Gastroesophageal Reflux Disease (GERD) In The Adult · Gastroesophageal reflux disease (GERD) is defined as a condition that ... gastroesophageal reflux disease (GERD) in the adult,

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Gastroesophageal

Reflux Disease

(GERD)

In The Adult

Elizabeth Boldon, RN, MSN

Elizabeth Boldon is a Nurse Education

Specialist at Mayo Clinic in Rochester,

Minnesota. She received a BSN from Allen College in Waterloo, Iowa in 2002 and an

MSN with a focus in education from the University of Phoenix in 2008. She has

bedside nursing experience in medical neurology and the neuroscience ICU.

Abstract

Gastroesophageal reflux disease (GERD) is defined as a condition that

develops when the reflux of stomach contents causes troublesome

symptoms with or without mucosal damage and/or complications. GERD

symptoms can include nausea, dysphagia, burning chest or abdominal pain,

respiratory disorders and mild to severe damage to the esophageal lining

and functioning. Patients that are not investigated for symptoms or not

followed up through recommended diagnostic testing when damage to the

esophagus has occurred are at risk of further injury and complications,

including Barrett’s esophagus (a precancerous condition). The diagnosis,

symptoms, complications and standard medical and surgical treatment of

GERD are discussed.

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Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Nurses need to recognize and stay informed of symptoms of

gastroesophageal reflux disease (GERD) in the adult, including the current

and evolving trends in GERD diagnosis and treatment management.

Course Purpose

To provide nursing professionals with knowledge to care for adult patients

with GERD and to help support improved quality of life.

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Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 10/27/2018

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned

will be provided at the end of the course.

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1. GERD affects up to _________ adults in the United States on a daily

basis.

a. 3.5 million

b. 5 million

c. 6.8 million

d. 10 million

2. The esophagus is a tube-like structure that is approximately _____

inches long and one _____ inch wide in adults.

a. 15 (inches long) and 2 (inch wide)

b. 13 (inches long) and 3 (inch wide)

c. 10 (inches long) and 1 (inch wide)

d. none of the above

3. Barrett's esophagus is associated with an increased risk of:

a. acid reflux

b. aspiration pneumonia

c. high incidence of malignancy

d. esophageal cancer

4. H-2-receptor blockers do not act as quickly as antacids do, but provide

longer relief and may decrease acid production up to ______ hours.

a. 6

b. 24

c. 8

d. 12

5. PPIs have been associated with slight increase in risk of bone fracture

and vitamin B-12 deficiency.

a. True

b. False

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Introduction

Gastroesophageal reflux disease, or GERD, is a digestive disorder that

affects the lower esophageal sphincter (LES), the ring of muscle between the

esophagus and stomach. Up to 10 million adults in the United States are

affected by GERD on a daily basis.1 GERD has been defined by experts within

international gastroenterology symposiums of the Rome Foundation, such as

Rome III, as a condition that develops when gastric contents reflux into the

esophagus leading to troublesome symptoms with or without damage to the

esophageal mucosa and/or complication.2

Many people, including pregnant women, suffer from heartburn or acid

indigestion caused by GERD. In most cases, GERD can be relieved through

diet and lifestyle changes; however, some people may require medication or

surgery.

Pathophysiology Of GERD

When food is consumed it is carried from the mouth to the stomach through

the esophagus, a tube-like structure that is approximately 10 inches long

and one inch wide in adults. The esophagus is made of tissue and muscle

layers that expand and contract to propel food to the stomach through a

series of wave-like movements called peristalsis.

At the lower end of the esophagus, where it joins the stomach, there is a

circular ring of muscle called the lower esophageal sphincter (LES). After

swallowing, the LES relaxes to allow food to enter the stomach and then

contracts to prevent the back up of food and acid into the esophagus.

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However, sometimes the LES is

weak or becomes relaxed because

the stomach is distended, allowing

liquids in the stomach to wash back

into the esophagus. This happens

occasionally in all individuals. Most

of these episodes occur shortly after

meals, are brief, and do not cause

symptoms. Normally, acid reflux

should occur only rarely during

sleep.

Acid reflux becomes gastroesophageal reflux disease when it causes

bothersome symptoms or injury to the esophagus. The amount of acid reflux

required to cause GERD varies. In general, damage to the esophagus is

more likely to occur when acid refluxes frequently, the reflux is very acidic,

or the esophagus is unable to clear away the acid quickly.

The most common symptoms associated with acid reflux are heartburn,

regurgitation, chest pain, and trouble swallowing (dysphagia). The

treatments of GERD are designed to prevent one or all of these symptoms

from occurring.3 Both acid reflux and heartburn are common digestive

conditions that many people experience from time to time. When these signs

and symptoms occur at least twice each week or interfere with daily life, or

when a health care provider can see damage to the esophagus, a diagnosis

of GERD may be given.

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Most people can manage the discomfort of GERD with lifestyle changes and

over-the-counter medications. But some people with GERD may need

stronger medications, or even surgery, to reduce symptoms.4 The symptoms

of GERD are discussed below, including those factors that trigger and

potentially alleviate symptoms.

Symptoms of GERD

GERD signs and symptoms include:4

A burning sensation in the chest

(heartburn), sometimes spreading to

the throat, along with a sour taste in

the mouth

Chest pain

Difficulty swallowing (dysphagia), or

food getting stuck

Painful swallowing (odynophagia)

Dry, chronic cough

Hoarseness or sore throat

Regurgitation of food or sour liquid

(acid reflux)

Sensation of a lump in the throat

Stomach pain (or pain in the upper abdomen)

Worsening dental disease

Chronic sinusitis

Waking up with a choking sensation

Nausea

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The most common symptom of GERD is heartburn. Also called acid

indigestion, GERD usually feels like a burning chest pain beginning behind

the breastbone and moving upward to the neck and throat. Many people say

it feels like food is coming back into the mouth leaving an acid or bitter

taste.

The burning, pressure, or pain of heartburn can last as long as two hours

and is often worse after eating. Lying down or bending over can also result

in heartburn. Many people obtain relief by standing upright or by taking an

antacid that clears acid out of the esophagus.

GERD Epidemiology

Gastroesophageal Reflux Disease is caused by frequent acid reflux — the

backup of stomach acid or bile into the esophagus. When a person swallows,

the lower esophageal sphincter — a circular band of muscle around the

bottom part of the esophagus — relaxes to allow food and liquid to flow

down into the stomach. Then it closes again. However, if this valve relaxes

abnormally or weakens, stomach acid can flow back up into the esophagus,

causing frequent heartburn. Sometimes this can disrupt daily life.

This constant backwash of acid can irritate the lining of the esophagus,

causing it to become inflamed (esophagitis). Over time, the inflammation

can wear away the esophageal lining, causing complications such as

bleeding, esophageal narrowing or Barrett's esophagus (a precancerous

condition).4

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Risk Factors

Conditions that can increase the likelihood of having GERD include:4

Obesity

Bulging of top of stomach up into the diaphragm (hiatal hernia)

Pregnancy

Smoking

Dry mouth

Asthma

Diabetes

Delayed stomach emptying

Connective tissue disorders, such as scleroderma

Certain foods – chocolate, peppermint, fried or fatty foods, coffee,

alcoholic beverages

Pressure changes within the esophagus may

be caused externally by the diaphragm, and

result in symptoms as those listed above.

The esophagus passes through an opening

in the diaphragm called the diaphragmatic

hiatus before it joins with the stomach. The

diaphragm is a large flat muscle at the base

of the lungs that contracts and relaxes as a

person breathes in and out.

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Normally, the diaphragm will contract, which improves the strength of the

LES especially during bending, coughing, or straining. If there is a

weakening in the diaphragm muscle at the hiatus, the stomach may be able

to partially slip through the diaphragm into the chest, forming a sliding

hiatus hernia.

The presence of a hiatus hernia makes acid reflux more likely. A hiatus

hernia is more common in people over age 50. Obesity and pregnancy are

also contributing factors. The exact cause is unknown but may be related to

the loosening of the tissues around the diaphragm that occurs with

advancing age. There is no way to prevent a hiatus hernia.3

Hiatal hernias usually do not require treatment. However, treatment may be

necessary if the hernia is in danger of becoming strangulated (twisted in a

way that cuts off blood supply, called a paraesophageal hernia) or is

complicated by severe GERD or esophagitis (inflammation of the

esophagus). The health provider may perform surgery to reduce the size of

the hernia or to prevent strangulation.

Diagnosing GERD

Gastroesophageal reflux disease is usually diagnosed based upon symptoms

and the response to treatment. In people who have symptoms of acid reflux

but no evidence of complications, a trial of treatment with lifestyle changes

and, in some cases, medication is often recommended without testing.

Specific testing is required when the diagnosis is unclear or if there are more

serious signs or symptoms as described above.

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It is important to rule out potentially life threatening problems that can

cause symptoms similar to those of gastroesophageal reflux disease. This is

particularly true with chest pain, which can also be a symptom of heart

disease.. Diagnosis of GERD is based on the following symptoms and

diagnostic testing outcomes.3,4

Symptoms:

Health care providers may be able to diagnose GERD based on

frequent heartburn and other symptoms.

Ambulatory acid (pH) probe tests:

The ambulatory pH test monitors the amount of acid in the esophagus

using a device to measure acid for 24 – 48 hours. The device identifies

when, and for how long, stomach acid regurgitates into the esophagus.

One method, is to insert a thin, flexible pH measuring probe (catheter)

through the nose and thread it past the upper section of the

esophagus to position the tube sensors just above the LES where

reflux may be found to occur.

The pH probe test is generally intended to last 24 hours. The external

portion of the pH probe connects to a small electronic receiver that is

worn around the waist or with a strap over the shoulder to retrieve

data, such as reflux episodes in relation to meals, activities or rest

periods.

Another type of pH test system involves a device that is placed in the

esophagus during endoscopy and adheres to the inner esophageal

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mucosa. The device within the esophagus is designed to remain for 24

to 48 hours and transmits pH data to a small portable receiver that is

worn by the patient. After about two days, the probe falls off the

esophageal mucosa to be passed in the patient’s stool.

Ambulatory pH monitoring is useful for confirming gastroesophageal

reflux disease in those with persistent symptoms (whether typical or

atypical) who do not have evidence of mucosal damage on endoscopy,

particularly if a trial of twice-daily medication has failed. It can also be

used to monitor the adequacy of treatment in those with continued

symptoms. Patients may need to stop taking GERD medications to

prepare for pH testing.

Patients with GERD who are candidates for surgery, may also have other

diagnostic tests, such as:3,4

X-ray of the upper digestive system:

Sometimes called a barium swallow or upper GI series, this procedure

involves drinking a chalky liquid that coats and fills the inside lining of

the digestive tract. A series of X-rays are then taken of the upper

digestive tract. The coating allows medical providers to see a

silhouette of the esophagus, stomach and upper intestine (duodenum).

Endoscopy:

Endoscopy is a diagnostic test using an upper flexible endoscope that

directly visualizes the inside of the esophagus and stomach for routine

screening or initial inspection of a condition. During endoscopy, the

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medical provider inserts a thin, flexible endoscope equipped with a

light source and camera located at the tip of the endoscope insertion

tube down the throat, and passes it into the stomach and often the

upper small bowel (duodenum) is inspected as well.

Upper endoscopy provides a mechanism for detecting, stratifying, and

managing the esophageal manifestations of GERD. On upper

endoscopy, biopsies should target any areas of suspected metaplasia,

dysplasia, or, in the absence of visual abnormalities, normal mucosa.

Providers may also use endoscopy to collect a sample of tissue

(biopsy) for further testing. Endoscopy is useful to look for

complications of reflux, such as esophageal inflammation or Barrett's

esophagus.

Esophageal Manometry (Motility) Testing:

Manometry measures movement and pressure in the esophagus. The

test involves placing a manometry catheter with pressure sensors

through the nose and into the esophagus. Manometry will indicate how

well the esophagus can perform peristalsis.

Manometry also allows the medical provider to examine lower

esophageal sphincter functioning. As the LES relaxes, food and liquid

are allowed to enter the stomach; and, when the LES closes it

prevents food and liquid from moving out of the stomach and back up

the esophagus.

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Complications Of GERD

Over time, chronic inflammation in the esophagus can lead to complications.

These may include the following conditions.3,4

Narrowing of the esophagus (esophageal stricture):

Damage to cells in the lower esophagus from acid exposure leads to

formation of scar tissue. The scar tissue narrows the food pathway,

causing difficulty swallowing.

An open sore in the esophagus (esophageal ulcer):

Stomach acid can severely erode tissues in the esophagus, causing an

open sore to form. The esophageal ulcer may bleed, cause pain and

make swallowing difficult.

Lung and throat problems:

Some people reflux acid into the throat, causing inflammation of the

vocal cords, a sore throat, or a hoarse voice. The acid can be inhaled

into the lungs and cause a type of pneumonia (aspiration pneumonia)

or asthma symptoms. Chronic acid reflux into the lungs may

eventually cause permanent lung damage, called pulmonary fibrosis or

bronchiectasis.

Epidemiologic evidence suggests that 15 million Americans suffer from

asthma, and that 34 to 89 percent of asthmatics have

gastroesophageal reflux disease (irrespective of the use of

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bronchodilators), and that up to 40 percent of asthmatics have peptic

esophagitis.

Pre-cancerous changes to the esophagus (Barrett's esophagus):

In Barrett's esophagus, the tissue lining the lower esophagus changes.

These changes are associated with an increased risk of esophageal

cancer. The risk of cancer is low, but providers will likely recommend

regular screening endoscopy exams to look for early warning signs of

esophageal cancer.

Esophageal cancer:

There are two main types of esophageal cancer: adenocarcinoma and

squamous cell carcinoma. A major risk factor for adenocarcinoma is

Barrett's esophagus, discussed above. Squamous cell carcinoma does

not appear to be related to GERD. Unfortunately, adenocarcinoma of

the esophagus is on the rise in the United States and in many other

countries. However, only a small percentage of people with GERD will

develop Barrett's esophagus and an even smaller percentage will

develop adenocarcinoma.

Treatment Of GERD

Gastroesophageal reflux disease

symptoms of mild heartburn at least

twice per week have been found to

have a considerable effect on quality of

life.7 Medical providers recommend

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lifestyle and dietary changes for most people needing treatment for GERD.

Treatment aims at decreasing the amount of reflux or reducing damage to

the lining of the esophagus from refluxed materials. General treatment

recommendations for GERD published by the National Institute of Health are

useful for primary care clinicians and nurses when educating patients, and

the recommendations are outlined below.5

Avoiding foods and beverages that can weaken the LES is often

recommended. These foods include chocolate, peppermint, fatty foods,

coffee, and alcoholic beverages. Foods and beverages that can irritate a

damaged esophageal lining, such as citrus fruits and juices, tomato

products, and pepper, should also be avoided if they cause symptoms.

Decreasing the size of portions at mealtime may also help control

symptoms. Eating meals at least two to three hours before bedtime may

lessen reflux by allowing the acid in the stomach to decrease and partial

emptying of the stomach. In addition, being overweight often worsens

symptoms. Many overweight people find relief when they lose weight.

Cigarette smoking weakens the LES. Stopping smoking is important to

reduce GERD symptoms.

Elevating the head of the bed on six to eight inches or sleeping on a

specially designed wedge reduces heartburn by allowing gravity to minimize

reflux of stomach contents into the esophagus. It is not recommended to

use pillows to prop oneself up; that position only increases pressure on the

stomach.

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Along with diet and lifestyle changes, treatment for heartburn and other

signs and symptoms of GERD usually begins with over-the-counter

medications that control acid. If patients are not able to experience relief

within a few weeks, health care providers may recommend other

treatments, including medications and surgery. Over-the-counter treatments

may help control heartburn. These treatments are briefly outlined below.5

Antacids that neutralize stomach acid:

Antacids, such as Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and

Tums, may provide quick relief. But antacids alone are not expected to

heal an inflamed esophagus damaged by stomach acid. Overuse of

some antacids can cause side effects, such as diarrhea or constipation.

Medications to reduce acid production:

Called H-2-receptor (histamine H-2) blockers, these medications

include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine

(Axid AR) or ranitidine (Zantac). The H-2-receptor blockers do not act

as quickly as antacids do, but they provide longer relief and may

decrease acid production from the stomach for up to 12 hours.

Stronger versions of these medications are available in prescription

form.

Medications that block acid production and heal the esophagus:

Proton pump inhibitors (PPI) are stronger blockers of acid production

than are H-2-receptor blockers and allow time for damaged

esophageal tissue to heal. Over-the-counter proton pump inhibitors

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include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec,

Zegerid OTC).

Once the optimal dose and type of PPI is found, the patient will

probably be kept on the PPI for approximately eight weeks. Depending

upon the symptoms after eight weeks, the medication dose may be

decreased or discontinued. If symptoms return within three months,

long-term treatment is usually recommended. If symptoms do not

return within three months, treatment may be needed only

intermittently. The goal of treatment for GERD is to take the lowest

possible dose of medication that controls symptoms and prevents

complications.

Proton pump inhibitors are safe, although they may be expensive,

especially if taken for a long period of time. Long-term risks of PPIs

may include an increased risk of gut infections, such as Clostridium

difficile (C. diff), or reduced absorption of minerals and nutrients. In

general, these risks are small. However, even a small risk emphasizes

the need to take the lowest possible dose for the shortest possible

time.

If heartburn persists despite initial approaches, health care providers may

recommend prescription-strength medications, which are outlined below.4,6

Prescription-strength H-2-receptor blockers:

These include prescription-strength cimetidine (Tagamet), famotidine

(Pepcid), nizatidine (Axid) and ranitidine (Zantac).

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Prescription-strength proton pump inhibitors:

Prescription-strength proton pump inhibitors include esomeprazole

(Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid),

pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole

(Dexilant). These medications are generally well tolerated, but long-

term use may be associated with a slight increase in risk of bone

fracture and vitamin B-12 deficiency.

Medications to strengthen the lower esophageal sphincter:

Baclofen may decrease the frequency of relaxations of the lower

esophageal sphincter and therefore decrease gastroesophageal reflux.

It has less of an effect than proton pump inhibitors, but it might be

used in severe reflux disease. Baclofen can be associated with

significant side effects, most commonly fatigue or confusion.

Medication for gastroesophageal reflux disease is sometimes combined to

increase effectiveness. Most GERD symptoms can be controlled through

medications. In situations where medications are not helpful or there is a

desire to avoid long-term medication use, health care providers may

recommend more-invasive procedures, briefly outlined below.4,6

Surgery to reinforce the lower esophageal sphincter (Nissen

fundoplication):

Fundoplication surgery involves tightening the lower esophageal

sphincter to prevent reflux by wrapping the very top of the stomach

20


around the outside of the lower esophagus. Surgeons usually perform

this surgery laparoscopically. In laparoscopic surgery, the surgeon

makes three or four small incisions in the abdomen and inserts

instruments, including a flexible tube with a tiny camera, through the

incisions.

Though the outcome of surgery is usually good, complications can

occur. Examples include persistent difficulty swallowing (occurring in

about five percent of patients), a sense of bloating and gas (known as

"gas-bloat syndrome"), breakdown of the repair (one to two percent of

patients per year), or diarrhea due to inadvertent injury to the nerves

leading to the stomach and intestines.

Surgery to strengthen the lower esophageal sphincter (Linx):

The Linx device is a ring of tiny magnetic titanium beads that is

wrapped around the junction of the stomach and esophagus. The

magnetic attraction between the beads is strong enough to keep the

opening between the two closed to refluxing acid, but weak enough so

that food can pass through it.

The Linx device can be implanted using minimally invasive surgery

methods. The U.S. Food and Drug Administration approved this newer

device and early studies on its efficacy to control GERD appear

promising.

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Summary

The passage of gastric contents into the esophagus (gastroesophageal

reflux) is a normal physiologic process. Most episodes are brief and do not

cause symptoms, esophageal injury, or other complications.

Gastroesophageal reflux becomes a disease when it either causes

macroscopic damage to the esophagus or causes symptoms that reduce the

quality of life.

International gastroenterology experts have identified that GERD symptoms

of mild heartburn at least twice per week can have considerable impact on

quality of life. This course has discussed the diagnosis, risk factors, causes,

symptoms, complications and treatment of gastroesophageal reflux disease,

which affects up to 10 million adults in the United States on a daily basis.

Please take time to help NurseCe4Less.com course planners evaluate

the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing

feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course

requirement.

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basis.

a. 3.5 million

b. 5 million

c. 6.8 million

d. 10 million



a. 15 (inches long) and 2 (inch wide)

b. 13 (inches long) and 3 (inch wide)

c. 10 (inches long) and 1 (inch wide)


3. The LES _________ to allow food/liquid to flow down into the stomach.

a. contracts

b. has peristalsis similar to esophagus

c. relaxes

d. None of the above

4. GERD is managed by most people with:

a. over the counter medication

b. PPIs

c. life style changes

d. answers a and c above


a. acid reflux

b. aspiration pneumonia

c. high incidence of malignancy

d. esophageal cancer

23


6. GERD symptoms can include:

a. burning sensation in the chest

b. difficulty swallowing

c. nausea

d. All of the above

7. Omeprazole is an example of a(n):

a. Antacid (over the counter)

b. H2 blocker

c. Proton pump inhibitor

d. Either a or b above

8. ___________ is implanted using minimally invasive surgery methods

and approved by the FDA to prevent reflux.

a. Nissan device

b. Linx device

c. pH probe device




a. 6

b. 24

c. 8

d. 12

10. True/False. Pregnancy is a risk factor for individuals to develop GERD.

a. True

b. False

24


11. Ambulatory pH monitoring is useful for confirming GERD in patients with

a. atypical symptoms only

b. typical symptoms only

c. persistent symptoms and failed trial of twice daily medication


12. Head of the bed elevation ___________ helps reduce GERD symptoms.

a. 4 – 5 inches

b. 6 – 8 inches

c. with a pillow

d. Answers a and c above

13. A reported complication of Nissen fundoplication is:

a. obstruction

b. severe chest pain

c. gas-bloat syndrome


14. True/False. GERD medications should be never combined for continued

symptoms.

a. True

b. False



a. True

b. False

25


CORRECT ANSWER KEY:


basis.

Correct Answer: 10 million



Correct Answer: 10 (inches long) and 1 (inch wide)

3. The LES _________ to allow food/liquid to flow down into the stomach.

Correct Answer: relaxes

4. GERD is managed by most people with:

Correct Answer: answers a and c above


Correct Answer: esophageal cancer

6. GERD symptoms can include:

Correct Answer: all of the above

7. Omeprazole is an example of a(n):

Correct Answer: Proton pump inhibitor

26


8. The ______________ is implanted using minimally invasive surgery

methods and approved by the FDA to prevent reflux.

Correct Answer: Linx device



Correct Answer: 12

10. True/False. Pregnancy is a risk factor for individuals to develop GERD.

Correct Answer: True

11. Ambulatory pH monitoring is useful for confirming GERD in patients with

Correct Answer: persistent symptoms and failed trial of twice daily

medication

12. Head of the bed elevation ___________ helps reduce GERD symptoms.

Correct Answer: 6 – 8 inches

13. A reported complication of Nissen fundoplication is:

Correct Answer: gas-bloat syndrome

14. True/False. GERD medications should be never combined for continued

symptoms.

Correct Answer: False



Correct Answer: True

27


References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. Kahrilas, P.J. (2015). Patient information: Acid reflux (gastroesophageal

reflux disease) in adults (Beyond the Basics). UpToDate. Waltham,

Mass: UpToDate. Retrieved online October 23, 2015 from

www.uptodate.com.

2. de Bertoli, N., et al. (2013). Overlap of functional heartburn and

gastroesophageal reflux disease with irritable bowel syndrome. World J

Gastroenterol 2013 September 21; 19(35): 5787-5797

3. Kahrilas, P.J. (2015). Clinical manifestations and diagnosis of

gastroesophageal reflux in adults in Talley, N.J. (Ed.), UpToDate.

Waltham, Mass: UpToDate. Retrieved October 19, 2015 from

www.uptodate.com

4. GERD (2014). Mayo Foundation for Medical Education and Research.

Retrieved October 18, 2015 from www.mayoclinic.org

5. Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease

(GERD) in Adults. (2014). National Institute of Diabetes and Digestive

and Kidney Diseases. Retrieved October 18, 2015 from

www.niddk.nih.gov

6. Kahrilas, P.J. (2015). Medical Management of gastroesophageal reflux in

adults in Talley, N.J. (Ed.), UpToDate. Waltham, Mass: UpToDate.

Retrieved October 19, 2015 from www.uptodate.com

http://www.uptodate.com/


http://www.mayoclinic.org/

http://www.niddk.nih.gov/


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7. Tamura, Y., et al. (2015). Pathophysiology of functional heartburn based

on Rome III criteria in Japanese patients. World J Gastroenterol. 2015

Apr 28; 21(16): 5009–5016.

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Gastroesophageal Reflux Disease (GERD) In The Adult · Gastroesophageal reflux disease (GERD) is defined as a condition that ... gastroesophageal reflux disease (GERD) in the adult,