Sunday, February 22, 2015

GERD - Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is an extremely common disease that is seen on the wards on Internal Medicine. Let's discuss how it presents and how its treated.



3 Most common symptoms:
  • Heartburn
  • Reflux
  • Dysphagia

Other common symptoms:
  • Bronchospasm
  • Laryngitis
  • Chronic cough

Less Common
  • Chest pain - May mimic angina pectoris, and is typically described as squeezing or burning, located substernally and radiating to the back, neck, jaw, or arms, lasting anywhere from minutes to hours, and resolving either spontaneously or with antacids. It usually occurs after meals, awakens patients from sleep, and may be exacerbated by emotional stress
  • Hypersalivation
  • Globus sensation
  • Odynophagia
  • Nausea

Pearl: GERD is purely a clinical diagnosis, defined as having the above symptoms causing troublesome symptoms and/or complications.

Approach to Therapy


There are only two lifestyle modifications that improve symptoms:
  • Weight loss
  • Elevate head of bed
  • Don’t ask patients to change their diet - except to avoid known dietary triggers specific to the patient.

Mild Disease:
  • In patients with mild and intermittent (less than two episodes per week) symptoms:
    • Low dose histamine 2 receptor antagonists (H2RAs).
    • If continued symptoms, increase the dose of H2RAs to standard dose, twice daily for a minimum of two weeks.
  • If symptoms persist, discontinue H2RAs and initiate low dose PPI once daily and then increase to standard doses as needed
  • Reassess dosing Q2-4 weeks
  • Minimum length of therapy is 8 weeks

Moderate to Severe Disease (symptoms >x2/week, including erosive esophagitis):
  • Standard dose PPI once daily
  • If failed, double dose and refer to GI. Definition of 'failure' is controversial. Note that the most common reason for failure is poor compliance - first address this issue before doubling the dose of the PPI.
  • If symptoms resolve, try trial off of treatment except those with severe esophagitis or Barrett's
  • If failed off of therapy in less than 3 months, need lifetime therapy
  • If fail later on, can try repeated on/off courses
When should upper endoscopy be done?
  1. Alarm features: Dysphagia, odynophagia, gastrointestinal bleeding, anemia, weight loss, and recurrent vomiting
  2. GERD symptoms after adequate 4­-8 week trial of PPI
  3. Any of the following features:
  • > 50 year old man
  • Chronic GERD x 5 years
  • Nocturnal reflux symptoms
  • Hiatal hernia
  • Elevated BMI
  • Smoker
Role of pH monitoring and manometry testing

Ambulatory pH monitoring: Confirm GERD in those with persistent symptoms who do not have evidence for mucosal damage on endoscopy, particularly if a trial of twice daily PPI has failed.

Esophageal manometry: Assess for motility issues like achalasia, the symptoms of which can mimic GERD. Suspect this with dysphagia and vomiting.


Monday, February 16, 2015

Elevated Liver Enzymes in Pregnancy

Let's discuss the approach to this common problem in pregnancy.

Helpful Hints in determining the etiology of elevated liver enzymes:
  • Use the gestational age to guide the diagnosis
  • Need to rule out viral/gallstone/cancer/autoimmune/drugs as the cause of elevated liver enymes at any time of the pregnancy.
  • Chronic hepatitis B or C poses a risk of transmission to the offspring
  • All of the below diagnoses can recur in subsequent pregnancy.
Liver tests affected by pregnancy (decrease, except ALP):
  • ALP (increased in the second and third trimester, due to the placenta)
  • Albumin and total protein (decreased from the first trimester due to hemodilution)
  • Bilirubin levels (slightly decreased from the first trimester)
  • GGT (slightly decreased in late pregnancy)
Liver tests not affected by pregnancy:
  • AST, ALT, PT, total bile acids, LDH
"Hi, can you please page GI to my cell phone?"

Differential Diagnosis
There are four main differential diagnoses to consider
  • Hyperemesis gravidarum - 1st trimester. 
    • Mild, often <200 alt="" often="">AST.
    • Admit to hospital if hypovolemic
    • Diclectin can be used for management for nausea
    • If persistent, make sure to rule out molar pregnancy
  • Cholestasis of pregnancy - 2nd Trimester. Common; 
    • Affected pregnancies are at increased risk for prematurity and stillbirth, and early delivery should be considered when possible. 
    • Pruritus starting in the hands and soles. NOT jaundiced but have high ALP
    • Enzymes are often very high with normal GGT. 
    • Measure bile acids  to help make the diagnosis (>10)
    • Often have history of pruritus during current and previous pregnancies. Likely to recur
    • Small risk to baby, none to the mom
    • Treatment
      • Deliver earlier
      • Ursodeoxycholic acid
      • Can also use hydroxizine, cholestyramine to help with symptoms
      • Vitamin K if INR is up
  • Acute fatty liver of pregnancy - Second half of pregnancy, usually 3rd trimester.
    • True hepatic dysfunction. ACUTE LIVER FAILURE Baby's free fat damages mom
    • Signs of pre-eclampsia and HELLP syndrome in 50% of patients.
    • Nausea/vomiting, pain, jaundice
    • Rare
    • Enzymes vary from 200-500. 
    • Uric acid, WBC, bilirubin, and INR elevated
    • Glucose and platelets are low
    • Must exclude HELLP (AFLP doesn't have hemolysis unless the patient also has DIC)
    • Screen mom and baby for LCHAD.
    • May recur in future pregnancies
    • Treatment
      • Deliver!
      • Glucose infusion 
      • Reversal of coagulopathy (FFP, cryoprecipitate, pRBC, platelets) PRN. 
      • Watch for pulmonary edema due to loss of proteins 
  • HELLP syndrome 
    • Hemolysis, Elevated Liver Enzymes, and Low Platelets
    • Present with neurological symptoms as well; abdominal pain, vision changes.
    • Microangiopathy Hemolytic Anemia
    • Elevated LDH, raised INR as well
    • AST > 70
    • Second half of pregnancy, usually 3rd trimester.
    • Management:
      • Prompt delivery!
      • Magnesium sulphate for seizure prevention
    • May recur in future pregnancies