Si está buscando comprar medicamentos en línea en España, es importante elegir una farmacia en línea de confianza y segura para garantizar que los medicamentos que reciba sean auténticos y de alta calidad. En comprar-farmacia.es, ofrecemos una amplia selección de medicamentos, incluido Cialis para la disfunción eréctil (DE), y trabajamos con farmacias acreditadas para garantizar la calidad y la autenticidad de nuestros productos.
Visite nuestro sitio web en comprar-farmacia.es para obtener más información sobre nuestros productos y servicios. Nuestro equipo de atención al cliente está disponible para ayudarlo en todo momento y garantizar una experiencia de compra en línea segura y satisfactoria.
Web.clas.ufl.edu
Gastroesophageal Acid Reflux: How to Effectively Recognize and Treat This Wide Spread Disease Contributors:
Eric Crihfield, MD, PhD, Director of the Acid Reflux Research Clinic, Washington
Daniel Ryczek, MD, PhD, Chairman of the College of Medicine, Johns Hopkins
Victoria Adams, MD, PhD, Director of the Department for Advancing Primary Care
Treatment and Research, UCLA, Los Angeles, CA
Introduction
Gastroesophageal acid reflux disease (GERD) is a large problem in western countries,
with a prevalence anywhere from 10 to 20%1. The disorder is currently defined as a condition
that produces troublesome symptoms and/or complications due to reflux of stomach contents2.
People who have the disease experience symptoms including throat pain, globus sensation,
hoarseness, and excessive throat clearing3. As a result, acid reflux significantly decreases the
quality of life, and symptomatic gastroesophageal acid reflux is actually the strongest known risk
factor for adenocarcinoma4. Due to the high prevalence of this disease, primary care physicians
are likely the first clinicians to whom patients will report symptoms.
Learning Goals: Upon completion of this activity, participants should be able to:
1) Recognize possible risk factors and symptoms for gastroesophageal acid reflux disease
2) Suggest possible lifestyle modifications and advise patients in achieving such changes
3) Suggest a relevant pharmacological approach if necessary
Case Presentation
A 42 year old man visits his primary care physician. He complains of heartburn that
frequently occurs in the middle of the night. His discomfort often causes him to awaken in the
night, resulting in a restless night sleep. He has been out of work for 7 months after being fired
for poor production levels. He has been working odd jobs in order to support his wife and two
children. He is not currently taking any prescription medications but does take a daily
multivitamin and is on a preventative aspirin regimen. He is not overweight and does not smoke.
When asked about his drinking habits, he admits that he has recently mildly increased his alcohol
multivitamin and is on a preventative aspirin regimen. He is not overweight and does not smoke.
When asked about his drinking habits, he admits that he has recently mildly increased his alcohol
ymptoms and Risk Factors
The defining symptoms of GERD are heartburn and regurgitation. In most patients, these
symptoms are caused by the reflux of acidic gastric content. However, in some patients non-acid
reflux may need to be considered5. Occasional GERD symptoms are often experienced by the
general population, but range in frequency and severity.
In population-based studies, most patients consider symptoms to be bothersome when
they occur in mild forms 2 or more days a week or more severely at least once a week5. Patient
self-evaluations can be useful to the physician in assessing symptom severity. Such
questionnaires include the Reflux Disease Questionnaire, the Gastrointestinal Symptom Rating
Scale, and the Quality of Life in Reflux and Dyspepsia questionnaire5. Patients who reported a
history of GERD-like symptoms usually had an abnormal 24 hour esophageal pH monitoring
using a pH sensor and probe placed in the esophagus6. However, 51% of patients with severe
symptoms did not have true pathological GERD6.
Approximately 25% of patients report having heartburn during sleep which caused sleep
disruption. Such disruption can cause daytime tiredness which negatively affects functioning and
productivity5. Dysphagia is also reported in 37% of patients5.
In some patients respiratory problems, such as reflux cough, laryngitis, and asthma, have
been reported; however, GERD is more likely to aggravate these problems rather than to be the
solitary cause5. Dental erosion may also be more pronounced in patients presenting with GERD5.
However some symptoms including persistent vomiting, evidence of gastrointestinal tract blood
loss, abdominal mass or involuntary weight loss, and dysphagia which persist after treatment are
atypical symptoms which warrant further examination for malignancy5.
Risk factors for GERD include the use of NSAIDs or aspirin, obesity, stressful
psychosocial factors including job strain, and increased alcohol consumption7-10.
Quiz 1) Which of the following symptoms warrants further investigation for malignancy? Case Diagnosis
Based on all the symptoms and risk factors, this patient is diagnosed with GERD. He
displays the classic symptom of heartburn, has the night time discomfort that is often
characteristic of GERD, and has some of the risk factors associated with GERD: increased
alcohol consumption and an aspirin regimen. The first step in treatment is lifestyle modification.
Life Style Modifications
When dealing with the control of GERD, lifestyle modifications are commonly
implemented either as the first treatment option or in conjunction with pharmacological
treatments. The effects of diet, obesity, physical activity, tobacco smoking, and head of bed
elevation on GERD prevalence and its symptoms are discussed below.
Certain eating habits and the consumption of specific foods cause, or aggravate the
symptoms of GERD11. A high caloric diet comprised of high amounts of cholesterol, saturated
fatty acids, and calories from fat increases esophageal acid exposure and the chance of reflux
events11. Alcohol has been suggested as an independent risk factor for GERD because its
consumption causes esophageal motility abnormalities such as lower esophageal sphincter (LES)
hypertension and non-peristaltic contractions12. Long term alcohol renunciation has been shown
to improve the abnormalities; however, these improvements are not accompanied by one in
esophageal pH, and alcohol consumption has been shown to be connected to a decrease in the
perception of intra-esophageal reflux events11-12. Coffee has not been shown to increase the
number of reflux events, though coffee does increase esophageal acid sensitivity, thus worsening
the symptoms of an event11. Double blind placebo studies have found no correlation between
ingesting spearmint and a change in symptoms, LES pressure, or reflux episodes12. Therefore, a
diet that is low in cholesterol, saturated fatty acids, and calories from fat, along with alcoholic
abstinence is recommended for the control of GERD related symptoms11.
The connection between obesity and the symptoms and prevalence of GERD has long
been noted, and recent research attributes this relationship to an increase in patients’
gastroesophageal gradient, intra-abdominal pressure, and output of bile and pancreatic
enzymes12. An increase in BMI is also positively correlated with an increase in the rate of reflux
related hospitalizations, and for every BMI increase of 5 the risk for GERD goes up by 1.2%11-
Exercise, once thought to be one of the best lifestyle modifications to implement for the
treatment of GERD, has proved to be ineffective at certain levels of exertion11. Current research
shows that strenuous or vigorous exercise is positively correlated with GERD11. Specifically,
running and resistance training in combination with high carbohydrate sport drinks provoke the
greatest risk for onset11. Studies have connected the number of moderate exercise sessions that
equaled or exceeded thirty minutes in length with a decreased risk of GERD11. Interestingly, a
monozygous co-twin study shows that physical activity in a work environment increases the risk
of GERD, while physical activity in a leisure environment decreases the risk of GERD11. A
healthy lifestyle consisting of moderate exercise sessions while avoiding high carbohydrate sport
drinks is recommended for both keeping BMI in a healthy range and controlling GERD related
The relation between tobacco smoking and GERD is sizable and multifaceted11. Through
a monozygous co-twin study, tobacco smoking has been connected to an increased risk for the
appearance of frequent GERD symptoms by increasing intra-abdominal pressure, reducing LES
pressure, and decreasing bicarbonate secretion in saliva, thereby reducing saliva’s pH
neutralizing effect11. Although tobacco smoking increases the number of reflux episodes, studies
have shown no increase in esophageal acid exposure time12. Although smoking does not increase
acid exposure time, quitting is highly recommended to control the variety of symptoms that are
The acidic contents of the stomach have a greater chance of refluxing into the esophagus
from a position that is parallel to the floor than one at an angle; therefore, head of bed (HOB)
elevation is commonly recommended12. A study that monitored esophageal pH in sitting, lying,
and elevated HOB showed that patients with a 28 cm block raising the head of their beds
experienced significantly fewer reflux episodes and GERD symptoms12.
When confronted with GERD, lifestyle modifications should be the first course of action.
Although the goal of lifestyle modifications are to contain, not cure, GERD, the specific
implementation of mild exercise, a diet rich in fiber and poor in fat, quitting smoking, and
elevating the head of the bed is advised to prevent or reduce GERD symptoms11.
Quiz 2) Correctly match the type of exercise to an increase/decrease in GERD symptoms
Resistance training, decrease; thirty minute moderate sessions, increase
Running, increase; resistance training, decrease
Resistance training, increase; thirty minute moderate sessions, decrease
3) How does tobacco smoking increase the risk for GERD?
By increasing intra-abdominal pressure, reducing LES pressure, and decreasing bicarbonate secretion
By damaging the stomach’s proton pumps
By increasing saliva secretion and esophageal peristalsis
Case Treatment: Life Style Changes
Because the patient’s symptoms present themselves when he is sleeping, it is likely that
lying flat causes the contents of his stomach to reflux into his esophagus. Alcohol consumption
leads to esophageal motility abnormalities, and long term consumption abstinence has shown to
re-regulate esophageal motility. For these reasons, elevating the head of his bead and abstaining
from alcohol consumption would be recommended as life style modifications. Also, an aspirin
regimen has been known to be a risk factor for GERD, so because he is using aspirin only for
preventative reasons and it is currently hurting him more than helping, he is removed from that
regimen to further alleviate his condition. At follow-up after one month of lifestyle modification,
the patient still complains of symptoms.
Pharmacological Treatment
If a lifestyle adjustment is not enough to alleviate the patient’s symptoms, then a
pharmacological approach is appropriate. The pharmacological approach to treatment of GERD
strives to not only relieve the symptoms of the disease, but also to heal damage to the esophagus,
and to ensure that complications do not develop13. According to the American College of
Gastroenterology, gastric acid suppression is the most important type of medical therapy
available for GERD13 because it is gastric acid in the stomach causing the problems associated
with GERD13-14. The two types of acid suppressors available are H2 receptor antagonists (H2
blockers) and Proton pump inhibitors (PPIs), the selection of which is dependent on the severity
Antacids and H2 blockers are used most by patients with occasional reflux13. Antacids
work by neutralizing the acid in the stomach, and as a result, they are recommended as a self-
care method for patients with mild GERD13. However, in mild to moderate cases of GERD,
antacids alone are not effective, and H2 blockers become the more appropriate method of
treatment, with an effectiveness of about 75%15. The H2 blockers work by preventing histamine2
from signaling the parietal cells to secrete acid: the most common ones available are Cimetidine
(Tagamet), Famotidine (Pepcid), Nizatidine (Axid), and Ranitidine (Zantac), all of which are
In moderate to severe cases of GERD, proton pump inhibitors become the treatment of
choice, as they are the most effective in healing esophagitis and have the most rapid symptomatic
relief13. The proton pump inhibitors work by blocking the hydrogen/potassium ATPase (gastric
proton pumps) in the parietal cells, rendering them incapable of secreting H+ ions15. For
moderate cases of GERD, one PPI, Omeprazole (Prilosec), is available over the counter and can
be used effectively for 14 days, up to three times a year13. If GERD proves to be more severe and
the symptoms persist, stronger prescription PPIs have been shown to heal 83% of the erosive
esophagitis cases caused by GERD13-14. The different forms of prescription PPIs available are
Pantoprazole (Protonix), Esomeprazole (Nexium), Lansoprazole (Prevacid), Omeprazole with
sodium bicarbonate (Zegerid), and Rabeprazole (Aciphex)14, all of which have demonstrated no
significant difference in effectiveness13-14. PPIs are less effective in treating symptoms of GERD
other than esophagitis (such as heartburn), but they still remain the most effective medicine
Despite their effectiveness, the pharmacological treatments available for GERD only
relieve the symptoms and prevent complications; they do not address the underlying causes15. As
a result, most cases of GERD are chronic, with 80% of patients having a relapse in esophagitis 6-
12 months after treatment is discontinued13,15. This means that continuous therapy is often
needed, so it is common practice to keep patients on PPI treatment as long as necessary to
maintain control over the symptoms of GERD13-15.
Patients on PPIs start out with once daily doses, but if this proves ineffective they can be
moved to twice daily doses13. Increasing the dosage typically increases the relief brought by the
medication, but about 25% of GERD patients fail to respond13. These patients are said to have
PPI refractory GERD, which means that the symptoms, the esophagitis, or both did not disappear
with treatment13. Most patients who experience PPI failure are suspected as having the non-
erosive (does not cause esophagitis) form of GERD, since PPIs are less effective in treating
symptoms other than esophagitis13. When patients fail to respond to treatment like this, it
becomes necessary to refer them to a gastroenterologist13-14.
4) Which of the following is the most effective at treating the esophagitis caused by GERD?
5) Which of the following treatment methods is most appropriate for mild to moderate GERD?
Case Treatment: Pharmacological Approach
Initially, the patient tries an over the counter H2 blocker, ranitidine (Zantac), and
symptoms are assessed after 2 weeks. Since patient continues to complain of symptoms, over
the counter omeprazole (Prilosec) is recommended. After his first two week trial, symptoms
have still not improved, so the patient is moved onto a once daily dose of lansoprazole
(Prevacid). Two weeks later this approach proved effective in alleviating the patient’s
symptoms. The patient is instructed to continue the lifestyle modifications he has made to
prevent his symptoms from reoccurring, and a six-month follow up is scheduled to ensure his
Conclusion
Gastroesophageal reflux disease is a fairly wide spread disorder, and as a result, needs
special attention from general practitioners. The general symptoms of GERD are heartburn and
regurgitation, causing damage to the esophagus, and often causing sleep disturbances as well.
Common risk factors are alcohol consumption, frequent use of aspirin, obesity, smoking, and
constant stressful conditions. The first line of defense against GERD is reversing the lifestyle
trends that put patients at risk or agitate their current condition. If this is not sufficient, it is
necessary to introduce a pharmacological treatment. Many patients’ symptoms can be relieved
by simple over the counter H2 blockers or proton pump inhibitors, but in more severe cases,
prescription proton pump inhibitors may need to be used and used continually if the condition
proves to be chronic. If the patient’s symptoms persist, it will be necessary to refer them to a
References 1. Wang C, Hunt RH. Precise role of acid in non-erosive reflux disease. Digestion 2008
2. Kahrilas PJ. Gastroesophageal reflux disease. N Engl J Med 2008 October 16;359(16):1700-7. 3. Khan A, Cho I, Traube M. Patients with throat symptoms on acid suppressive therapy: Do
they have reflux? Digestive Diseases & Sciences 2010 02;55(2):346-50.
4. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the
aetiology of gastro-oesophageal reflux. Gut 2004 December;53(12):1730-5.
5. Flook, N. (2007). GERD: A fresh look at a common problem in primary care. Journal of
6. Chan, K., Liu, G., Miller, L., Ma, C., Xu, W., Schlachta, C., et al. Lack of Correlation
Between a Self-Administered Subjective GERD Questionnaire and Pathologic GERD Diagnosed by 24-h Esophageal pH Monitoring. Journal of Gastrointestinal Surgery, 2010;14(3), 427-436.
7. Ruszniewski, P., Soufflet, C., Barthélémy, P. Nonsteroidal anti-inflammatory drug use as a
risk factor for gastro-oesophageal reflux disease: an observational study. Alimentary Pharmacology & Therapeutics, 2008; 28(9), 1134-1139.
8. Sakaguchi, M., Oka, H., Hashimoto, T., Asakuma, Y., Takao, M., Gon, G., et al. Obesity as a
risk factor for GERD in Japan. Journal of Gastroenterology, 2008; 43(1), 57-62.
9. Jansson, C., Wallander, M., Johansson, S., Johnsen, R., Hveem, K. Stressful psychosocial
factors and symptoms of gastroesophageal reflux disease: a population-based study in Norway. Scandinavian Journal of Gastroenterology, 2010; 45(1), 21-29.
10. Veugelers, P., Porter, G., Guernsey, D., Casson, A. Obesity and lifestyle risk factors for
gastroesophageal reflux disease, Barrett esophagus and esophageal adenocarcinoma. Diseases of the Esophagus, 2006; 19(5), 321-328.
11. Festi D, Scaioli E. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease.
World J Gastroenterol. 2009 Apr 14;15(14):1690-701.
12. Kaltenbach T, Crockett S. Are Lifestyle Measures Effective in Patients With
Gastroesophageal Reflux Disease? An Evidence-Based Approach. Arch Intern Med. 2006;166:965-971.
13. Wang C, Hunt RH. Medical management of gastroesophageal reflux disease. Gastroenterol
14. Kahrilas PJ. Gastroesophageal reflux disease. N Engl J Med 2008 October 16;359(16):1700-
15. Liu JJ, Saltzman JR. Management of gastroesophageal reflux disease. South Med J 2006
ADVANCED PAEDIATRIC CONSCIOUS SEDATION: AN ALTERNATIVE TO DENTAL GENERAL ANAESTHETIC IN THE UK. Hand DP1, Averley PA2, Lyne JP3, Girdler NM4. 1Senior House Officer, Department of Child Dental Health, Newcastle Dental Hospital. 2Principal General Dental Practitioner, Queensway Anxiety Management Clinic, Billingham, Teesside. 3Honorary Clinical Lecturer, Department of Sedation, Newcastle De
Alcohol Alert From Moderate drinking is difficult to define because it means different things to different people. Theterm is often confused with "social drinking," which refers to drinking patterns that are acceptedby the society in which they occur. However, social drinking is not necessarily free of problems. Moderate drinking may be defined as drinking that does not generally cause