GERD (Gastroesophageal Reflux Disease)
Who you are:
FY2 in the GP surgery
Who you are talking to:
Ryan Helpart, a 54 year old male patient, came to the GP with the complaint of Dyspepsia and indigestion.
What you should do:
Talk to him & address his concern, take relevant hx and discuss a proper plan of management.
Doctor: Hello, my name is Doctor(name). I am one of the doctors here. Are you Ryan?
Patient: Yes.
D: Can I get your full name and date of birth?
P: (Confirms details)
D: How can I help you today?
P: I have this heartburn doctor and it’s starting to agitate me.
D: Oh I see. Can you tell me more about it?
P1
Explore
SOCRATES
D: Site : Where is it exactly? Can you point to it with your finger?
P: It is in the midline of my chest and upper tummy.
D: Onset: How did it start?
P: It started gradually and kept getting worse.
D: Character: Can you describe that pain for me?
P: It is more like stinging heartburn.
D: Radiation: Does it go anywhere else?
P: No.
D: Is it continuous or comes and goes?
P: Comes and goes.
D: Duration (time): When did it start exactly?
P: I’ve had it for some time now doctor, maybe 2 years ago.
D: Alleviating factors: Anything that makes it better ?
P: When I sit upright.
D: Exacerbating Factors: Anything that makes it worse?
P: Yes doctor I think when I eat dairy products/ spicy food or drink alcohol actually at night I am lying in bed it gets bad.
D: Severity: Can you score the pain for me on a scale from 1 to 10, 1 being the least and 10 being the highest pain possible?
P: 7.
D: Have you tried anything for it?
P: Yes doctor I have tried Antacids and it was helping before but not anymore
D: Anything else with the pain? Open Q before asking about DDx
Associated Sx
Think of MI then ask about the main GIT symptoms.
D: Does this pain go to your left side of the body, left jaw or do you feel it increases by exertion?
P: No.
D: Have you got any tummy pain/ diarrhoea/ constipation (flatus)/ nausea and vomiting/ fever?
DDx
D: Any change in stool colour as if darker and with very offensive smell or blood? (Bowel cancer/melena)
- Any pain during swallowing?
- Any difficulty swallowing? (cancers)
- Any painful breathing?
- Any difficulty breathing?
- Any change in the tone of voice?
- Any coughing of blood or food (regurgitation)
- Any bad breath or sour taste in your mouth?
- Any bloating/belching?
GERD Symptoms:
- Heart burn
- Sour taste in mouth
- Bad odour from mouth
- Pain on swallowing
- Bloating/ belching
- Sore oesphagus
Risk factors:
- Spicy food
- Smoking
- NSAIDS
- Stress
- Alcohol
Complication:
- Barret’s oesphagus
- Cancer oesphagus
- FLAWS
Oesophageal cancer
- Difficulty in swallowing
- FLAWS
- Family hx
- If dysphagia: exclude other causes including oesophageal cancer, strictures, motility disorder.
Gastric ulcer / peptic ulcer:
- Tummy pain
- Have you been dx with PU
Gastric carcinoma:
- Weight loss
- Lumps and bumps
- FLAWS
FLAWS (in details)
Barret’s oesophagus / Gastric Cancer/ oesophageal cancer
D: Any lumps or bumps anywhere in your body?
P: No.
D: Do you feel like you are tired more than usual?
P: No.
D: Any appetite change or weight loss recently?
P: No.
D: Any night sweats?
P: No.
ICE
IDEA
D: Are you thinking of any possible cause for this heartburn?
P: No.
CONCERN
D: Do you have any specific concern regarding this pain?
P: Not really doctor I just want anything to help with the pain because it has
become unbearable.
P2
D: Ah I do understand you say you have had it for 2 years now that sounds
really dreadful. Have you ever had it before that?
P: No.
D: Any medical condition? 5 main conditions, mainly any problems with gut
P: No.
MAFTOSA
D: Are you currently on any medications? (Bisphosphonates/ NSAIDS)
P: No.
D: Do you have any allergies?
P: No.
D: Any family members with similar complaints?
P: No.
D: What do you do for a living?
P: I am a businessman and I work in the stock market.
D: That sounds like a stressful job, have you been stressed lately?
P: Yes doctor it has gone crazy lately, but again that’s how it’s always been when it comes to stock trading…
D: How is this heartburn affecting your life / job ?
P: It’s pretty agitating doctor.
DESAS
D: How is your diet? What type of food do you eat? Do you think that it might be affecting your Sx?
P: Not so good to be honest I eat everything…
D: Do you eat lots of spicy food or drink caffeinated drinks frequently?
P: Yes doctor.
D: How are you with physical activity in general?
P: Generally fine.
D: Do you smoke?
P: Yes.
D: How much and for how long?
P: About a pack and half a day for 20 years now.
D: Do you drink alcohol?
P: Yes doctor every weekend.
Examination:
Thank you for answering all my questions. I would like to examine you now if you don’t mind? I would like to take your vitals and examine your tummy and do a general physical examination and examine your neck and chest as well.
Provisional diagnosis:
I believe you have Gastro – oesophageal reflux disease, a condition where acid reflux or overflow from your stomach into your food pipe leads to an unpleasant sensation in your mouth.
Management:
- Admission / Discharge: No admission needed.
- Talk to Senior
- Investigation:
- FBC- LFT/KFT/TFT- vitamins level- U&E
- Infection markers: CRP and ESR
- Immune markers: Faecal calprotectin- TTG (celiac)
- Stool analysis- faecal occult blood (rule out cancer) especially if older than 55 with new onset or unexplained symptoms.
- H-Pylori testing (breath test or antigen in stool).
- ECG to exclude MI
Are you following me so far ?
- Symptomatic and advice
- PPI like omeprazole in the morning before breakfast.
- Keep a diary of foods that cause the symptoms, if you find your Sx related to certain products like the milk you mentioned, you can try and eliminate it from you regular meals.
- Example of such foods causing it might be coffee, spices and alcohol which can increase Sx. Smoking and stress exacerbate the symptoms as well.
- Avoid smoking, alcohol, heavy fatty meals and caffeinated drinks, including energy drinks, hot liquids, peppermint and citric fruits and juices.
- Eat small frequent meals.
- Elevate the bed from head side when you lay down.
- Do not eat at least 3 hours before bedtime.
- Stress management is crucial. I would like to suggest a few options like going for exercise and short walks - Yoga - Meditation - talk therapy.
- How do you feel about this plan?
- Specialist:
- If condition does not improve we might have to involve a Gut specialist who can do a special test called, Tonometry to assess the tone of Lower Oesophageal Sphincter (LES). Or another one which is a camera test called Upper GI endoscopy and biopsy which means we take sample as
well to exclude strictures of Barret’s Oesophagus, oesophageal cancer and any Gastric Ulcer.
- Psychotherapist: can provide techniques for handling stress and offer
- CBT (the talking therapy)
- Dietitian: Help modify your diet to reduce Sx and provide your body with sufficient nutrients.
- Smoke cessation clinics
- Safety net
- Bowel cancer symptoms + Dysphagia + FLAWS, Dizziness, SOB, feeding problems, chest pain.
- We will arrange for a follow up in 2 - 3 weeks’ time to check for improvement or development of warning signs.
Your job here is mainly lifestyle modifications
DON’T
- Eat spicy food
- Alcohol
- Smoking
- Stress advice
- Take medications without GP advice
DO
- Small frequent meals well before bedtime.
- Plenty of fluid.
- Raise your head by putting extra pillow.