Mr. Jorgan

Case # 1Case # 1

Mr. H. Jorgan 40 y/o w/m here for initial evaluation CC: “sour stomach & acid back-up” This

started about 3-4 years ago and only occurred about 1x week. It has

progressively increased in frequency and severity.

During the past year it has occurred daily after most meals. He has a feeling of fullness

and bloating with nausea for about 2 hrs. post-prandially. There are times, especially after eating a late snack, when it may wake him from sleep. He avoids spicy foods because it makes him worse.

Mr. H. Jorgan PMH:

Fractured left leg six years ago Hypertension for three years

Medications: Aspirin as needed for left leg pain Tagamet-HB twice daily Procardia

Allergies: None

Mr. H. Jorgan Social History:

Works as a loan officer for a large

suburban bankDenies tobacco useHas 1 or 2 glasses of wine at dinner

Family History: Mother 68 y/o with hypertensionFather 70 y/o with chronic stable anginaTwo daughters age 18 and 16, both

healthy

Mr. H. Jorgan

ROS: Twenty pound weight gain over the past 6

years, which he attributes to a more

sedentary life-style than he had

previously

He denies dysphagia, odynophagia, chest

pain, shortness of breath, hoarseness,

and sore throat.

Develop a Develop a differential diagnosisdifferential diagnosis

for Mr. Jorgan’s for Mr. Jorgan’s problemproblem

Stop Here and Discuss

Differential Diagnosis Developed by the

Gastroenterology Panel:

Gastroesophageal Reflux Disease (GERD)

Delayed Gastric Emptying

Esophageal Motility Disorder

What workup, if any, What workup, if any, would you orderwould you order

at this time?at this time?

Stop Here and Discuss

Our panel of Gastroenterologists

recommends no diagnostic studies at this point.

Now, what is your Now, what is your treatment treatment

plan for Mr. Jorgan?plan for Mr. Jorgan?

Stop Here and Discuss

Treatment Plan Recommendedby our Gastroenterologists:

Lifestyle modification - including dietary

change and weight loss Consider change in anti-hypertensive

medication Trial of prokinetic therapy Change aspirin to acetaminophen if

tolerated

With what Prokinetic With what Prokinetic agent did you agent did you choose to treat choose to treat

Mr. Jorgan?Mr. Jorgan?

Stop Here and Discuss

Prokinetics Considered by the Gastroenterologists:

Metoclopramide - Cheap; frequent side effects (acute and long-term)

Bethanechol - Cheap; modest effect; cholinergic side-effects

Cisapride - Expensive; generally well tolerated; rare ventricular arrhythmias

Erythromycin - Investigational; antibiotic side-effects

The Gastroenterologists chose to place Mr. Jorgan on Cisapride 10 mg QID taken

twenty minutes before meals and before bed. He is instructed to double the dose if no

better in a week and to return in two weeks. He is also switched from

Procardia to Inderal.

Treatment Chosen by Gastroenterologists :

Mr. Jorgan Returns Two Weeks Later

He has been adhering to the lifestyle modifications with avoidance of late meals, elevation of the head of the

bed, working at weight loss and a low fat diet.

Symptoms:

Postprandial bloating and nausea virtually gone

Substernal burning once in past 2 weeks

Some loose stools for three days

Week Two Follow-up Visit (continued.)

Medications: Cisapride 20 mg ac & hs Propranolol Hydrochloride

Physical Exam: BP = 134/80 P = 68 Weight = 187 lbs. Abdominal exam: Normal

Now, what do you Now, what do you recommend recommend

to Mr. Jorgan?to Mr. Jorgan?

WHY?WHY?

Stop Here and Discuss

The Gastroenterologists chose to continue the current regimen along

with a PRN antacid.

When do you want to see When do you want to see Mr. Jorgan again?Mr. Jorgan again?

Stop Here and Discuss

The Gastroenterology panel wants to

see Mr. Jorgan in four months

Mr. Jorgan Returns

Mr. Jorgan finally returns eight months later He ran out of Cisapride four (4) months ago His heartburn continues to be a problem 4-5

days and 1 night/week No postprandial bloating or nausea as long

as he followed his low fat diet & avoided large meals

His weight is down to 180 lbs No new symptoms

What would you do What would you do next?next?

Stop Here and Discuss

The Gastroenterologists recommend beginning an H2

Receptor Antagonist

Which H2 Receptor Which H2 Receptor antagonist drugantagonist drug

would you choose?would you choose?

Stop Here and Discuss

H2 Antagonist options (equivalent):

Cimetidine 800 mg BID

Ranitidine 150 mg BID

Famotidine 20 mg BID

Nizatidine 150 mg BID

The Gastroenterology Panel Suggests:

Generic Cimetidine 800 mg BID

Continue lifestyle modifications

Call in ten days to report

Continue Cimetidine 800 mg BID Inform Mr. Jorgan about

Laparoscopic Fundoplication

as an alternative if he is interested

Our Gastroenterologists Would:

Ten Days Later

Six Months Later

He is still symptom free

Tolerating the Cimetidine well &

following the anti-reflux routine

Symptom free

GERD is a Chronic Relapsing Condition

Effective Maintenance Therapy is the Key!