GASTROESOPAGEAL REFLUX

DISEASE
SCENARIO:

M.R. is a 56-year-old general contractor who is admitted to your telemetry unit

directly from his internist’s office with a diagnosis of chest pain. On report, you are
informed that he has an intermittent 2-month history of chest tightness with
substernal burning that radiates through to the mid back off and on, in a stabbing
fashion. Symptoms occur after a large meal; with heavy lifting at the construction
site; and in the middle of the night when he awakens from sleep with coughing,
shortness of breath, and a foul, bitter taste in his mouth. Recently he has developed
nausea, without emesis, that is worse in the morning or after skipping meals. He
reports having "heartburn" three or four times a day. When this happens, he takes a
couple of Rolaids or Tums. He keeps a bottle at home, at the office, and in his truck.
Vital signs (VS) at his physician's office were 130/80 lying, 120/72 standing, 100, 20,
98.6Åã F (37Åã C), Spo2 92% on room air. A 12-lead electrocardiogram (ECG)
showed normal sinus rhythm with a rare premature ventricular contraction (PVC).

QUESTIONS:

1. What are some common causes of chest pain?

2. What MNEMONIC can you use to help you better evaluate his pain
3. What other history is important?

ANSWERS:
1. Common causes of chest pain are pneumothorax, myocardial infarction, angina,
pericarditis, anxiety, hyperventilation.

2. “OPQR”-mnemonic
ONSET: Symptoms occur after a large meal; with heavy lifting at the
construction site.
PROVOCATION: M.R experiences various symptoms in the morning or after
skipping meals makes it become worse
QUALITY: Intermittent 2-chest pain/tightness, stabbing burning sensation
RADIATION: Substernal burning that radiates through to the mid back off and on
 3. Family history, Over-the-Counter drugs, surgical history, pain relieving methods,
pain worsening symptoms, sleep apnea, smoking habits

Case study progress

M.R. indicates that usually the chest pain is relieved by his antacids, but this time
they had no effect. A "GI cocktail" consisting of Mylanta and viscous lidocaine given
at his physician's office briefly helped decrease symptoms.

QUESTIONS:
4. What tests can be done to determine the source of his problems?

ANSWERS:
4. To determine the source of his problems he needs to undergo the following diagnostic
test:
 Serologic testing for igg anti-H pylori antibody
 CBC
 12-lead EKG
 Troponin, cardiac enzymes
 Echo
 Stress test
 Catheterization
 Blood gasses
 EGD
 Ph monitoring
 Chest x-ray
 Endoscopy

Case study progress

M.R. has smoked one pack of cigarettes a day for the past 35 years, drinks two or three
beers on most nights, and has noticed a 20-pound weight gain over the past 10 years.
He feels "so tired and old now." M.R. has dark circles under his eyes and complains of
constant daytime fatigue. His wife is even sleeping in another bedroom because he is
snoring so loudly. He also reinjured his lower back a month ago at work, lifting a pile of
boards, so his physician prescribed ibuprofen (Motrin) 800 mg bid or tid for 4 weeks

QUESTIONS:

5.Which factors in M.R.'s life are likely contributing to his chest pain and
nausea? Explain how
ANSWERS:

5.The factors that most likely contributing to his chest pain and nausea is
smoking. Since he is a one pack a day smoker for past 35 years, it can
extremely harm the health of the lungs that could be seen symptoms alone
while drinking frequently of two-three beers has a detrimental effect on his
immune system and liver function.

Case study progress

M.R. explains that 6 months ago his physician prescribed ranitidine (Zantac) 150 mg
PO at bedtime for heartburn, and that it helped a little, but that it never really "did the
job." Now he keeps a bottle of Tums or Rolaids in his truck and at his bedside and
takes these in addition to the ranitidine, "because I always seem to need them."

QUESTIONS:
6.Why do you think the famotidine did not help M.R.?

ANSWERS:
6. Because it’s not heartburn gastric ulcer. Smoking while taking H2 antagonist
reduces the effectiveness

Case study progress

M.R.'s 12-lead ECG was normal, and the first set of cardiac enzymes was normal.
CBC showed WBC 6000/mm3, Hgb 15.0 g/dL, Hct 47%, platelets 220,000/mm3.
Complete metabolic panel (CMP) revealed Na 140 mEq/L, K 3.7 mEq/L, BUN 20
mg/dL, creatinine 1.0 mg/dL, lipase 20 units/L, amylase 18 units/L, PT 12.0 sec, INR
1.0. The H. pylori a body test came back as 20 units/mL. The chest x-ray showed no
abnormal es. Room air SpO2 is 94%, and breathing is unlabored. Suddenly, M.R.
begins to complain of nausea; as you hand him the emesis basin, he promptly
vomits coffee-ground emesis with specks of bright red blood. VS remains stable.

QUESTIONS:

7. What concerns do you have about the coffee-ground emesis?

8. What is the significance of the H. pylori a breath test result?

ANSWERS:

7. Upper GI bleeding is my concern about the coffee-ground emesis

 8. The significance of H. pylori to the breath test result is that H. Pylori is a
common cause of gastric ulcers

Case study progress

You ask the charge nurse to contact the gastrointestinal (GI) consulting physician to
explain the recent
events while you stay with M.R. The gastroenterologist gives several orders and
states he will be there in
30 minutes. The orders are as follows:
Chart view
Physician's Orders
• NPO status for emergent esophagogastroduodenoscopy (EGD)
• STAT CBC
• Oxygen by nasal cannula; trate oxygen to maintain SpO2 over 92%
• Type and crossmatch (T&C) 2 units packed RBCs (PRBCs), and hold
• Start a pantoprazole (Protonix) drip at 8 mg/hr, preceded by an 80-mg
bolus IV over8 minutes.
• Insert a Salem Sump nasogastric tube (NGT) and start a gastric lavage
with normal saline.
• Insert two large-bore IVs and start normal saline (NS) at 100 mL/hr.

QUESTIONS:
9. List the previous orders in order of priority.
10.Explain the rationale for each of the preceding orders.

ANSWERS:

9. ORDERS IN ORDER OF PRIORITY.

 Nothing by mouth (NPO) status for emergent

esophagogastroduodenoscopy (EGD)
 Repeat CBC STAT
 Type and crossmatch (T&C) 2 units packed red blood cells (PRBCs),
and hold
 Oxygen by nasal cannula; titrate oxygen to maintain SpO 2 over 94%
 Insert first large-bore IVs and start NS at 100 mL/hr
 Start a pantoprazole (Protonix) drip at 8 mg/hr, preceded by a 40-mg
bolus IV over 2 minutes
 Insert a Salem Sump nasogastric tube (NGT) and start a gastric
lavage with normal saline (NS)
 Insert second large-bore IVs and start NS at 100 mL/hr
 10.The EGD was a diagnostic test used to see his stomach and small
intestine, the CBC gives us lab values on his blood level count and
hematocrit, the nasal cannula brings his Spo2 up, Protonix is used to treat
his GERD and lower his stomach levels, the gastric lavage with saline
helps clean out his stomach and prevent

Case study progress:

The gastroenterologist finds erosive esophagi s LA Class B, a moderately sized

hiatal hernia,
diffuse erosive gastritis, and an ulcer in the antrum of the stomach that is oozing
blood. The duodenal bulb yielded a normal endoscopic appearance. During the
EGD, the bleeding was stopped with cautery. Biopsies were obtained of the gastric
mucosa, and the biopsies are negative for H. pylori bacteria; his bleeding ulcer is a
tributed to the NSAIDs (i.e., ibuprofen). He is kept NPO un l the next morning to
allow good hemostasis of the cauterized site. Clear liquids are allowed at breakfast.
His hematocrit (Hct) dropped to 32%, but he remained asymptomatic c from the mild
anemia; the drop was believed, in part, to reflect that he was dehydrated on
admission, and the decrease reflected the dilu on of the blood from the IV fluids
added. Thus, he did not receive a transfusion of blood. M.R. tolerated the liquid diet
without any nausea and vomiting and is discharged to home the next day with the
following instructions:
a. Advance diet slowly, as tolerated, to mechanical so
b. Take pantoprazole 40 mg PO q AM on an empty stomach at least 30
minutes before ea ng
• Make a follow-up appointment in 6 to 8 weeks with physician (give
name and telephone #)
• Stop all aspirin and over-the-counter (OTC) or herbal pain relief
medica- tions (Ibuprofen, naproxen, etc.)
• Stop or limit alcohol intake and smoking

QUESTIONS:

11.Why does the patient need to take the pantoprazole first thing in the
morning?

12.After discussing lifestyle modifications for controlling acid reflux with M.R.,
which statement by M.R. indicates a further need for teaching?
a. “I will try to stop smoking.”
b. “I will wait thirty minutes before lying down or sitting in my recliner after
meals.”
c. “I will avoid fa y foods, caffeine, and chocolate.”
d. “I will avoid ea ng two to three hours before my bed me.”
ANSWERS:

11.Taking pantoprazole first in the morning is the most important to do

because it is the most effective, PPIs

12. After discussing lifestyle modifications for controlling acid reflux with
M.R., which statement by M.R. indicates a need for further teaching?
a. "I will try to stop smoking."
b. "I will wait 30 minutes before lying down or sitting in my recliner after
meals."
c. "I will avoid fatty foods, caffeine, and chocolate."
d. "I will avoid eating 2 to 3 hours before my bedtime."