3. Case Presentation
• 43-year-old male
• C/o One-month episodes of mid-epigastric pain, a
“burning” sensation in his chest, an associated dry cough,
and occasional regurgitation.
• Pain worsens after eating & when lying flat
• Increasing postprandial fullness and early satiety
• Waking up from the pain and burning, with a sore throat
and hoarse voice
• Also reports associated episodic, mid-thoracic, bilateral
back pain
• Symptoms partially relieved by adjusting from a lying to
sitting position & with the use of antacids
4. Physical Examination
• Weight 76 Kg
• Vitals:
• Temperature, 99.1° F
• BP 132/78 mmHg
• Respiratory Rate 18
• Pulse, 80/ min
• Throat: Oropharynx pink & moist; no erythema, tonsillar enlargement, lesions,
lingual erosion of teeth,no lymphadenopathy, or nodularity; thyroid normal size.
• CVS/ Lungs/ Abdomen/ Musculoskeletal/ Neuro/ Eyes: NAD
5. Q1. Which of the following are among the
Differential Diagnoses to consider when assessing
the patient with symptoms of GERD?
• Esophageal neoplasm
• H pylori infection
• Coronary artery disease
• Cholelethiasis
• All of the above
6. DD of Chest Pain of GI origin
Condition Differentiating signs/symptoms Differentiating investigations
CAD (Coronary Artery
Disease)
•Cardiac aetiology must be ruled out before considering a diagnosis of
GERD in people with chest pain.
•Cardiac chest pain is typically substernal, precipitated by exertion,
and relieved by rest.
•ECG may show ST changes or Q waves.
•Exercise stress testing may abnormal.
Functional
oesophageal
disorder/functional
heartburn
• No reliable differentiating signs or symptoms. •Functional heartburn denotes endoscopy-negative
heartburn by definition. A normal oesophageal pH study
differentiates between non-erosive GERD and
functional heartburn.
Achalasia • Dysphagia is typically prominent. • Oesophageal manometry and/or oesophagram are
abnormal and consistent with achalasia.
Biliary colic • Right upper quadrant or epigastric pain usually increasing in intensity
and lasting several hours.
• USG may show gallstones.
Non-ulcer dyspepsia • At least 3 months of recurrent upper abdominal pain, bloating, and
nausea, with no obvious structural cause.
• No definitive differentiating tests. Oesophagitis is
absent on endoscopy for both non-erosive GERD &
non-ulcer dyspepsia, while peptic ulcer disease was
excluded.
Peptic ulcer disease • Burning pain in the epigastrium, which occurs hours after meals or
with hunger.
• The pain often wakes the patient at night and is relieved by food and
antacids.
• Endoscopy demonstrates ulcer.
• Testing for H pylori infection is often positive (not
diagnostic)
PPI-responsive
oesophageal
eosinophilia
• Should be diagnosed when patients have oesophageal symptoms &
histological findings of oesophageal eosinophilia, but demonstrate
symptomatic & histological response to proton-pump inhibition.
• This entity is considered distinct from eosinophilic oesophagitis, but
is not necessarily a manifestation of GERD.
• Therapeutic response to PPI
Malignancy • Suspected in older adults presenting with alarm symptoms: anaemia,
acute or progressive dysphagia, hematemesis, melena, persistent
vomiting, or involuntary weight loss.
•Laboratory tests may show anaemia or abnormal
LFTs.
•Tissue biopsies diagnostic.
http://bestpractice.bmj.com/best-practice/monograph/82/diagnosis/differential.html
7. Q2. When characterizing
gastroesophageal reflux disease (GERD),
which of the following statements is true?
• Chief symptoms that GERD patients experience are associated with
esophageal injury
• Patients with reflux symptoms are likely to have erosive esophagitis
• GERD is defined as symptoms or mucosal damage produced by the
abnormal reflux of gastric contents into the esophagus
• GERD is not typically associated with extraesophageal symptoms
8. GERD
• American College of Gastroenterology (ACG)
• GERD as symptoms or mucosal damage produced by the abnormal reflux of
gastric contents into the esophagus
Recent global evidence-based consensus added "troublesome
symptoms or complications" to the definition of GERD (affects
individual well being)
Most patients with GERD symptoms have no visible signs of erosive
esophagitis on endoscopy, thus diagnosed with non-erosive reflux
disease
Experience typical symptoms associated with esophageal injury as well as
atypical extra-esophageal syndromes
9. Q3. Which of the following are generally associated with
the spectrum of GERD & its accompanying
complications?
• GERD symptoms without endoscopically visible esophageal
injury
• Stricture formation
• Barrett's esophagus and esophageal adenocarcinoma
• Esophagitis and hemorrhage
• All of the above
10. The Global Montreal Definition and Classification
of GERD Consensus
Formal classification of esophageal and extra-esophageal
syndromes
Esophageal Syndromes Extra-esophageal Syndromes
Symptomatic
Syndromes
Syndromes With
Esophageal Injury
Established
Associations
Proposed
Associations
Typical reflux
syndrome
Reflux chest pain
syndrome
Reflux esophagitis
Reflux stricture
Barrett's
esophagus
Esophageal
adenocarcinoma
Reflux cough
syndrome
Reflux laryngitis
syndrome
Reflux asthma
syndrome
Reflux dental
erosion syndrome
Pharyngitis
Sinusitis
Idiopathic
pulmonary fibrosis
Recurrent otitis
media
11. GERD – Spectrum of Disease
• Important concept from the Montreal consensus -
GERD should be considered a spectrum of
disease
• Spectrum of GERD begins with GERD symptoms
(without endoscopically visible esophageal injury) &
moves to GERD-associated esophageal complications
• Reflux esophagitis
• Hemorrhage
• Stricture
• Barrett's esophagus
• Esophageal adenocarcinoma
12. Q4. Which of the following should not be considered
an Alarm symptom prompting endoscopy?
• Laryngitis or hoarseness of the voice
• Dysphagia (difficulty swallowing) or Odynophagia (painful
swallowing)
• Gastrointestinal tract bleeding or Anaemia
• Involuntary and significant weight loss
• Persistent vomiting
13. Alarm Symptoms of Gastroesophageal
Reflux Disease
DeVault KR, Castell DO. Am J Gastroenterol. 1999;94:1434–42.
Weight Loss Bleeding
Choking
Chest Pain
Dysphagia
14. Q5. What information is the least useful for initial
assessment of a patient with symptoms of GERD?
• Assessment of extraesophageal symptoms
• Timing of symptoms (day time and/or night time)
• Duration of symptoms (months, years)
• Endoscopy results
• Information on medications previously used by the patient
to treat GERD symptoms
15. Diagnostic Options for Patients with Suspected
GERD
• Endoscopy
• Ambulatory monitoring
(pH, impedance/pH)
• Therapeutic trial of Acid
suppression + Prokinetic
Vaezi MF. Clin Cornerstone. 2003;5(4):32-38.
16. • Routine:
• Test CBC: Haemoglobin and haematocrit
within normal range; not showing microcytic
indices.
• Upper GI Endoscopy: Mild inflammation at
GE junction.
• Special Diagnostics:
• Diaphragmatic tightness noted
• Rib motion decreased
• Rotation measured at 40 degrees bilaterally
Diagnostic tests
17. Diagnosing GERD
• No gold standard diagnostic test for uncomplicated GERD
• Initial diagnosis obtained via clinical symptoms & confirmed via
empiric PPI treatment
• Endoscopy: – Reserved for patients with alarm symptoms or disease
complications – To screen for Barrett’s oesophagus in patients with
long-standing GERD
• pH Monitoring: patients not responsive to medical or surgical
treatment
DeVault KR, Castell DO. Am J Gastroenterol. 2005;100:190-200.
19. Management of GERD
• Non-Pharmacologic (Life-style changes)
• Pharmacologic treatment
• Anti-reflux surgery
20. Q6. In regard to response to empiric PPI therapy,
which of the following statements is not correct?
• EGD is not helpful in PPI nonresponders
• Even if a patient does not respond to initial empiric
therapy with a PPI, a diagnosis of GERD may be made on
increased PPI dose response
• GERD symptoms very often (70% to 80%) return
following discontinuation of a PPI
• The PPI dosage may be increased to twice a day if the
patient does not experience complete relief
21. Management – Practical tips
• Patients with a probable diagnosis of GERD treated
empirically with PPI (approx. 4 wks) should return for a
follow-up
• Patients may experience complete relief, partial relief, or
no relief of symptoms
• Complete discontinuation of therapy - not advised for
patients with relief of symptoms
• Up to 80% of GERD patients experience symptom recurrence
when medication is stopped
22. Practical tips :– On Demand or Intermittent
treatment
• 60% of patients could benefit from on-demand or intermittent
treatment
• Initially diagnosed and treated, these patients are classified as having
mild disease with relatively infrequent symptom relapses
• Such patients are ideal for on-demand or intermittent treatment to
reduce symptoms and improve QOL
23. Practical tips :– No relief from symptoms
• In cases patient receives no relief from symptoms or is dissatisfied with
symptom relief, the clinician should revisit the patient's history
• Check whether the patient is able to adhere to the timing and dosing
• If the medication is being taken correctly, increasing the dosage to twice a
day may be considered. Doubling the dose of may provide symptom relief
• Scheduling an endoscopy (especially if there has been a complete lack of
response to initial treatment)
24. Q7. Which of the following statements is not of key
importance when discussing GERD treatment and
management?
• Understanding how GERD symptoms affect a patient's
QOL
• Night time disturbances related to GERD and affecting a
patient
• Risk factors for GERD and expectations from therapy
• Exercise regimen changes
• Testing for H pylori
25. American Gastroenterological Asso. Survey
• Nationwide survey of 1000 adults experiencing heartburn at least once
a week, conducted by the Gallup Organization for the American
Gastroenterological Association
• 79% of respondents reported night time heartburn
• Of these, 75% reported that symptoms affected their sleep
• 63% believed that heartburn negatively affected their ability to sleep well
• 40% believed that nocturnal heartburn impaired their ability to function the
following day
• Researchers concluded that night time heartburn in a majority of adults
with GERD results in sleep disturbances and impaired next-day function
• However, sleep disturbances improve substantially with medications
26. Q8. Which of the following statements in regard to long-term
management of patients with GERD is not correct?
• Once symptoms have improved, yearly visits are recommended
• Long-term treatment and monitoring can prevent complications and
progression of disease
• Patients are likely to adhere to therapy when symptoms are relieved
• Alarm symptoms are unlikely to develop on PPI or therapy
27. Q9. In your experience, which of the following is the most
important barrier to the optimal management of GERD?
• Lack of diagnosis of GERD in patients presenting with atypical
symptoms of GERD
• Not distinguishing uncomplicated from complicated GERD
• Lack of consensus on duration of pharmacotherapy
• Lack of consensus on appropriate time for surgical treatment
29. Other formulations of Rabeprazole & Domperidone SR have the following
disadvantages:
1. SR Domperidone is released in duodenum (alkaline pH) where it is not soluble,
therefore can not produce desired pharmacological response.
2. The entire domperidone is in SR form, so there is no drug available for
immediate action.
Combination therapy in gastric disorders
30. Rabemac-DSR Technology ensures that the SR domperidone released in
alkaline pH of duodenum has good solubility – Ensures excellent
pharmacological response
31. Technology in making the right combination
Rabemac-DSR
Domperidone the recommended daily dosage is 10-20 mg
3-4 times daily
Yet the available formulations gives the same dosage as
once or twice daily
Less conc. of drug in blood for less time, hence less relief
Less therapeutic utility in diabetic gastroparesis, asthmatic
and ENT indications
32. Only Rabemac-DSR provides with a 3 way
release technology
Immediate
release of
Domperidone to
control Nausea
and Vomiting
Rabeprazole
released to
control acid
reflux
Slow sustained
release of
Domperidone
over 24 hours
for action
34. Summary of Rabemac-DSR
• Rabemac- DSR is an advanced formulation of Domperidone once a day and
Rabeprazole once a day with unique Three Way Release Technology
Rabeprazole in Rabemac- DSR is the best acid suppressant that:
• Maintains intragastric pH of 4 for all 24 hours.
• Better control of night time heartburn compared to all PPIs
• Fastest resolution of symptoms compared to all PPIs.
• Has gastro-protective action
• No drug-drug interactions.
• The only PPI effective even in acidic medium
• Once a day dosage
35. Domperidone in Rabemac-DSR is the best GI prokinetic that:
• Increases GI motility
• Increases LES pressure
• Controls nausea & vomiting
• Promotes healing in erosive esophagitis
• No neurological / cardiac side effects
Summary of Rabemac-DSR
