Chapter Gastroenterology N - Theme 18 - GERD

ONMedU, Department of internal medicine #2. Practical lesson #18.
Gastroesophageal reflux disease.
ODESSA NATIONAL MEDICAL UNIVERSITY

Department of internal medicine #2
ENDORSED
Head of the Department
__________ (Shtanko V.A.)
“29“ August 2022
METHODICAL GUIDE FOR PRACTICAL LESSON
V-th course, International Faculty

Educational discipline «Internal Medicine»
Practical lesson #18. Theme 20: Gastroesophageal reflux disease
Practical lesson was updated by:

PhD, Assistant Professor
_________(Tofan N.V.)
Practical lesson endorsed on

methodical meeting of the department
«29» August 2022
Protocol #1
Odessa – 2022
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Methodical guide for practical lesson, Specialty “Medicine”, V course, International Faculty
Practical lesson #18
Theme: Gastroesophageal reflux disease.
2. Goal:
To study:
- etiology, pathogenesis, classification, clinic, complications, diagnosis and
treatment of GORD;
- classification of antisecretory, prokinetic drugs and antacids;
- general and dietary recommendations, duration of treatment with endoscopic-
negative GORD and reflux- esophagitis. Methods for monitoring the effectiveness
of treatment;
- general principles of endoscopic and surgical treatment of Barrett's esophagus
and GORD.
3. Basic concepts. GERD: definition, epidemiology, aetiology, pathophysiology.

Classification of GERD. Step-by-step diagnostic approach. Risk factors of GERD.
Diagnostic tests. Diagnostic criteria. Differential diagnostics. Step-by-step treat-
ment approach. Emergency treatment. Complications. Prognosis. Treatment guide-
lines.
GORD is defined as symptoms or complications resulting from the reflux of

gastric contents into the [o]esophagus or beyond, into the oral cavity (including
larynx) or lung'.
Typical symptoms are heartburn and acid regurgitation. Atypical symptoms
include cough, laryngitis, asthma, or dental erosion. GORD may occur with or
without oesophageal inflammation (oesophagitis). Symptoms may be without ero-
sions on endoscopic examination (non-erosive reflux disease or NERD), or with
erosions present (ERD)
Incompetence of the lower esophageal sphincter allows reflux of gastric con-
tents into the esophagus, causing burning pain. Prolonged reflux may lead to
esophagitis, stricture, and rarely metaplasia or cancer. Diagnosis is clinical, some-
times with endoscopy, with or without acid testing. Treatment involves lifestyle
modification, acid suppression using proton pump inhibitors, and sometimes surgi-
cal repair.
Montreal definition
This classifies oesophageal syndromes.
1. Syndromes with symptoms and no injury:
• Typical reflux syndrome
• Reflux chest pain syndrome.
2. Syndromes with oesophageal injury:
• Reflux oesophagitis
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• Reflux stricture
• Barrett's oesophagus
• Oesophageal adenocarcinoma.
3. Extra-oesophageal syndromes
3.1. Established associations:
• Reflux cough syndrome
• Reflux laryngitis syndrome
• Reflux asthma syndrome
• Reflux dental erosion syndrome.
3.2. Proposed associations:
• Pharyngitis
• Sinusitis
• Idiopathic pulmonary fibrosis
• Recurrent otitis media.
Etiology
The presence of reflux implies lower esophageal sphincter (LES) incompe-
tence, which may result from a generalized loss of intrinsic sphincter tone or from
recurrent inappropriate transient relaxations (ie, unrelated to swallowing). Tran-
sient LES relaxations are triggered by gastric distention or subthreshold pharyngeal
stimulation.
Factors that contribute to the competence of the gastroesophageal junction in-
clude the angle of the cardioesophageal junction, the action of the diaphragm, and
gravity (ie, an upright position). Factors contributing to reflux include weight gain,
fatty foods, caffeinated or carbonated beverages, alcohol, tobacco smoking, and
drugs. Drugs that lower LES pressure include anticholinergics, antihistamines, tri-
cyclic antidepressants, Calcium channel blockers, progesterone, and nitrates.
Symptoms and Signs
The most prominent symptom of GORD is heartburn, with or without regurgi-
tation of gastric contents into the mouth. Infants present with vomiting, irritability,
anorexia, and sometimes symptoms of chronic aspiration. Both adults and infants
with chronic aspiration may have cough, hoarseness, or wheezing.
Esophagitis may cause odynophagia and even esophageal hemorrhage, which is
usually occult but can be massive. Peptic stricture causes a gradually progressive
dysphagia for solid foods. Peptic esophageal ulcers cause the same type of pain as
gastric or duodenal ulcers, but the pain is usually localized to the xiphoid or high
substernal region. Peptic esophageal ulcers heal slowly, tend to recur, and usually
leave a stricture on healing.
Diagnosis
TEST RESULT
proton-pump inhibitor (PPI) trial symptom improvement
Further tests are indicated if symptoms do not improve may show oesophagitis
with therapeutic 8-week trial of a PPI or if patient has
alarm symptoms.
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oesophagogastroduodenoscopy (OGD) (erosion, ulcerations,

• Indicated for alarm symptoms or symptoms suggesting strictures) or Barrett's
complicated disease (atypical, persistent, or relapsing
symptoms).
• Normal findings on endoscopy can occur with GORD oesophagus
(i.e., nonerosive reflux disease [NERD]).Routine
biopsies are not recommended by guidelines.
• Evidence is conflicting as to whether frequency and pH <4 more than 4% of the
severity of symptoms can predict Barrett's oesophagus,
severity of oesophagitis, or other complications.
• Higher grades of erosive oesophagitis may be time is abnormal
associated with the finding of Barrett's oesophagus with
healing. Thus, if endoscopy is performed to diagnose
GORD, it may best be performed off therapy.
If performed because of concern for Barrett's may suggest achalasia,
oesophagus (e.g., longstanding symptoms), it may be
best to carry out the procedure during treatment.
Complications
GERD may lead to esophagitis, peptic esophageal ulcer, esophageal stricture,
Barrett's esophagus, and esophageal adenocarcinoma. Factors that contribute to the
development of esophagitis include the caustic nature of the refluxate, the inability
to clear the refluxate from the esophagus, the volume of gastric contents, and local
mucosal protective functions. Some patients, particularly infants, aspirate the re-
flux material.
Treatment
Head of bed elevated.
Coffee, alcohol, fats, and smoking avoided.
Proton pump inhibitors.
Management of uncomplicated GERD consists of elevating the head of the
bed about 15 cm (6 in) and avoiding the following: eating within 2 to 3 h of bed-
time, strong stimulants of acid secretion (eg, coffee, alcohol), certain drugs (eg, an-
ticholinergics), specific foods (eg, fats, chocolate), and smoking.
Drug therapy is with a proton pump inhibitor. For example, adults can be
given esomeprazole 40 mg 30 min before breakfast. In some cases, proton pump
inhibitors may be given bid. These drugs may be continued long-term, but the dose
should be adjusted to the minimum required to prevent symptoms. H2 blockers
(eg, ranitidine 150 mg at bedtime) or promotility agents (eg, metoclopramide
10 mg 30 min before meals and at bedtime) are less effective.
Antireflux surgery (usually via laparoscopy) is done on patients with serious
esophagitis, large hiatal hernias, hemorrhage, stricture, or ulcers. Esophageal stric-
tures are managed by repeated balloon dilation.
Barrett's esophagus may or may not regress with medical or surgical therapy.
Because Barrett's esophagus is a precursor to adenocarcinoma, endoscopic surveil-
lance for malignant transformation is recommended every 1 to 2 yr. Surveillance
has uncertain cost-effectiveness in patients with low-grade dysplasia but is impor-
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tant in high-grade dysplasia in patients who are unable to undergo surgical resec-
tion. Alternatively, Barrett's esophagus may be treated with endoscopic mucosal
resection, photodynamic therapy, cryotherapy, or laser ablation.
4. Equipment: study room, acknowledge with protocol and procedure of fibrogas-

troduodenoscopy and results interpretation during visit to functional department
(1st floor in University Clinic).
5. Learning hours: 2 hours.
Plan of the lesson
I. Organizational moment (greetings, checking who is present on the lesson, an-

nouncing topic and goal of the lesson, motivating students to study the topic).
II.Control of basic knowledge (oral questioning, tests, checking of how clinical

cases and workbooks are fulfilled).
II.1. Demands for students theoretical preparation
Student should know:

1) GORD definition.
2) GORD epidemiology, aetiology and pathogenesis..
3) GORD classification.
4) Clinical manifestions of GORD.
5) GORD diagnostics.
6) Differential diagnostics of GORD.
7) GORD complications.
8) Standarts of treatment for GORD.
9) GORD prevention.
10) GORD complications.
Didactic units list:

- interview the patient with detailing complaints, identify main symptoms and
syndromes of GORD;
- conduct patient’s physical examination, to reveal and estimate abnormal changes;
- perform investigation methods used in GORD, point indications for their use and
the diagnostic value;
- interpret the results of investigation: oesophagogastroduodenoscopy, ambulatory
PH-monitoring, esophageal manometry, barium swallow test;
- substantiate and formulate preliminary and final clinical diagnosis based on
results of diagnostic tests;
- correctly choose regimen of treatment, depending on the specific clinical
situation;
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- to be acknowledged with last updated diagnostic and treatment guidelines.
Questions (tests, tasks, clinical situations) to test basic knowledge on the topic of
the lesson:
Tests for self-control

1. The reason of GERD may be:
A.Dolichocolon.
B.Hernia of esophageal diaphragm hole. +
C.Overdose of antacids.
D.Lack of fiber in food.
E. All of above.
2. What is not a GERD complication?
A.Bleeding.
B.Esophageal adenocarcinoma.
C.Stricture.
D.Acute intestinal obstruction. +
E. Erosion of esophageal mucous.
3. What degree of reflux esophagitis if : one (or more) erosion longer than 5 mm,
limited by the boundaries of one fold?
A.A.
B.B. +
C.C.
D.D.
E. E.
4. Which drugs do not block the secretion of hydrochloric acid?
A.Famotidine.
B.Rabeprazole.
C.Atropine. +
D.Maalox.
E. Gastrocepine.
5. Which method is not informative in the GERD diagnosis?
A.PPI-test.
B.Upper endoscopy.
C.CT. +
D.impedance -metry.
E. Complete blood count.
6. Famotidine is:
A.Prokinetic.
B.Antacid.
C.H2 -receptor histamine blockers. +
D.Peripheral M-cholinolitics.
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E. Antiviral drug
7. In the treatment of duodenogastral reflux in GERD you can include:
A.H2 blocker at night. +
B.Enzyme preparations.
C.Ursodeoxycholic acid.
D.Laxatives drugs.
E. Probiotics.
8. What method of diagnosis is optimal as a screening for GERD?
A.PPI-test +
B.Upper endoscopy.
C.X-ray.
D.Ultrasound.
E. ECG.
9. What PPI is used for faster achievement acid-inhibitor effect, sufficient for
GERD ?
A.Esomeprazole. +
B.Pantoprazole.
C.Rabeprazole.
D.Lanzoprazol.
E. Omeprazole
10. Patient, 42 y.o. Complaints: difficulty in swallowing food, pain in the lower
part of the sternum, sometimes at night with food regurgitation, which is eaten in
the evening. Lost weight over 4 months to 2 kg. On examination revealed no
pathology. On ECG - a slight depression of ST segment in III lead. X-ray:
esophageal peristalsis is absent, a significant expansion of the esophagus to the
cardiac department, where the esophagus is narrowed in the form of the beak. A
blood test – normal. Your diagnosis?
A.Achalasia of the esophagus.
B.Cancer of the esophagus.
C.Sclerodermia with esophagitis.
D.Esophagus diverticulum.
E. Diaphragmatic hernia. +
III. Formation of professional skills, abilities:

3.1. content of tasks (tasks, clinical situations, etc.)
Case history.
A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For
the past 4 to 6 months she has had symptoms several times per week. Symptoms
are worse when she lies down or bends over. Antacids help somewhat. The patient
has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or
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weight loss. Past medical history and family history are non-contributory. The
patient drinks alcohol occasionally and does not smoke. On physical examination,
height is 1.63 m (5 feet 4 inches),weight 77.1 kg, and BP 140/88 mmHg. The
remainder of the examination is unremarkable.
3.2. recommendations (instructions) for performing tasks (professional algorithms,

orientation maps for the formation of practical skills, etc.)
Professional algorithms.
I. Patient’s examination.
During patient’s examination students should keep such communicative skills:
1. Friendly face expression.
2. Kind voice tone.
3. Greetings, showing concern and respect about the patient.
4. Find out patient’s complaints and anamnesis .
5. Explanation of investigation results.
6. Explanation of specific actions (hospitalization, carrying out investigations)
which are planned to be performed in the future.
7. Finishing of the talk.
II. Patient’s examination and investigation algorithm.

1. Diagnosis is clinical, supported by testing when required. Heartburn and
regurgitation are the most reliable symptoms.
2. A short trial (8 weeks) of PPIs and lifestyle therapy (such as weight loss if
needed, and elevation of head of bed for nocturnal features) should be started in
patients with typical symptoms.
3. Upper endoscopy (oesophagogastroduodenoscopy) is indicated in patients with
atypical, relapsing or persistent symptoms.
4. Patients with persistent symptoms on therapy with PPIs and unrevealing
endoscopy undergo further testing: manometry next to evaluate oesophageal
contractions and lower oesophageal sphincter function. Also ambulatory
reflux (pH or impedance-pH) monitoring test.
5. It should be explained to patient which investigation will be held and indications
for this investigation.
6. A doctor should receive patient’s agreement on investigation.
7. A doctor should warn patient about possibilities of unpleasant feelings during
oesophagogastroduodenoscopy.
8. Results of investigation should be explained to a patient.
III. Step-by-step algorithm of treatment.

1. A patient should informed be about necessity of the prescribed treatment.
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2. Dosages, drugs intake regimens, duration of treatment, side effects of the

prescribed therapy should be kindly explained to patient.
3. Most patients with GORD require prolonged pharmacotherapy with acid
suppressants and proton pump inhibitors are the most effective drugs in this
category.
4. For patients <40 years old who have typical, regular heartburn and no alarm
symptoms, treatment should be started with standard-dose PPIs for about 8 weeks.
It is recommended to start treatment with the lowest effective dose of PPI.
5. Lifestyle changes are recommended for all patients. These include: weight loss
for overweight people; smoking cessation for tobacco smokers; head-of-bed-
elevation and avoidance of late-night eating if nocturnal symptoms are present.
6. Bedtime adjunctive use of H2 antagonists may be considered in people with
nocturnal symptoms or pH-monitoring evidence of nocturnal oesophageal acid
reflux, when PPIs are not completely effective.
7. Patients who present with complicated or atypical GORD (e.g., dysphagia or
evidence of GI bleeding) usually have immediate endoscopy. These patients
should also be treated with PPIs.
8. People with non-erosive reflux disease may be able to use on-demand or
intermittent PPI therapy.
9. Surgery (open or laparoscopic fundoplication) is reserved mainly for people who
have had a good response to PPIs but who do not wish to take long-term medical
treatment.
10. Patients should be involved in the decision to initiate surgery, as evidence for
surgery is conflicting.
3.3. requirements for students work results.

As a results of studying students must perform the following:
-possess skills of communication and clinical examination of a patient with GERD;
-collect data on patient complaints, medical history, life history;
-evaluate information about the diagnosis of GERD using a standard procedure,
based on the results of laboratory and instrumental studies. Determine the list of
required clinical, laboratory and instrumental studies and evaluate their results;
- identify the leading clinical symptom or syndrome. Establish the most probable
or syndrom diagnosis GERDS. Assign laboratory and instrumental examination of
the patient. Carry out differential diagnosis of GERD. Establish preliminary and
clinical diagnosis;
- determine the principles of treatment, the required regime of work/rest and
alimentary regime of patients with GERD;
- diagnose emergencies in the clinic of GERD;
- define tactics and provide emergency medical care;
- perform an expertise of work capacity of patients with GERD.
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3.4. control materials for the final stage of the lesson.

Materials for self- training quality.
A. Review Questions.
1. Definition of GERD.
2. Etiology and pathogenesis of GERD.
3. Classification by ICD-10 and clinical classification of GERD.
4. Typical and atypical symptoms of GERD.
5. Stages of diagnosis in accordance with modern standards of medical care.
6. The program of differential diagnosis.
7. Principles of treatment to modern standards of rendering medical care.
8. Principles of the management in the patients with GERD.
B. Work 1
1. Collection of complaints, anamnesis, examination of a patient with GERD.
2. Detection of clinical and instrumental symptoms.
3. Grouping symptoms into syndromes.
4. Definition of the leading syndrome.
5. Interpretation of laboratory and instrumental data (clinical analysis of blood,
urine, biochemical analysis of blood, PPI - test, radiography of the esophagus
and stomach with barium, FGDS, ECG, echocardiography, etc.).
6. Carrying out a differential diagnosis.
7. Formulation of the clinical diagnosis.
8. Write a prescription list for patients diagnosed with GERD, which would
include diet and prescribed drugs.
9. Determining of the disability degree.
Work 2.
Assignment of differentiated treatment programs according to the clinical
protocol of medical care.
Work 3.
Work in the Internet, in the reading room of the department library with
thematic literature.
The student fills in the protocol of the patient's examination. An example of
the initial examination of the patient is attached.
C. The tests for self-control with standard answers.

1. A 38 y.o. man complains of having occasional problems with swallowing of
both hard and fluid food for many months. Sometimes he feels intense pain behind
his breast bone, epecially after hot drinks. There are asphyxia onsets at night. He
has not put off weight. Objectively: his general condition is satisfactory, skin is of
usual colour. Examination revealed no changes of gastrointestinal tract. X-ray
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picture of thorax organs presents esophagus dilatation with level of fluid in it.
What is the preliminary diagnosis?
A Oesophagus achalasia
B Myastenia
C Cancer of oesophagus
D Esophagus candidosis
E Gastroesophageal reflux
2. A 49-year-old patient complains of deglutition problems, especially with solid
food, hiccups, voice hoarseness, nausea, regurgitation, significant weight loss (15
kg within 2,5 months). Objectively: body weight is reduced. Skin is pale and dry.
In lungs: vesicular breathing, heart sounds are loud enough, heart activity is
rhythmic. The abdomen is soft, painless on palpation. Liver is not enlarged. What
study is required to make a diagnosis?
A Clinical blood test
B Esophageal duodenoscopy along with biopsy
C X-ray of digestive tract organs
D X-ray in Trendelenburg's position
E Study of gastric secretion
3. A male patient complains of heartburn which gets stronger while bending the
body, retrosternal pain during swallowing. There is a hiatus hernia on X-ray. What
disorder should be expected at gastroscopy?
A Gastric peptic ulcer
B Chronic gastritis
C Gastroesophageal reflux
D Acute erosive gastritis
E Duodenal peptic ulcer
4. A 35-year-old patient complains of heartburn, sour eructation, burning,
compressing retrosternal pain and pain along the esophagus rising during forward
bending of body. The patient hasn't been examined, takes Almagel on his own
initiative, claims to feel better after its taking. Make a provisional diagnosis:
A Gastric ulcer
B Functional dyspepsia
C Cardiospasm
D Gastroesophageal reflux disease
E Duodenal ulcer
5. A patient complains of retrosternal pain, difficult swallowing, over 10 kg weight
loss within three months, general weakness. In blood: hypochromic anaemia,
neutrophilic leukocytosis. In feces: weakly positive Gregersen's reaction. On
esophagram a filling defect with ill-defined serrated edges shows up along a large
portion of the oesophagus. What is the most likely diagnosis?
A Sideropenic dysphagia
B Benign tumour
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C Esophageal achalasia
D Peptic ulcer
E Esophageal carcinoma
6. A patient suffering from gastroesophageal reflux has taken from time to time a
certain drug that "reduces acidity" over 5 years. This drug was recommended by a
pharmaceutist. The following side effects are observed: osteoporosis, muscle
asthenia, indisposition. What drug has such following effects?
A Aluminium-bearing antacid
B Inhibitor of proton pump
C H2-blocker
D Metoclopramide
E Gastrozepin
7. A 35-year-old man complains on chest pain for several months, occasionally
having a bitter taste in the mouth. The pain is localized behind the chest, occurs at
rest and sometimes radiates to the neck, does not increase with exercise, may
increase after alcohol and large amounts of food. Occasionally there is a dry cough
and hoarseness. The condition worsens at night. Swallowing is not disturbed, body
weight is increased. No changes detected during examination. What is the most
likely diagnosis?
A. Chronic pharyngitis
B. Esophageal cancer
C. Bronchial asthma
D. GORD
E. Hysteria
8. In 22-year-old patient during fall appeared pain in the right epigastrium, which
occurs 1.5-2 hours after eating and at night. He complains on heartburn,
constipation. The pain is aggravated by eating spicy, salty and sour food, decreases
after Na-hydrocarbonate usage and after putting a warm bag on the "painful place".
Ill for a 1 year. Objectively: on palpation of the abdominal organs there is pain in
the epigastrium on the right side, in the same area - a slight resistance of the
abdominal muscles. Which disease is most likely?
A. Diaphragmatic hernia
B. Gastroesophageal reflux disease
C. Chronic pancreatitis
D. Peptic ulcer of the stomach
E. Peptic ulcer of the duodenum
9. A 48-year-old woman complains of a feeling of compression in the esophagus,
palpitations, difficulty breathing when eating solid foods; sometimes vomiting with
a full mouth, at night - a symptom of a "wet pillow". Ill for about 6 months.
Objectively: t - 36.5 C, height - 168 cm, weight - 72 kg, pulse - 76 beats / min.,
blood pressure - 120/80 mm Hg. Radiologically: the esophagus is significantly
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dilated, in the cardiac part - narrowed. What pathology most likely caused
dysphagia in the patient?
A. Achalasia of the cardia
B. Primary esophagospasm
C. Hernia of the esophageal lumen of the diaphragm
D. Esophageal cancer
E. Gastroesophageal reflux disease
10. A 41-year-old patient complains of epigastric pain after exercise, heartburn,
prolonged hiccups, increased salivation. Laboratory: signs of hypochromic anemia,
positive reaction on occult blood in feces. X-ray of the stomach in the position of
Trendelenburg shows passing of barium mixture into the cardiac part of the
stomach, which is located in the chest. Which diagnosis is most likely?
A Hernia of the esophageal lumen of the diaphragm
B Gastritis with reduced acid function of the stomach
C Gastroesophageal reflux disease
D Peptic ulcer disease
E Duodenogastric reflux
11. The patient complains of heartburn, which is exacerbated while bending
forward, chest pain during swallowing. The presence of GERD is suspected.
Which of the research methods should be used to confirm the diagnosis?
A. Fibrogastroscopy
B. Computed tomography of the thoracic cavity
C. Outpatient impedance-pH monitoring
D. A and C
E. All the abovementioned
12. A patient with gastroesophageal reflux disease for 5 years periodically, on the
recommendation of a pharmacist, takes a drug "reducing acidity". The following
side effects occurred: osteoporosis, muscle weakness, malaise. What drug has such
a side effect?
A. Metoclopramide
B. Rabeprazole
C. Almagel
D. Gastrocepin
E. Famotidine
13. The 58-year-old patient complains of heartburn, belching, which are
aggravated by bending forward, pain when swallowing behind the sternum.
Fibrogastroscopic investigation revealed Barrett's esophagus. By what can be
complicated this pathology?
A. Gastric dyspepsia
C. Gastric ulcer
D. Erosive gastritis
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E. Duodenal ulcer
14. A 55-year-old patient complains on heartburn, which is exacerbated by bending
forward, chest pain when swallowing. X-ray investigation revealed a hernia of the
esophageal lumen of the diaphragm. GERD was established during
fibrogastroscopy. Concomitant pathology - hypertension, constantly taking
amlodipine. Direction of treatment?
A. Prescribe pantoprozole
B. Prescribe domperidone
C. Replace amlodipine with another antihypertensive
D. All of the abovementioned
E. None of the abovementioned
Standard answers: 1-A, 2-B, 3-C, 4-D, 5-E, 6-A, 7-D, 8-E, 9-A, 10-A, 11-D, 12-C,
13-B, 14-D.
Information necessary for the formation of knowledge-skills can be found in:

- Basic literature source:
1. Gyawali CP, Kahrilas PJ, Savarino E, et al. Modern diagnosis of GERD: the
Lyon Consensus. Gut 2018; 67:1351-62. doi:10.1136/gutjnl-2017-314722
pmid:29437910
2. Sandhu D.S., Fass R. Current Trends in the Management of Gastroesophageal
Reflux Disease / Gut Liver, 2018 Jan; 12(1): 7–16.
- Additional literature source:
1. Eusebi LH, Ratnakumaran R, Yuan Y, Solaymani-Dodaran M, Bazzoli F, Ford
AC. Global prevalence of, and risk factors for, gastro-oesophageal reflux
symptoms: a meta-analysis. Gut 2018; 67:430-40. doi:10.1136/gutjnl-2016-313589
pmid:28232473
Appendix 1
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Example of the primary examination of the patient

Passport data: name and surname, age
Complaints:
Burning pain, which is localized behind the sternum, do not have a clear
connection with exercise and occur immediately after eating, the pain does not
pass after taking nitroglycerin (which the patient has taken by himself); as well as
heartburn, heaviness and fullness in the epigastric region after eating, belching
with air and eaten food.
Anamnesis morbi
The patient ill for 6 months, previously did not look for medical help, was not
examined.
Anamnesis vitae
Living conditions are satisfactory. Botkin's disease, tuberculosis, sexually
transmitted diseases, malaria denies.
Professional anamnesis: not burdened.
Hereditary history is not burdened.
Рave not been in contact with infectious patients for the last 3 days. He has not left
the country in the last 3 years.
Hereditary history: not burdened
Neurological history
At the time of examination signs of focal neurological symptoms were not detected.
Allergic history: not burdened
Epidemiology
Tuberculosis, malaria, viral hepatitis, Botkin's disease, veneral disease, HIV,
AIDS, pediculosis – denies.
Oncoanamnesis: denies.
Insurance anamnesis: There is no need to issue a seak leave, for the last 12
months a seak leave document has not been issued in this regard.
Postponed operations: denies.
Bad habits: smokes for 20 years, 1 pack a day
Examination of organ systems:
GENERAL Condition: satisfactory
CONSCIOUSNESS: clear
Body shape: hyperstenic
Fatness: high nutrition
POSITION OF THE PATIENT: active
BODY TEMPERATURE: 36.6 C. Signs of alcohol intoxication - no
SKIN: Skin of normal color, clean. Tissue turgor is normal. Skin pigmentation: de-
pigmentation - no. Rash: no; other changes in the skin: no.
Visible mucous membranes: Normal color
LYMPH NODES: not enlarged
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THYROID GLAND: no pathology

Oncological examination was performed, no visual forms of oncopathology were
detected
Cardiovascular system:
PERCUSSION OF THE HEART: the limits of relative cardiac dullness: right on
the right edge of the sternum, upper -III rib on the left parasternalis line, left - 2
cm outward from the left mediaclavicularis line in the V intercostal space
HEART activity: rhythmic, heart rate - 74 per 1 min. Pulse 74 in 1 min. Heart
tones: muffled
HEART MURMURS: no
EDEMA: no
BP 125 / 85 mm Hg
EXAMINATION OF ARTERIES: no pathology
VEIN STUDY: no pathology
RESPIRATORY SYSTEM:
BREATHING: no dyspnea at rest, RR 16 in 1 min.
Sputum: no
CHEST: cylindrical, not deformed. Intercostal spaces: NOT smoothed. Participa-
tion of additional muscles: no, RR – 16 in 1 min. SpO2 = 98%
Percussion over the lungs: clear lung sound.
PULMONARY AUSCULTATION: vesicular breathing over both lungs. Pleural
friction noise - no
DIGESTIVE SYSTEM:
TONGUE: wet; covered with white plaque
Tonsils: not enlarged
STOMACH: participates in the act of breathing. No hernia. Pulsation in the epi-
gastrium - no. There is no dilation of the subcutaneous veins
Palpation: moderately painful in the epigastric region
Pathological symptoms: not detected
Liver: not enlarged
Gallbladder: not palpable
Pancreas: painless
Spleen: not palpable,
PERCUTIONAL SOUND OVER THE ABDOMINAL CAVITY: unchanged,
FECES: normal, no pathological impurities
URINARY SYSTEM:
Palpation of the kidneys: not palpable
Pasternatsky's symptom is negative on both sides.
Urination: free, painless, frequency per day: 3-4 times.
Urinary incontinence: no.
SENSES:
SIGHT: not violated (OU). There is no other pathology
Page 16
HEARING: normal, no deafness, pain: no. Tinnitus: no.

Musculoskeletal system:
Pathology of the musculoskeletal system was not detected
On the basis of complaints, anamnesis, objective examination, it is possible to
make a preliminary diagnosis:
GERD
Plan of investigation
general blood test, general urine test, glycemia level (8.00, 13.00, 17.00, 21.00)
Biochemistry: liver tests, glucose, transaminases, protein, lipid spectrum, coagulo-
gram, amylase, AF, LDG, GGT, CPK, serum iron, potassium, CRP, seromucoid,
RF, ASLO.
ECG, FGDS with biopsy, helpil-test, ultrasound of abdominal organs
Consultation with a neurologist, cardiologist, gastroenterologist.
Treatment plan
Normalization of lifestyle
Drug therapy:
- Omeprazole 20 mg - 1 tab. x 2 times/day, 20 minutes before eating
- Motilium 10 mg - 1 tab. x 3 times/day, 20 minutes before eating
- Almagel - 1 pack. during heartburn
- Eradication of Helicobacter pylori if there is a positive helpil test
Appendix 2
Page 17
Tests of basic knowledge level in KROK format

Theme 20. Gastroesophagel reflux disease
1. A 35-year-old man complains on chest pain for several months, occasionally

having a bitter taste in the mouth. The pain is localized behind the chest, occurs at
rest and sometimes radiates to the neck, does not increase with exercise, may
increase after alcohol and large amounts of food. Occasionally there is a dry cough
and hoarseness. The condition worsens at night. Swallowing is not disturbed, body
weight is increased. No changes detected during examination. What is the most
likely diagnosis?
A. Chronic pharyngitis
C. Bronchial asthma
D. GORD
E. Hysteria
2. In 22-year-old patient during fall appeared pain in the right epigastrium, which
occurs 1.5-2 hours after eating and at night. He complains on heartburn,
constipation. The pain is aggravated by eating spicy, salty and sour food, decreases
after Na-hydrocarbonate usage and after putting a warm bag on the "painful place".
Ill for a 1 year. Objectively: on palpation of the abdominal organs there is pain in
the epigastrium on the right side, in the same area - a slight resistance of the
abdominal muscles. Which disease is most likely?
A. Diaphragmatic hernia
B. Gastroesophageal reflux disease
C. Chronic pancreatitis
D. Peptic ulcer of the stomach
E. Peptic ulcer of the duodenum
3. A 48-year-old woman complains of a feeling of compression in the esophagus,
palpitations, difficulty breathing when eating solid foods; sometimes vomiting with
a full mouth, at night - a symptom of a "wet pillow". Ill for about 6 months.
Objectively: t - 36.5 C, height - 168 cm, weight - 72 kg, pulse - 76 beats / min.,
blood pressure - 120/80 mm Hg. Radiologically: the esophagus is significantly
dilated, in the cardiac part - narrowed. What pathology most likely caused
dysphagia in the patient?
A. Achalasia of the cardia
B. Primary esophagospasm
C. Hernia of the esophageal lumen of the diaphragm
D. Esophageal cancer
E. Gastroesophageal reflux disease
4. A 41-year-old patient complains of epigastric pain after exercise, heartburn,
prolonged hiccups, increased salivation. Laboratory: signs of hypochromic anemia,
positive reaction on occult blood in feces. X-ray of the stomach in the position of
Page 18
Trendelenburg shows passing of barium mixture into the cardiac part of the
stomach, which is located in the chest. Which diagnosis is most likely?
A Hernia of the esophageal lumen of the diaphragm
B Gastritis with reduced acid function of the stomach
C Gastroesophageal reflux disease
D Peptic ulcer disease
E Duodenogastric reflux.
5. The patient complains of heartburn, which is exacerbated while bending
forward, chest pain during swallowing. The presence of GERD is suspected.
Which of the research methods should be used to confirm the diagnosis?
A. Fibrogastroscopy
B. Computed tomography of the thoracic cavity
C. Outpatient impedance-pH monitoring
D. A and C
E. All the abovementioned
6. A patient with gastroesophageal reflux disease for 5 years periodically, on the
recommendation of a pharmacist, takes a drug "reducing acidity". The following
side effects occurred: osteoporosis, muscle weakness, malaise. What drug has such
a side effect?
A. Metoclopramide
B. Rabeprazole
C. Almagel
D. Gastrocepin
E. Famotidine
7. The 58-year-old patient complains of heartburn, belching, which are aggravated
by bending forward, pain when swallowing behind the sternum. Fibrogastroscopic
investigation revealed Barrett's esophagus. By what can be complicated this
pathology?
A. Gastric dyspepsia
C. Gastric ulcer
D. Erosive gastritis
E. Duodenal ulcer
8. A 55-year-old patient complains on heartburn, which is exacerbated by bending
forward, chest pain when swallowing. X-ray investigation revealed a hernia of the
esophageal lumen of the diaphragm. GERD was established during
fibrogastroscopy. Concomitant pathology - hypertension, constantly taking
amlodipine. Direction of treatment?
A. Prescribe pantoprozole
B. Prescribe domperidone
C. Replace amlodipine with another antihypertensive
D. All of the abovementioned
Page 19
E. None of the abovementioned

9. A patient complains of retrosternal pain, difficult swallowing, over 10 kg weight
loss within three months, general weakness. In blood: hypochromic anaemia,
neutrophilic leukocytosis. In feces: weakly positive Gregersen's reaction. On
esophagram a filling defect with ill-defined serrated edges shows up along a large
portion of the oesophagus. What is the most likely diagnosis?
A Sideropenic dysphagia
B Benign tumour
C Esophageal achalasia
D Peptic ulcer
E Esophageal carcinoma
10. A patient suffering from gastroesophageal reflux has taken from time to time a
certain drug that "reduces acidity" over 5 years. This drug was recommended by a
pharmaceutist. The following side effects are observed: osteoporosis, muscle
asthenia, indisposition. What drug has such following effects?
A Aluminium-bearing antacid
B Inhibitor of proton pump
C H2-blocker
D Metoclopramide
E Gastrozepin
Page 20

Chapter Gastroenterology N - Theme 18 - GERD

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Chapter Gastroenterology N - Theme 18 - GERD

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ONMedU, Department of internal medicine #2. Practical lesson #18.

Gastroesophageal reflux disease.

ODESSA NATIONAL MEDICAL UNIVERSITY

METHODICAL GUIDE FOR PRACTICAL LESSON

V-th course, International Faculty

Practical lesson was updated by:

Practical lesson endorsed on

Practical lesson #18

Theme: Gastroesophageal reflux disease.

3. Basic concepts. GERD: definition, epidemiology, aetiology, pathophysiology.

GORD is defined as symptoms or complications resulting from the reflux of

oesophagogastroduodenoscopy (OGD) (erosion, ulcerations,

4. Equipment: study room, acknowledge with protocol and procedure of fibrogas-

Plan of the lesson

I. Organizational moment (greetings, checking who is present on the lesson, an-

II.Control of basic knowledge (oral questioning, tests, checking of how clinical

Student should know:

Didactic units list:

- to be acknowledged with last updated diagnostic and treatment guidelines.

Tests for self-control

III. Formation of professional skills, abilities:

3.2. recommendations (instructions) for performing tasks (professional algorithms,

II. Patient’s examination and investigation algorithm.

III. Step-by-step algorithm of treatment.

2. Dosages, drugs intake regimens, duration of treatment, side effects of the

3.3. requirements for students work results.

3.4. control materials for the final stage of the lesson.

C. The tests for self-control with standard answers.

Information necessary for the formation of knowledge-skills can be found in:

Example of the primary examination of the patient

THYROID GLAND: no pathology

HEARING: normal, no deafness, pain: no. Tinnitus: no.

Tests of basic knowledge level in KROK format

1. A 35-year-old man complains on chest pain for several months, occasionally

E. None of the abovementioned

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