presenting symptoms of gastric MALT lymphoma are dyspepsia, epigastric pain, nausea, and chronic manifestations of GI bleeding, such as anemia. The upper GI complaints often lead to an endoscopy that usually reveals nonspecific gastritis or peptic ulcer with mass lesions being unusual.41

Variability In The Development Of Sensitized States

To determine whether peripheral sensitization and central sensitization can occur in healthy human viscera in response to injury inflammation, a model was developed which has demonstrated that acid infusion localized to the distal esophagus can reduce subsequent pain thresholds to electrical stimulation at the site of the infusion compared to preacid baseline levels. After the acid infusion, a previously nonpainful stimulus is reported as painful demonstrating hypersensitivity at the site of infusion (93). This hypersensitivity is likely to be due to peripheral sensitization. Although continuous pH monitoring demonstrates no acid reflux into the proximal esophagus, a similar reduction in pain thresholds to electrical stimulation can be demonstrated at this site. This secondary hypersensitivity is believed to occur through the sensitization of spinal neurons (central sensitization), and indeed further work in our department has shown that this secondary esophageal hypersensitivity can...

Evidence for Genotypic Influences

Apart from abnormalities in reuptake transporters as described above, a role for underlying second messenger abnormalities has also been proposed. Holtmann et al. reported the association of functional dyspepsia with specific G-protein P3 subunit genotypes (142). G-pro-teins are heterotrimeric second messenger proteins that are essential in mediating cellular responses by coupling extracellular receptor activation to intracellular effector systems such as adenylcyclases and protein kinases (143). Approximately 80 of all known membrane receptors transduce their signals via heterotrimeric G-proteins. G-proteins are composed of different a, P, and y subunit isoforms, the P-y subunit forming a functional monomer. On receptor activation, both a and P-y subunits dissociate from the receptor to then modulate a variety of intracellular effector systems. Dysfunction of these important second messenger systems could therefore alter intracellular signal transduction (142). A common C825T...

Approach To Peptic Ulcer Disease Definitions

Dyspepsia Pain or discomfort centered in the upper abdomen (mainly in or around the midline), which can be associated with fullness, early satiety, bloating, or nausea. Dyspepsia can be intermittent or continuous, and it may or may not be related to meals. Functional (nonulcer) dyspepsia Symptoms as described for dyspepsia, persisting for at least 12 weeks but without evidence of ulcer on endoscopy. Dyspepsia refers to upper abdominal pain or discomfort that can be caused by PUD. but it also can be produced by a number of other gastrointestinal disorders. Gastroesophageal reflux typically produces heartburn. or burning epigastric or midchest pain, usually occurring after meals and worsening with recumbency. Biliary colic caused by gallstones typically has acute onset of severe pain located in the right upper quadrant or epigastrium, usually is precipitated by meals, especially fatty foods, lasts 30-60 minutes with spontaneous resolution, and is more common in women. Irritable bowel...

Reversible Proton Pump Inhibitors

A tetrahydroisoqunoline-based compound, YH-1885, discovered by Yuhan, is currently one of the most clinically advanced reversible proton-pump inhibitors (170). It is now being codeveloped with GlaxoSmithKline for stomach ulcers and gastroesophageal reflux disease. Clinical data on YH-1885 have demonstrated that it is safe and well tolerated when administered as a single dose (60 to 300 mg) or multiple doses (150 to 300 mg) to healthy volunteers. The compound significantly increased gastric pH and increased the fraction of time above pH 3 at doses above 150 mg. During multiple dosing, YH-1885 exhibited a reversible mode of action with no significant

Why Women And Men Experience Different Risk For Heart Attacks

It has only been through recent research that the effect of lowered estrogen levels in postmenopausal women with coronary artery disease has become evident. Previously risk of heart attacks was not studied in women because it was not considered a common event. Also, there currently is evidence that women do not express the same physical symptoms of a heart attack as do men. Women may have a silent heart attack in which they feel milder and less specific chest pain than men. Women having heart attacks complain of indigestion, abdominal pain, even lower back pain. These are not the characteristic midchest pain and pain radiating up the left arm and neck that are common in men. Because of the difference in or milder symptoms, women tend to ignore the possibility that they are having a heart attack.

Evidence for Autonomic Nervous System Dysfunction

A number of studies have addressed the role of the ANS in modulating visceral perception in FGD. Chen and Orr demonstrated enhanced sympathetic dominance to esophageal acid infusion in patients with gastroesophageal reflux disease (GERD), which appeared to be secondary to decreased vagal tone in these subjects (121). During acid infusion, there was a significant decrease in LF band power (a measure of sympathetic tone) in the control group, which was unchanged in the patient group, whereas the HF band power (a measure of vagal tone) was lower during all the infusion periods in the GERD group. The findings suggest the autonomic effects of acid infusion are different between healthy subjects and GERD patients. Indeed, the between-group comparisons did reveal a significant group difference during acid infusion, with GERD patients demonstrating a significantly larger LF HF ratio compared with controls (p < 0.05). The healthy controls who had heartburn with acid infusion did not have a...

Visceral Hypersensitivity

Although FGD patients show marked heterogeneity in their clinical presentation and response to treatment, common features have become apparent, as our knowledge of these disorders has increased. It was documented over 30 years ago by Ritchie that recto-sigmoid balloon distension was perceived as painful at lower volumes in IBS patients than in controls (3). This heightened pain sensitivity to experimental gut stimulation, a phenomenon known as visceral hypersensitivity, has been repeatedly demonstrated in patients with FGD. For instance, hyper-sensitivity to intraesophageal balloon distension has been reported in patients with NCCP as compared to controls, which was independent of esophageal tone and motility (4). In addition, hypersensitivity to intragastric balloon distension has been demonstrated in patients with functional dyspepsia as compared to controls, with them reporting higher scores for nausea, bloating, and pain (5). This visceral hypersensitivity does not appear to be...

Topography of the Sensory Dysfunction

Several studies have attempted to define the regions of the gut and the specific pathways affected in different subsets of patients, and there seems to be a region specificity (6). Increased gastric but normal duodenal sensitivity was shown in a specific subset of patients with motility-like dyspepsia predominantly complaining of postcibal bloating (48). In this study, dyspeptic patients invariably recognized that gastric distension, but not duodenal distension, reproduced their customary symptoms, whereas in healthy subjects both stimuli were perceived alike.

Interaction of Sensory and Reflex Dysfunctions

The cause of the concomitant dysfunction of sensory and reflex pathways is not clear, both predisposing and triggering factors may be involved, acting at peripheral and central levels. Potential causes include genetic and early life influences, enteric infection and inflammation, alterations in enteric flora, dietary factors and food intolerance, autonomic dysfunctions, psychosocial stress, and other cognitive factors. In any case, altered reflex activity and altered conscious perception of gut stimuli may combine to different degree in patients with various functional gut syndromes, and their interaction may explain the origin of clinical symptoms. These aspects will be discussed in detail in Section IV, but following are two pathophysiolo-gical models in relation to functional dyspepsia and IBS. Normally, ingestion of a meal induces a relaxation of the proximal stomach to accommodate the meal volume, and the magnitude of the relaxation is regulated by a complex net of reflexes...

Psychophysical Studies Of Visceral Sensation

Psychophysical studies have demonstrated evidence of hypersensitivity to visceral stimuli in virtually all clinically relevant visceral pain disorders. This includes hypersensitivity to gastric distension in patients with functional dyspepsia (21), intestinal and rectal distension in patients with irritable bowel syndrome (7,22), biliary and or pancreatic duct distension in patients with postcholecystectomy syndrome or chronic pancreatitis (23), and bladder distension in patients with interstitial cystitis (17). In all cases, pain and or discomfort were experienced at intensities of stimulation lower than required to produce the same quality and intensity of sensation in a healthy population. It is notable that in many cases, the hyper-sensitivity was limited to the particular organ system being studied. An example of this was reported by Aspiroz (24), who observed hypersensitivity to gastric distension but normal sensitivity in the duodenum and upon cutaneous testing in subjects with...

The Gastrointestinal Tract

Pain Intestine And Bladder Fistula

How is your appetite is a good starting question and may lead into other important areas such as indigestion, nausea, vomiting, and anorexia. Patients often complain of indigestion, a common complaint that refers to distress associated with eating, but patients use the term for many different symptoms. Find out just what your patient means. Possibilities include Heartburn, or a sense of burning or warmth that is retrosternal and may radiate from the epigastrium to the neck. It usually originates in the esophagus. If persistent, especially in the epigastric area, it may raise the question of heart disease. Some patients with coronary artery disease describe their pain as burning, like indigestion. Pay special attention to what brings on the discomfort and what relieves it. Is it precipitated by exertion and relieved by rest, suggesting angina, or is it related to meals and made worse during or after eating, suggesting gastroesophageal reflux Heartburn suggests gastric acid reflux into...

Drug Induced Ventricular Arrhythmias

Astemizole, and cisapride) because their risk for triggering lethal arrhythmias was believed to outweigh therapeutic benefits (Walker et al. 1999). A number of histamine receptor-blocking drugs, including astemizole and terfenadine and more recently loratadine, have been shown to block IKr as an adverse side effect and prolong the Q-T interval of the electrocardiogram (Crumb 2000). Cisapride (Propulsid), a widely used gastrointestinal prokinetic agent in the treatment of gastroesophageal reflux disease and gastroparesis, also blocks KCNH2 K+ channels and is associated with acquired LQTS and ventricular arrhythmias (Wysowski and Bacsanyi 1996). Cisapride produces a preferential prolongation of the APD of M cells, leading to the development of a large dispersion of APD between the M cell and epi endocardium (Di Diego et al. 2003 Fig. 4). Changes in the morphology of the T wave were observed in more than 85 of patients treated for psychosis when the plasma concentration of the...

Visceral Hypersensitivity Historical Background

Some reports in the 1970s described disturbances of gut perception in patients with the irritable bowel and related syndromes, but these studies remained largely ignored. These classic observations were later reconfirmed and expanded, clearly showing a colonic and rectal hypersensitivity in these patients. Further studies tested whether symptoms after meal ingestion in patients with functional dyspepsia were due to a sort of gastric rigidity, that is, to altered compliance and an abnormal response of the stomach to distension. Gastric accommodation to a meal was experimentally reproduced by distending the stomach with an air-filled bag, either with fixed volumes or at fixed pressure levels maintained by a barostat. With both the methods, the results were equivalent. Gastric distension studies showed that the pressure-volume relationship, that is, compliance, was normal. However, the patients developed their customary symptoms at distending levels that were largely unperceived by...

Clinical Presentation Based On Severity Of Pain And Implications For Treatment

Patients with chronic abdominal and visceral pain can fall under a variety of diagnostic syndromes and categories. This may include longstanding structural diagnoses such as chronic pancreatitis, a variety of functional GI diagnoses (e.g., IBS, functional chest pain or dyspepsia, functional biliary pain, levator syndrome, etc.), or combinations (e.g., inflammatory bowel disease (IBD) with IBS). In this chapter, the proposition is that, independent of diagnosis, the nature and severity of the pain as well as clinical decisions regarding treatment will depend on integrating the relative contributions of the peripheral and central determinants that affect the nature and severity of the pain and its psychosocial concomitants.

History and Examination

Dyspepsia symptoms are common and there is significant overlap between the symptoms of PUD. GERD. and functional dyspepsia. Patients with symptoms primarily of heartburn or acid regurgitation are more likely to have GERD. Classic symptoms associated with PUD include epigastric abdominal pain that is improved with the ingestion of food, or pain that develops a few hours after eating. Nocturnal symptoms are also common with PUD. The symptoms are often gradual in onset and present for weeks or months. Patients often self-medicate with over-the-counter antacid medications, which usually provide some relief, prior to presenting to the physician. Dyspepsia in patients younger than age 55 years with no alarm symptoms can be managed with a noninvasive H. pylori test-and-treaf protocol. A test for an active H. pylori infection (urea breath test, presence of . pylori antigens in stool) should be performed. If positive, treatment to eradicate the infection, along with a PPI to suppress acid...

Bile Salt Malabsorption

This condition affects 20 of the population and is the commonest reason for referral to a gastroenterologist. It is manifested by a variety of gastrointestinal symptoms including disordered bowel habit (constipation, diarrhoea or both), abdominal pain and bloating. Upper gastrointestinal symptoms manifest as nonulcer dyspepsia (see Chapter 31). All these symptoms occur in the absence of demonstrable pathology in the gastrointestinal tract, although patients with IBS often have abnormalities of gut motility. Another feature of the condition is visceral hypersensitivity patients with IBS have lower thresholds for pain from colonic distension induced by inflating balloons placed in the bowel. A proportion of patients develop their IBS symptoms after an episode of gastroenteritis and in many emotional stress is an important precipitating factor. Associated psychopathology, with anxiety and sometimes depression, are common.

Visceral Pain Therapy Current And Future

The current treatment of visceral pain associated, for instance, with functional bowel disorders (FBDs) such as functional dyspepsia and irritable bowel syndrome (IBS) is unsatisfactory. Therapeutic advances are badly needed in view of the high prevalence of chronic or recurrent visceral pain and its socioeconomic burden as outlined in Chapters I 1 and I 2. This gap in the pharmacologic management of visceral pain reflects the incomplete understanding of the underlying mechanisms, which lags behind the knowledge of somatic pain mechanisms. In addition, the utility of nonsteroidal anti-inflammatory drugs and opiates, which are the mainstay in somatic pain management, is limited by their severe adverse effects on gastrointestinal (GI) mucosal homeostasis and motility, respectively. Although progress in the use of opioid and nonopioid drugs for the treatment of abdominal pain is being made (see Chapters III 18 and III 19), there is clearly a need to identify new targets for visceral pain...

Hydroxytryptamine Receptors

In terms of drug development, 5-HT3 and 5-HT4 receptors have been in the focus of interest, because their pharmacologic manipulation may correct both the functional disturbances in the gut and the pain associated with FBDs (12). This is particularly true for 5-HT3 receptors, which are present on vagal afferent neurons originating in the nodose ganglia, spinal afferents originating in the DRG, enteric neurons, and other cells of the gut. 5-HT-evoked excitation of extrinsic sensory neurons is primarily mediated by 5-HT3 receptors (10,12,18). Antagonism of 5-HT3 receptor-mediated stimulation of vagal afferents inhibits emesis induced by release of 5-HT from enterochromaffin cells (10), and blockade of 5-HT3 receptor-mediated activation of spinal afferents by alosetron depresses the afferent signaling of colorectal distension in the rat (19). Accordingly, alosetron has been found to reduce the discomfort and pain in female patients suffering from functional dyspepsia or...

Cholecystokinin CCK1 Receptors

Dyspepsia, since the CCK receptor antagonist dexloxiglumide attenuates the meal-like fullness and nausea associated with intraduodenal lipid administration during gastric distension of normal volunteers and dyspeptic patients (31). Since in IBS patients CCK causes exaggerated intestinal motor responses and abdominal pain (32,33) and intestinal infection and inflammation causes upregulation of the CCK system (34,35), it is thought that CCK1 receptor antagonists may also be beneficial in IBS (36).

Historical Context

Cancer is a leading cause of death in Americans, second only to heart disease. While breast cancer kills the most women, many gynecological cancers are part of the overall cancer statistic. Ovarian cancer, the so-called whispering disease because of its insidious nature, is detected in one in 70 predominantly perimenopausal and postmenopausal American women and often metastasizes undetected. Risk factors include family history of ovarian and breast cancer, high dietary fat, delayed menopause, and no or late childbearing. The use of oral contraceptives appears to decrease risk. Ovarian cancer often presents itself with a cluster of three persistent and severe symptoms a swollen abdomen, a bloated feeling, and urgent urination. Other symptoms associated with the disease include gas pains, anorexia, backache, and indigestion. Unfortunately most women seek medical advice when their ovarian cancer is in the advanced stage because the symptoms might be associated with other gynecological...

Abdominal aortic surgery

The incidence of adverse events was similar for the two treatment groups, although rashes were more common in the HBOC-201-treated patients (P< 0.1). The majority (14 17) of patients who experienced a rash were from one study center and required no treatment. Although asymptomatic, the areas of skin where the rash appeared were delineated by a particular adhesive film used to cover the operative field. Adverse reactions that were more common (P< 0.1) in the RBC group included postural hypotension, vesiculobullous rash, dyspepsia, ketosis, monocytosis, hypesthe-sia, confusion and abnormal mentation. Laboratory abnormalities (including creatinine) were similar in both treatment groups except for serum urea nitrogen, which was increased significantly in the HB0C-201 treatment group and thought to be the result of the high protein load. Small increases (approximately 10mmHg) in mean systolic blood pressure occurred in the HB0C-201-treated patients only after the first treatment....

Section Iv Clinical Syndromes Pathophysiology Diagnosis And Management

Pathophysiology of Functional Dyspepsia 399 Jan Tack Dyspepsia Symptom Pattern 399 Subgroups of Functional Dyspepsia Patients 399 Pathogenesis of Functional Dyspepsia 401 Dyspepsia Clinical Features and Management 404 Nimish Vakil Definitions . . . . 404 Prevalence . . . . 405 RAP - Functional Abdominal Pain and Irritable Bowel Syndrome 438 Functional Dyspepsia . . . . 447 Summary . . . . 448 References . . . . 448

Physical Examination Multiple Choice

A 68-year-old homemaker presents to your clinic complaining of difficulty swallowing. It began several months ago when she would attempt to eat steak. Over time, it has progressed to the point that she can only sip on soups and broths. She has sometimes had to regurgitate her food back up to get relief from the pain in her chest when she attempts to eat. Her past medical history is significant for diet controlled, type-2 diabetes. She had a 60-pack-year smoking history but quit smoking 15 years ago. She denies any drug or alcohol abuse. On review of systems, she has lost approximately 15 lbs in the past 3 months. She denies any heartburn, constipation, or diarrhea. On exam, you find a pleasant elderly woman in no acute distress. Her cardiac, pulmonary, and abdominal exams are all normal. What disorder of dysphagia is the most likely cause for her symptoms

Sensory Neurons And Gi Hypersensitivity

Studies of the possible mechanisms underlying FBDs have shown that abdominal hypersensi-tivity is an important factor in noncardiac chest pain, functional dyspepsia, and IBS (see Chapters II 3, II 6, II 7, II 9 and II 10). The concept that primary afferents are a relevant target for treating abdominal pain implies that these neurons are sensitized in states of hyper-algesia or undergo other functional changes that are relevant to hypersensitivity. Indeed, most extrinsic afferents innervating the gut have the ability to sensitize in response to a number of proinflammatory mediators and display enhanced excitability following experimentally induced inflammation. The mechanisms whereby hypersensitivity and hyperexcitability of afferent neurons are initiated and maintained are thus of prime pharmacologic interest, if therapeutic options to prevent or reverse sensitization are pursued. Since the prevalence of FBDs, particularly of functional dyspepsia and irritable bowel syndrome, can be...

Clinical Approach

In more than 90 of cases, a negative chest radiograph in an immunocompetent nonsmoker guides the physician to one of three diagnoses postnasal drip, asthma, or GERD. In the outpatient setting, the mainstay of diagnosis relates to the response with empiric therapy, and multiple etiologies are addressed in terms of treatment. Often, a definitive diagnosis for chronic cough depends on observing a successful response to therapy. A rational approach includes stopping an ACE inhibitor if present, chest radiograph, and avoiding irritants. If persistent, then three conditions postnasal drip, asthma, GERD should be considered. Referral to a pulmonologist is recommended when the diagnostic and empiric therapy options are exhausted. If suspicion for carcinoma is high, a high-resolution CT scan of the thorax or bronchoscopy should be actively pursued. A diagnosis of psychogenic cough should be one of exclusion. See Figure 35-1 for example of an algorithm. Gastroesophageal Reflux Disease GERD...

Theoretical background

The theory is easy to demonstrate with a real life example. If you experience chest pain after lunch, you may initially think it is indigestion. You may take antacid tablets and are unlikely to be worried or concerned. If, however, the pain persists and even gets worse - perhaps radiating down your arm - then there is pressure for you to revise your initial perception of the illness. Once this is done and a new cognitive model is adopted, such as 'I may be having a heart attack', then your coping strategies and emotional response are likely to be quite different.

Side Effects Toxicity and Contraindications of the Macrolide Antibiotics

The most frequently reported events in adults are diarrhea, nausea, abnormal taste, dyspepsia, abdominal pain (substantially less with newer macrolides), and headache. Like other kinds of antibiotics, pseudomembranous colitis has been reported with macrolide use, ranging in severity from mild to life-threatening. There have been isolated reports of transient central nervous system side effects such as confusion, hallucinations, seizures, and vertigo associated with erythromycin use.

Answers To Case 40 Irritable Bowel Syndrome

Summary A 28-year-old female presents with a several-year history of abdominal pain and constipation. She denies any fever, weight loss, heartburn, or bloody stools. Her past medical history and family history are otherwise unremarkable. The physical examination, including abdominal and pelvic examination, are grossly within normal limits.

TABLE 91 Abdominal Pain

Dyspepsia (These disorders cannot be Peptic ulcer refers to a demonstrable ulcer, usually in the duodenum or stomach. Dyspepsia causes similar dyspepsia to cause pain that Nausea, vomiting, belching, bloating heartburn (more common in duodenal ulcer) weight loss (more common in gastric ulcer). Dyspepsia is more common in the young (20-29 yr), gastric ulcer in those over 50 yr, and duodenal ulcer in those from 30-60 yr.

Functional Gut Disorders

More than half of the patients in a gastroenterological clinic complain of abdominal symptoms, without demonstrable cause by conventional diagnostic tests. In the absence of positive findings, unexplained abdominal symptoms have been categorized as functional gastrointestinal disorders, and several syndromes, such as noncardiac chest pain, functional dyspepsia, and the irritable bowel syndrome (IBS), have been defined. Non-cardiac chest pain refers to patients with thoracic symptoms without cardiac, pulmonary, or esophageal disorders. Functional dyspepsia applies to symptoms such as epigastric pain, pressure, fullness, and bloating that presumably originate from the upper gastrointestinal tract, and that are frequently precipitated by meals. The IBS is attributable to the distal gut, and is characterized by abdominal pain or discomfort associated to disordered bowel habit. The diagnosis of those syndromes is solely based on clinical criteria, because their underlying pathophysiology...

Approach To Suspected Irritable Bowel Syndrome

Patients with IBS complain of constipation, diarrhea, alternating constipation with diarrhea, and periods of normal bowel habits that alternate with either constipation and or diarrhea. The abdominal pain associated with IBS is frequently in the lower part of the abdomen, with the left lower quadrant being the most common location. However, both the location and the nature of the pain in IBS is subject to great variability. The pain is described as a cramping sensation of intermittent frequency and variable intensity, often improved or relieved with defecation. Other gastrointestinal symptoms seen in IBS include the passage of mucus with stool, bowel urgency, bloating, dyspepsia, gastroesophageal reflux, and the sensation of incomplete stool evacuation.

Periodontal Disease And Acute Respiratory Infections

Hospital-acquired pneumonia is usually caused by aspiration of oropharyngeal contents. Oropharyngeal colonization with potential respiratory pathogens (PRPs) increases during hospitalization, and the longer the hospital stay the greater the prevalence ol PRPs.' PRPs arc-found predominantly in the gastrointestinal tract and may be passed through esophageal reflux into the oropharynx where they colonize. Subsequent aspiration may lead to pneumonia. Patients whose posterior oropharynx becomes colonized with PRPs have a significantly increased risk of developing nosocomial pneumonia compared with those without oropharyngeal colonization by PRPs.

HCV tropism

Is common in SS but full evidence for an antigen-driven B-cell expansion has not been demonstrated. De Vita et al. 79 described a low-grade gastric lymphoma concomitantly with H. pylori infection in a patient with SS. After H. pylori eradication, a dramatic regression of gastric lymphoma into chronic gastritis was observed, but no amelioration occurred in the parotid and nodal involvement. Multiple molecular analyses showed the expansion of the same B-cell clone in synchronous and metachronous lymph node, parotid, and gastric lesions before and after H. pylori eradication. Other authors 80 studied the gastric tissue in SS in order to define whether the presence of MALT in the stomach is associated with several infectious agents, and showed that H. pylori infection is not more frequent among patient with SS than in controls, and that the abnormal accumulation of MALT may occur in the stomach even in the absence of H. pylori infection. Other studies performed on a limited number of SS...

Therapeutic Market

The therapy for gastric acid-related gastrointestinal disorders has evolved from nonspecific gastro-protective agents to treatments directed at specific sites regulating the secretion of gastric acid. H2-receptor antagonists and PPIs are currently the major therapies used to inhibit the production of gastric acid. The discovery that H. pylori infection was highly correlated with the presence of duodenal ulcer and hypersecretion of gastric acid has introduced an additional therapy that targets the eradication of H. pylori. This combination therapy of an antisecretory agent and an antibiotic has been shown to dramatically reduce the number of patients in which ulcer formation recurs (1).The incidence of upper gastrointestinal disorders such as ulcer and GERD shows an element of global variation. For example, in Western countries duodenal ulcers are more common, whereas in Eastern countries gastric ulcers predominate (2).These dif- i ferences may be attributable to any of a number of...

Chest discomfort

Is one of the most common and complex, accounting for about 5.6 million ED visits annually 1 . It is important to keep in mind that many patients will not admit having chest pain, but will acknowledge the presence of chest discomfort because of their definition of pain. Published reports suggest that up to 5 of visits to the ED involve complaints relating to chest discomfort 30 . The complaint of chest discomfort encompasses many varying conditions, ranging from insignificant to high-risk in terms of threat to the patient's life, including, but not limited to, acute coronary syndromes (AMI and UAP), thromboembolic disease (pulmonary embolism), aortic dissection, pneumothorax, pneumonia, myocarditis, and pericarditis. Chest discomfort may be perceived as pain with descriptions such as crushing, vicelike constriction a feeling equivalent to an elephant sitting on the chest'' tightness pressure heartburn or indigestion, or as discomfort most noticeable for its radiation to an adjacent...

Allyl Amine

Terbinafine interferes with ergosterol biosynthesis, and thereby with the formation of the fungal cell membrane. It is absorbed from the gastrointestinal tract and undergoes extensive metabolism in the liver (tY2 14 h). Terbinafine is used topically for dermatophyte infections of the skin and orally for infections of hair and nails where the site (e.g. hair), severity or extent of the infection render topical use inappropriate (see p. 315). Treatment (250 mg d) may need to continue for several weeks. It may cause nausea, diarrhoea, dyspepsia, abdominal pain, headaches and cutaneous reactions.

Reflux Esophagitis

Esophagitis is a disorder of the defense mechanisms at the esophagealjunction, which is caused by regurgitation of the gastric contents, especially of gastric acid. GERD is associated with decreased gastric emptying and or increased incidence of transient lower esoph-ageal relaxation (T-LESR). Smoking and obesity are factors that increase the incidence cf GERD-like symptoms such as heartburn, belching, and bloating. Reflux has been observed in humans and dogs but not in rodents. can be subdivided into T-LESR. free reflux, and stress reflux. H. pylori infection does not necessarily correlate with GERD, although a reduction in acid secretion reduces the chances of reflux. The effectiveness cf PPIs is reduced in the absence of H. pylori infection therefore the majority of patients with GERD require > 20 mg day to provide symptom relief and to heal the esophagitis produced by gastric acid reflux. This dose is much higher than that required to inhibit acid secretion associated with DU...

Adverse Reactions

Gastric and intestinal mucosal damage is the commonest adverse effect of NSAIDs. The physiological function of mucosal prostaglandins is cytoprotective, by inhibiting acid secretion, by promoting the secretion of mucus and by strengthening resistance of the mucosal barrier to back-diffusion of acid from the gastric lumen into the submucosal tissues where it causes damage. Inhibition of prostaglandin biosynthesis removes this protection. Indigestion, gastro-oesophageal reflux, erosions, peptic ulcer, gastrointestinal haemorrhage and perforation, and small and large bowel ulceration occur. Clinical trial evidence in general appears to support the theory that COX-2 selective inhibitors are as effective as, but have fewer adverse effects than, non-COX-2 selective compounds for example meloxicam is better tolerated than diclofenac or piroxicam.5-6 The relative risk of serious gastrointestinal effects (bleeding peptic ulcers) due to rofecoxib (COX-2 selective) was 0.51 compared with...

Background

Chronic episodic pain is the commonest presenting complaint in functional gastrointestinal disorders (FGD) such as functional dyspepsia, irritable bowel syndrome (IBS), and noncardiac chest pain (NCCP). These conditions are characterized by recurrent, unexplained symptoms for which extensive investigations often fail to identify a cause. FGD are among the most common medical conditions seen in primary care as well as gastroenterology clinics. Symptoms often lead to recurrent attendances in hospital, poor patient satisfaction, and significant morbidity. Health care costs are estimated to be around 34 billion in the seven largest western economies (1,2). Despite intense research, our understanding of the mechanisms of pain in these patients remains far from complete.

Diet Ulcer

Dietary factors play a central role in ulcer frequency and severity.3,4 High intakes of sugar and refined carbohydrate can contribute to ul-cers.5 Milk, traditionally recommended to reduce acidity, actually produces only a transient rise in pH. This is often followed by a large rebound increase in acid secretion, which can worsen ulcers. Heavy alcohol consumption can cause erosions and ulceration of the stomach lining. Both decaffeinated and regular coffee can aggravate heartburn and ulcers. Food sensitivities (such as allergy to cow's milk) may contribute to ulcer formation identifying and avoiding the offending foods often improves healing and may prevent recurrence.6 Raw cabbage juice contains large amounts of S-methylmethionine and glutamine, two amino acids that can accelerate healing of ulcers.

Erectile Dysfunction

Adverse effects are short-lived, dose-related, and comprise headache, flushing, nasal congestion and dyspepsia. High doses can inhibit PDE6 which is needed for phototransduction in the retina, and some patients report transient colour vision disturbance. (The more recently developed PDE5 inhibitors, cialis and vardenafil, appear less likely to cause visual upset.) Priapism7 has been reported.

Reflex Dysfunctions

It has been shown that dyspeptic patients with gastric hypersensitivity also have impaired gastric reflexes (14,48). Physiologically, duodenal distension releases a vagal reflex that induces gastric relaxation. In a group of dyspeptic patients with normal duodenal sensitivity and compliance, duodenal distension induced impaired relaxation of the stomach. It has been suggested that vagal function is impaired in dyspepsia (60), and this could explain the defective duodenogastric reflex. Other studies have shown that IBS patients also display abnormal reflex responses of the gut (40).

Mild Symptoms

Activities, have little or no psychosocial difficulties (although they may experience symptom exacerbation with stress) or chronic pain behaviors, and are not high health-care utilizers. Like case 1, they commonly have IBS, dyspepsia, or other functional GI disorders where the pain is associated with altered GI motility or sensitivity indicating a greater peripheral (i.e., gut related) contribution to the condition. Treatment involves education, reassurance, and dietary lifestyle changes (Fig. 1) or possibly pharmacological treatments (e.g., antidiarrheals and anti-cholinergics) targeted to gut function.

Miscellaneous

Although arsenic's accolades primarily revolve around its reputation as an almond-flavored poison, as it was depicted in Frank Capra's 1944 film Arsenic and Old Lace, it has an older and more admirable history as a medicinal agent. In the eighteenth century, Thomas Fowler compounded a potassium-bicarbonate-based solution of arsenic trioxide (As2O3) that was used empirically to treat a variety of diseases.56 In 1910, Nobel prize winner Paul Ehrlich created the organic arsenical compound salvarsan that was best known as the magic bullet for syphilis, but also found use in treating hypertension, ulcers, heartburn, and chronic rheumatism.57 With evolutions in medicine and the concerns for toxicity, arsenic's use declined over time. In the late 1970s, observational studies preformed in China reported the effectiveness of arsenic trioxide as part of a treatment regimen for APL.58 These results have since been confirmed in trials in the United States, leading to FDA approval in September...

Esophagomyotomy

It should also be noted that esophagomyotomy alone remains controversial as there are some groups that routinely perform fundoplication with their esophagomyotomies to prevent gastroesophageal reflux. Most groups, however, feel that fundoplication is not necessary as gastroesophageal reflux should not be a problem if the lower extent of the esophagomyotomy is limited to the lower esophageal sphincter. The myotomy should only extend onto the surface of the stomach to the extent as determined by the endoscopist seeing a sudden relaxation of the lower esophageal sphincter. Laparoscopic esophagomyotomy without fundoplication is conceptually sound.

Andrea Lazzaretto

Cardiovascular disease (e.g., vascular rings and slings), gastroesophageal reflux, and immunologic disorders (e.g bronchopulmonary dysplasia, cystic fibrosis). This case concentrates on acute onset of wheezing other than asthma in children (Case 6 provides a more detailed discussion of asthma). A 28-year-old White female presents to your office with a chief complaint of constipation and abdominal pain. On further questioning, she reports she has had this problem since beginning college at the age of 18 years. Her symptoms have waxed and waned since this time, but never have worsened. She describes her abdominal pain as dull, crampy, and nonfocal but more prominent in the left lower quadrant, and sometimes relieved with defecation. She denies radiation of pain, nausea, vomiting, fever, chills, weight loss, heartburn, or bloody or dark stool. She reports having a bowel movement every 1-2 days that is hard and feels incomplete. She has tried over-the-counter remedies, including stool...

Tetracyclines

Heartburn, nausea and vomiting due to gastric irritation are common, and attempts to reduce this with milk or antacids impair absorption of tetracyclines (see below). Loose bowel movements occur, due to alteration of the bowel flora, and this sometimes develops into diarrhoea and opportunistic infection (antibiotic associated or pseudomembranous colitis) may supervene. Disorders of epithelial surfaces, perhaps due partly to vitamin B complex deficiency and partly due to mild opportunistic infection with yeasts and moulds, lead to sore mouth and throat, black hairy tongue, dysphagia and perianal soreness. Vitamin B preparations may prevent or arrest alimentary tract symptoms.

YAmino Butyric Acid

Y-Amino butyric acid (GABA) has a major inhibitory role in the CNS, which mediates its effect via three classes of receptors, the ionotropic GABAA, GABAC receptors, and the G-protein-coupled GABAB receptors. GABAB receptor agonists inhibit vagal afferent mechanosensitivity in the upper gastrointestinal tract and GABAB receptors are expressed on gastric vagal afferent neurons. This peripheral action is associated with a reduction in triggering of transient lower esophageal relaxations (TLESRs) (87,176-179), which are the major cause of acid reflux. This has led to interest in these receptors as therapeutic targets for gastroesophageal reflux disease by reducing TLESRs and therefore reflux episodes. More recently, inhibitory actions of GABAB receptors have been demonstrated on pelvic afferents from rat colon (180), suggesting they may have a peripheral antinociceptive action. Endogenous activation of peripheral GABAB receptors on afferent endings is probably minimal, whereas endogenous...

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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