Gastrointestinal Assessment

GERD

Gastroesophageal refl ux disease (GERD) is a common, life-long condition that requires long-term treatment. Accounting for 75% of diseases that occur in the esophagus, GERD entails the reflux of gastric and duodenal contents through the lower esophageal sphincter (LES) into the esophagus to cause symptoms or injury to esophageal, oropharyngeal, or respiratory tissues. GERD cannot be diagnosed by symptoms alone because patients with similar presentation may have achalasia, diffuse esophageal spasm, gastritis, cholecystitis, duodenal ulcer, esophageal cancer, or coronary artery disease. Patients may also have atypical symptoms and may consult several physicians before the correct diagnosis is established. Medical therapy cannot resolve abnormal LES function. Therefore, the medical treatment of GERD centers on suppression of intragastric acid secretion. Goals of treatment are to provide effective symptomatic relief, prevent symptom relapse, achieve healing of esophageal damage, and prevent complications of esophagitis.

Lifestyle and dietary changes are the first steps for treatment because of their low cost and simplicity; these include elevating the head of the bed, modifying the size and composition of meals,  consuming low-fat foods, and avoiding coffee, wine, tomato, chocolate, and peppermint. These changes should be continued even if more potent therapies are added. Medical treatment begins with a step-up approach as an  H 2 -receptor antagonist (H 2 RA) is prescribed for 8 weeks.

If symptoms do not improve, patients are changed to a PPI. Titration to the lowest effective medication type and dosage should be performed in all patients. H2 RA is taken on demand, whereas PPIs are taken 30 to 60 minutes before the fi rst meal of the day. PPI therapy is the most successful medical treatment. Of the PPI medications, esomeprazole at 40 mg once daily is more effective than standard doses of lansoprazole, omeprazole, pantoprazole, or rabeprazole in patients with symptoms of GERD.  [1]

[1] Netter's Gastroenterology, 2 th Edition, Martin H. Floch, MD


“Proton-pump inhibitors (PPIs) are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available. The group followed and has largely superseded another group of medications with similar effects, but a different mode of action, called H2-receptor antagonists. These drugs are among the most widely sold drugs in the world, and are generally considered effective.” [2]

[2] en.wikipedia.org/wiki/Proton-pump_inhibitor

“Why Medications for Heartburn Can Do More Harm Than Good

One of the most commonly prescribed drugs for heartburn and acid reflux are proton pump inhibitors (PPIs), which are very effective at blocking acid production in your stomach.

While that may sound like an appropriate remedy, considering the fact that stomach acid is creeping up your esophagus, in most cases it's actually the worst approach possible, as a major part of the problem is typically related to your stomach producing too little stomach acid.

There are over 16,000 articles in the medical literature showing that suppressing stomach acid does not address the problem. It only temporarily treats the symptoms.”

Warning: Proton Pump Inhibitors Tend to Cause Dependence

It's also worth noting that you'll also develop both tolerance and dependence on PPI drugs, so you should not stop taking proton pump inhibitors cold turkey. You need to wean yourself off them gradually or else you might experience a severe rebound of your symptoms. In some cases, the problem may end up being worse than before you started taking the medication.

Ideally, you'll want to get a lower dose than you're on now, and then gradually decrease your dose. Once you get down to the lowest dose of the proton pump inhibitor, you can start substituting with an over-the-counter H2 blocker like Tagamet, Cimetidine, Zantac, or Raniditine. Then gradually wean off the H2 blocker over the next several weeks.

While you wean yourself off these drugs (if you're already on one), you'll want to start implementing a lifestyle modification program that can eliminate this condition once and for all. Antibiotics can typically eradicate H. pylori, but there are many other effective strategies that can also work. Ideally, you'd want to try these first, as antibiotics will also kill off the beneficial bacteria in your gut, which can cause other health complications. Besides, H. pylori is growing increasingly resistant to antibiotics, making the availability of non-drug alternatives even more important.”

Your First Line of Treatment – Unprocessed Foods and Probiotics

Ultimately, the answer to heartburn and acid indigestion is to restore your natural gastric balance and function.

Next, you need to make sure you're getting enough beneficial bacteria from your diet. Ideally, you'll want to get your probiotics from fermented foods.

High-quality sea salt (unprocessed salt), such as Himalayan salt, will not only provide you with the chloride your body needs to make hydrochloric acid, it also contains over 80 trace minerals your body needs to perform optimally, biochemically. Sauerkraut or cabbage juice is also a strong—if not the strongest—stimulant for your body to produce stomach acid.

Raw, unfiltered apple cider vinegar” [3]
 
[3] articles.mercola.com/sites/articles/archive/2014/04/28/acid-reflux-ulcer-treatment.aspx



“I have taken Braggs ACV for eight straight months. That's right, I've religiously taken 1-2 tablespoons 2-3 times per day for 250 days. I'd like to share my personal experiences and the changes my body has gone through since I started last October.

Addiction. Before taking ACV, I was drinking far too much alcohol and caffeine. A pot of coffee was my mainstay during the day and a bottle of wine was easy to finish after dinner. A few years ago I was getting heart palpitations from drinking too much caffeine so I quit cold turkey, but my usage was creeping back up again. Fast forward to after eight months on Braggs--I drink one glass of coffee per day (maybe two) and am lucky if I can finish a bottle of wine or a few heavy beers. My stomach just says ENOUGH. Oh, and no heart palpitations since!

Weight loss. While not a magical fat-burning elixir, it will control your blood sugar and cravings, resulting in a slow weight loss over time. My "spare tire" is nearly gone and some of my pants are looking big on me. I'm continuing to lose weight slowly, and family and friends who only see me a few times per year always remark how thin I'm getting. ACV also gets rid of water bloat, which will have the visual effect of weight loss right away. Take it before going out to Macaroni Grill to prevent feeling like a lumbering dinosaur afterwards. Now that the weather is warmer I've started jogging and this magnifies the weight loss even more, and a shot beforehand always ensures a great workout with high energy levels.

Digestion. If you suffer from heart burn or acid reflux (I had both!) ACV works wonders. It also calms the stomach after a large meal and eliminates bloating and hangovers. It acts as a "cleanser" of sorts, so don't stray too far from the bathroom the first few times you take it. You'll be amazed at what comes out. On second thought, no you won't. Just flush.” [4]

[4] www.amazon.com/Bragg-Apple-Cider-Vinegar-Organic/dp/B001I7MVG0/ref=pd_sbs_hpc_1?ie=UTF8&refRID=175F68WGCAM0C741W1HH



“I have GERD, or more accurately, esophagitis due to a damaged esophageal sphincter. My GI doctor originally prescribed the usual acid blockers, but there were problems. The acid blockers didn't really help, as I didn't have a high acid problem, just a damaged sphincter. Plus, research I did on my own confirmed that low stomach acid levels hinder proper digestion. The biggest problem, however, was stopping the acid blockers. It always caused a rebound effect: true acid reflux for days or even weeks after stopping the pills. My solution: DGL. A nutrition doctor that my wife used recommended to her that I try them. I did and they worked great. They greatly eased the esophageal discomfort, yet did not suppress stomach acid, hence no rebound if I should miss a dose.” [5]

[5] www.amazon.com/Enzymatic-Therapy-Chewables-Original-Tablets/dp/B003DI98D6/ref=sr_1_3?s=hpc&ie=UTF8&qid=1427138983&sr=1-3&keywords=Licorice

Step One - Examine the patient’s hands and nails - Continued

Terry's nails is a physical finding in which fingernails and/or toenails appear white with a characteristic "ground glass" appearance, with no lunula. The condition is thought to be due to a decrease in vascularity and an increase in connective tissue within the nail bed. It frequently occurs in the setting of liver failure, cirrhosis, diabetes mellitus, congestive heart failure, hyperthyroidism, and/or malnutrition. Eighty percent of patients with severe liver disease have Terry's nails, but they are also found in patients with kidney failure, in patients with congestive heart failure[4] and are described as a brown arc near the ends of the nails. [1]



[1] en.wikipedia.org/wiki/Terry%27s_nails

See other nail conditions:

www.medicine.virginia.edu/clinical/departments/medicine/grad-ed/geri/learning-materials/learning-modules/NailExamination.pdf

Two assess the radial pulse.



There is some argument as to whether this should be performed or not in an abdominal exam; however, it can be a good indication of sepsis or thyroid disease.

When taking a patient's pulse, you should note the patient's pulse rate, the strength of the pulse, and the regularity of the pulse. Most of the pulse characteristics discussed in this paragraph are illustrated in figure 3-1.

a. Pulse Rate.

Adults: 60 to 100 beats per minute.
Children: 70 to 120 beats per minute.
Toddlers: 90 to 150 beats per minute.
Newborns: 120 to 160 beats per minute.

(2) Pulse rates that are outside the normal range are classified as tachycardia or bradycardia.
(a) Tachycardia. If the patient's pulse rate is over 100 beats per minute, the patient is said to have tachycardia. Tachycardia means "swift heart." Constant tachycardia could be a sign of certain diseases and heart problems. Often, however, tachycardia is only temporary. Temporary tachycardia can be caused by exercise, pain, strong emotion, excessive heat, fever, bleeding, or shock.
(b) Bradycardia. If the patient's pulse rate is below 50 beats per minute, the patient is said to have bradycardia. Bradycardia means "slow heart." Bradycardia can be sign of certain diseases and heart problems. Certain medicines, such as Digitalis, can result in bradycardia.

b.   Strength. The strength (force) of the pulse is determined by the amount of blood forced into the artery by the heartbeat. A normal pulse has a normal strength. You will be able to identify a normal strength pulse with practice.

(1) Bounding. If the heart is pumping a large amount of blood with each heartbeat, the pulse will feel very strong. This strong pulse is called "bounding" pulse (as in "by leaps and bounds"). A bounding pulse can be caused by exercise, anxiety, or alcohol consumption.
(2) Weak. If the heart is pumping only a small amount of blood with each heartbeat, the pulse will be harder to detect. This type of pulse is called weak, feeble, or thready. If the pulse is weak, you may have trouble finding (palpating) the pulse at first.
(3) Strong. A strong pulse is stronger than normal pulse, but is less than bounding. Shock and hemorrhage (serious bleeding) can cause a strong pulse.

c. Rhythm. Rhythm refers to the evenness of the beats. In a regular pulse, the time between beats is the same (constant) and the beats are of the same strength.

(1) Irregular. A pulse is irregular when the rhythm does not have an even pattern. The time between beats may change, or the strength of the beats may change or the pulse may vary in both time between beats and strength.
(2) Intermittent. An intermittent pulse is a special type of irregular pulse. A pulse is intermittent when the strength does not vary greatly, but a beat is skipped (missed) either at regular or irregular intervals. If the missing beats in an intermittent pulse were present, then the pulse rhythm would be normal. [2]



[2] www.waybuilder.net/sweethaven/medtech/vitals/default.asp?iNum=0301

Sepsis (/ˈsɛpsɨs/) is a whole-body inflammation caused by an infection. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. There may also be symptoms related to a specific infection such as a cough with pneumonia or painful urination, with a kidney infection. In the very young, old, and people with a weakened immune system, there may be no symptoms of a specific infection and the body temperature may be low or normal rather than high. Severe sepsis is sepsis causing poor organ function or insufficient blood flow. Insufficient blood flow may be evident by low blood pressure, high blood lactate, or low urine output. Septic shock is low blood pressure due to sepsis that does not improve after reasonable amounts of intravenous fluids are given.
Sepsis is caused by an immune response triggered by an infection. The infection is most commonly by bacteria, but can also be by fungi, viruses, or parasites. Common locations for the primary infection include: lungs, brain, urinary tract, skin, and abdominal organs.

Signs and symptoms

In addition to symptoms related to the provoking cause, sepsis is frequently associated with either fever or low body temperature, rapid breathing, elevated heart rate, confusion, and edema. Early signs are a fast heart rate, decreased urination, and high blood sugar. Signs of established sepsis include confusion, metabolic acidosis (which may be accompanied by faster breathing leading to a respiratory alkalosis), low blood pressure due to decreased systemic vascular resistance, higher cardiac output, and dysfunctions of blood coagulation (where clotting can lead to organ failure). [2]

[2] en.wikipedia.org/wiki/Sepsis

A thyroid disease is a medical condition impairing the function of the thyroid.

Imbalance in production of thyroid hormones arises from dysfunction of the thyroid gland itself, the pituitary gland, which produces thyroid-stimulating hormone (TSH), or the hypothalamus, which regulates the pituitary gland via thyrotropin-releasing hormone (TRH). [3]

[3] en.wikipedia.org/wiki/Thyroid_disease