Natural Acid Reflux Treatment Book

Heartburn and Acid Reflux Cure Program

Acidity is of the most dangerous problem that not only middle aged or old aged people faces but also the young generation is also facing. Untreated and ill treatment of this disease can lead to even heart stroke. The synthetic anti acidic products available in the market causes more harm in the fast relief process and does cure it holistically so that you do not suffer from it now and then. Here comes the best book on step acid reflux treatment written by Jeff Martin, a well renowned researcher and nutrionist.While these easy process stated in this book allows you to get heal of all types of digestive disorders on a permanent solution basis but in addition to it you get a three months direct counseling from Jeff Martin himself while ordering this product direct from this website. The treatment is so easy to follow and a 100% results is well expected but even then in case on is not satisfied with the results can get even 100 % refund. Indeed one of the cheapest and best ways to get rid of the long lasting digestive disorders especially heart burn in a holistic way without drugs and chemicals. Read more here...

Heartburn and Acid Reflux Cure Program Summary


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Gastroesophageal Reflux

Gastroesophageal reflux is a common endoscopic finding (Fig. 3.22). It is seen even in healthy individuals and usually causes no complaints. As a result, endoscopic detection does not necessarily indicate a pathological condition. Pathophysiology. Because gastric juice contains substances that are corrosive to the esophageal mucosa, there are physiological mechanisms designed to protect the esophagus. Gastroe-sophageal reflux causes clinical complaints when these antireflux mechanisms fail. They include the sphincter mechanisms, the regenerative capacity of the esophageal epithelium, and the clearance function of esophageal motility, which curtails exposure to the corrosive gastric juice. Factors that predispose to gastroesophageal reflux are listed in Table 3.2.

TABLE 712 Causes of Gastroesophageal Reflux Disease

As noted, differentiating esophageal symptoms from acute ischemic coronary symptoms is often not possible in the ED. Heartburn is the classic symptom of GERD, and chest discomfort may be the sole manifestation of the disease. The burning nature of the discomfort is probably due to localized lower esophageal mucosal inflammation. Many GERD patients will report other associated gastrointestinal symptoms, such as odynophagia, dysphagia, acid regurgitation, and hypersalivation. The association of pain with meals can be helpful in identifying pain that is due to GERD. Postural changes in pain can also be useful increasing intraabdominal pressure or negating the esophagus's gravity advantage can exacerbate reflux symptoms dramatically. Antacid-induced relief of symptoms is often noted in reflux disease, though the pain can return after the transient antacid effect wears off, and a certain number of patients with ischemic disease also report improvement. Unfortunately, like cardiac pain,...

Gastrooesophageal reflux disease

Symptoms are variable 'heartburn' is common with retrosternal burning and discomfort, regurgitation of food and acid into the mouth is unpleasant, and dysphagia to both solids and liquids can occur. Symptoms are worse when lying down, or bending over, and waking at night choking is described. Respiratory disease may be worsened by nocturnal aspiration, and teeth may be eroded by gastric acid. Clinical examination is unremarkable, and the diagnosis is most often obtained from history alone.

Pharyngeal and Gastric Contents

Aspiration of gastric contents is common in individuals with a decreased level of consciousness (drug overdose, anesthesia 395,397,398 ). Critically ill patients are at risk (395). The supine position predisposes to gastroesophageal reflux (398). Reflux is enhanced by decreased gastric motility, which leads to retained gastric contents and stomach distension in critically ill individuals (395). The risk of aspiration is high after removal of an endotracheal tube because of the residual effects of sedative drugs, the presence of a nasogastric tube, swallowing dysfunction related to upper airway sensitivity, glottic injury, and laryngeal muscular dysfunction (395). Although a nasogastric tube is present, significant volumes of acid can still accumulate, depending on tube placement (398). The tube also passes through the esophageal sphincters, interfering with their function (398). Gastrostomy-tube and nasogastric-tube feeding offer no protection from aspiration of colonized oral...

Clinical Features

Patients with acute biliary colic display a wide range of symptoms. Location, radiation, and duration of pain are all poor discriminators of gallbladder disease. There is overlap of signs and symptoms with peptic ulcer disease, gastritis, esophageal reflux, and nonspecific dyspepsia. In addition, it has been difficult to determine which symptoms are attributable to biliary tract disease.7,8 RUQ pain is a common symptom in patients with and without gallstones.39 Up to 25 percent of postcholecystectomy patients may experience RUQ pain of unknown cause. Biliary tract disease is an important consideration in the evaluation of dyspepsia. 10 Biliary dyskinesia or increased resting pressure of the sphincter of Oddi, or incoordination between gallbladder contraction and relaxation of the sphincter of Oddi, has been proposed as a cause of biliary tract induced dyspepsia. 10

Appendix Information on Recommended Measures Child Health Questionnaire

Gastroesophageal Reflux Disease - Health-Related Quality of Life The GERD-HRQL is a measure of symptom severity for use with individuals who have GERD 130, 133 . Ten common and distressing symptoms are listed. The first six are ordered in terms of their relative annoyance to patients. Each symptom is rated on a 6-point categorical scale that ranges from 0 (no symptoms) to 5 (symptoms are incapacitating - unable to do daily activities). The overall score is from 0 to 50, but there is an additional question asking about satisfaction with the patient's present condition. The GSRS is a clinical symptom rating scale originally designed for patients with irritable bowel syndrome and peptic ulcer disease 122 . It has subsequently been evaluated in patients with GERD 105, 123 . GSRS for use with GERD patients contains 15 items, each assessed on a 1-point to 7-point scale, with 7 representing extreme discomfort. The items combine into five syndromes labeled reflux, abdominal pain, indigestion,...

Peptic Ulcer Disease And Gastritis

Peptic ulcer disease is a chronic illness manifested by recurrent ulcerations in the stomach and proximal duodenum. Acid and pepsin are thought to be crucial to ulcer development, but it is now recognized that the great majority of peptic ulcers are directly related to infection with Helicobacter pylori or nonsteroidal anti-inflammatory drug (NSAID) use.12 Gastritis is acute or chronic inflammation of the gastric mucosa and has various etiologies. Dyspepsia is continuous or recurrent upper abdominal pain or discomfort with or without associated symptoms (nausea, bloating, regurgitation, etc.).34 Dyspepsia may be caused by a number of diseases or may be functional.

Historical Development And Regulation Of Parenteral Dosage Forms

Voluminous newspaper advertisements (sometimes one-fourth of the space), traveling doctors and pitch men with or without their slide shows, druggists, and general storekeepers proclaimed loudly and constantly the merits of various panaceas. So powerful was the influence that millions of people had come to expect, all in one remedy (at a dollar or two the bottle), certain cure for consumption, cholera morbus, dyspepsia, fevers, ague, indigestion, diseases of the liver, gout, rheumatism, dropsy, St. Vitus's dance, epilepsy, apoplexy, paralysis, greensickness, smallpox, measles, whooping cough, and syphilis (52).

TABLE 13012 ASA Physical Status Classification System

For nonemergent sedation, fasting for two hours from clear liquids and four to eight hours for solids and nonclear liquids, is recommended. Children requiring urgent or emergent sedation despite recent oral intake should not receive deep sedation to avoid depression of protective airway reflexes that may result in aspiration. Procedures should be delayed, if possible, to facilitate gastric emptying that may decrease the risk of regurgitation and aspiration. Ranitidine (1 mg kg IV) and metoclopramide (0.15 mg kg IV) given 30 to 60 min prior to sedation may increase gastric pH and reduce gastric volume. Obese patients or patients with a history of gastroesophageal reflux may also benefit from premedication with these drugs.

Bile acid sequestering agents resins

The biggest proportional reduction in lipid levels occurs at low doses and in those who have moderately elevated levels of cholesterol.54 Careful selection of the vehicle and logistics used in resin administration will promote long-term patient adherence. Premixing with cold water (taking advantage of the resin's hygroscopic nature) and drinking the preparation slowing is by far the most frequent and successful method of administration. Still, some patients prefer mixing with a heavily textured juice. Pre-existing gastrointestinal symptoms should be addressed before resin therapy is started. Bloating, belching and increased flatus are related to rapid ingestion. Dyspepsia and increased stool consistency or frank constipation can be managed with increases in fluids or dietary fiber intake.

TABLE 1131 Causes of Acute Respiratory Deterioration in Infants with BPD

Sudden respiratory deterioration in a patient with BPD is usually due to aspiration, either from gastroesophageal reflux or to a poorly coordinated suck swallow reflex. Exposure to cigarette smoke or other environmental pollutants may precipitate acute bronchospasm. An increase in pulmonary edema is usually accompanied by the development of peripheral edema and excessive weight gain.

Gastroschisis and Omphalocele

Complications include gastroesophageal reflux, malabsorption, diarrhea, dehydration, and failure to thrive. The mortality of omphalocele is 25 to 30 percent, largely as a result of congenital heart disease and sepsis, while death in patients with gastroschisis is associated with intestinal atresia.

Selected Structural Obstructive Causes

Esophageal stricture occurs as a result of scarring from GERD or other chronic inflammation. Generally they occur in the distal esophagus, proximal to the gastroesophageal (GE) junction. Strictures may interfere with LES function. Symptoms may build over years and are often noted solely with solids. Stricture can serve as a barrier to reflux, so heartburn may decrease as dysphagia increases. Workup involves ruling out malignancy and treatment is dilatation. 9 Schatzki's ring is the most common cause of intermittent dysphagia with solids. Ihis fibrous, diaphragm-like stricture near the GE junction is present in up to 15 percent of the population, the majority of whom are asymptomatic. Ihe etiology of these rings is debated they may form over time in response to GERD.10 Steakhouse syndrome, food impaction in the esophagus due to poorly chewed meat, is a frequent presentation for patients with this obstructive phenomenon. Ireatment of Schatzki's ring is dilatation.

Treatment Of Ascites And Edema In Patients With Hepatic Cirrhosis [35

Tense ascites and edema do produce significant adverse clinical consequences which can be mitigated by judicious treatment. Ascites can exacerbate gastroesophageal reflux, contribute to anorexia, and possibly increase portal venous pressures, which will heighten the risk of variceal bleeding. Massive ascites in cirrhotic patients commonly becomes infected and the abdominal wall pressure may produce umbilical eventration skin ulceration and necrosis. Elevation of the diaphragms restricts respiration and contributes to development of basilar atelectasis.

Dosage Form Decisions

The other key item in selecting the product profile is defining how the product will be used. A product intended for surgical anesthesia would be most amenable to an injectable dosage form that can be easily titrated to achieve the desired level of anesthesia. A product intended to treat heartburn would likely need to be self-administered as an oral dosage form. A product intended to be given predominantly to smaller children would be easier to administer as a solution or a suspension. Product use and the resulting product profile also may be dependent on the disease being treated. Diseases producing significant nausea such as cancer may need non-oral alternatives to ensure proper dosing. Asthma can be treated with inhalation products, depending on the mechanism of action, given the pulmonary site of disease and the accessibility of lung tissue to direct product administration. Diseases that harbor in specific tissues may benefit from special direct extravascular administration, such...

TABLE 992 Pregnancy Related Contraindications of Some Frequently Used Antibiotics

Physiologic changes in pregnancy often lead to dyspepsia during the third trimester. Most over-the-counter antacid preparations are regarded as acceptable. 11 The histamine antagonists cimetidine and ranitidine have no known teratogenic effect in animals. Although they have not been evaluated in humans, their use in general is considered safe.

Language of breathlessness

Patients who present to their physician complaining of chest pain are routinely asked to describe the quality of the pain. Is it a burning sensation, a pressure, or a sharp pain Clinicians quickly learn to use these qualitative descriptions of pain to gain insight into the pathophysiologic mechanisms underlying the discomfort. For example, burning chest pain may indicate acid reflux into the esophagus, while pressure-like pain is in suggestive of ischemia of the myocardium, and sharp, stabbing pain is characteristic of inflammation of the pleura or pericardium.

Chest Pain Of Esophageal Origin

Most esophageal causes of chest pain are not immediate threats to life however, differentiating esophageal pain from ischemic chest pain can be impossible in the ED. Patients with esophageal pain can report spontaneous onset of pain or pain at night, regurgitation, odynophagia, dysphagia or meal-induced heartburn however, these symptoms are also found in patients with coronary artery disease (CAD), and there is no historical feature that is sensitive or specific enough to routinely make a differentiation between the two. If chest pain is determined to be noncardiac in nature, treatment aimed at esophageal disease is often initiated empirically, without further diagnostic workup. There are no good data on which to base a therapeutic plan for these patients.13 Outpatient workup options in addition to 6 to 8 weeks of empiric treatment for GERD include an acid infusion test, esophagoscopy, and or manometry to help clarify pain of esophageal origin.

Postoperative Dysphagia

Operations for gastroesophageal reflux disease (GERD) have a 6 rate of postoperative esophageal dysphagia, characterized by a sensation of swallowed food sticking in the lower esophagus, and delayed esophageal emptying. While there is no increased risk of aspiration in these patients, postoperative feeding can be significantly impaired, leading to weight loss and malnutrition. Esophageal dysphagia can also complicate other esophageal procedures, such as esophagectomy.

Meningomyelocele Myelomeningocele

Children with meningomyelocele have multiple, complex medical problems due to impairment of nerves at or below the site of the lesion. There is variable impairment of sensory and motor nerves controlling voluntary and autonomic functioning. Associated medical concerns include neurogenic bowel and bladder function, contractures, scoliosis, club feet, hydrocephalus, Chiari II malformation, tethering of the spinal cord, spinal cord syrinx, vesicoureteral reflux, decubitus ulcers, constipation, encopresis, recurrent urinary tract infections, growth failure, latex allergy, gastroesophageal reflux, apnea stridor syndrome, seizures, partial agenesis of the corpus callosum, strabismus, visual acuity impairment, precocious puberty, and osteoporosis. Individuals also may have cognitive impairments. Mild forms of cognitive impairment may affect visual motor functioning. More severe cognitive impairment has been associated with sparing of verbal skills and a cocktail party syndrome, in which the...

Clinical presentation

Asthma may present acutely or as a chronic pulmonary disease. Symptoms of acute asthma include shortness of breath, chest tightness, wheezing and cough, often productive of clear or slightly colored sputum. When present, chest pain is usually musculoskeletal in origin. Audible wheezing may not be present in mild asthma, but may be elicited by forced expiratory maneuvers. Increased diurnal variations in pulmonary function are often associated with nocturnal exacerbations. Triggers for worsening asthma include cold air exposure, exercise, viral respiratory infections, sinusitis, gastroesophageal reflux, exposure to seasonal or perennial inhalant allergens, and exposure to inhaled irritants such as cigarette smoke. Seasonal variations in asthma severity often correlate with seasonal allergen exposure. Finally, a number of medications, including P adrenergic blockers and nonsteroidal anti-inflammatory agents, as well as sulfite preservatives, may exacerbate asthma in susceptible subjects....

TABLE 731 Traditional Drugs for Peptic Ulcers

Patients generally do not present to the emergency department with a definitive diagnosis of peptic ulcer disease but, rather, with a symptom, such as epigastric pain. If appropriate history, physical examination, and laboratory evaluation result in a physician's impression of possible peptic ulcer disease or dyspepsia, the physician is left with three main options empiric treatment with conventional antiulcer medication, immediate referral for definite diagnosis (endoscopic or radiologic study), or noninvasive testing for H. pylori followed by antibiotic therapy for patients with positive test results. 119

Apnea And Home Apnea Monitors

Sepsis, gastroesophageal reflux and aspiration, aspiration with feedings, anemia, and metabolic problems, such as hypoglycemia. Other, more unusual causes include seizures, cardiac dysrhythmias, and posthemorrhagic hydrocephalus. Therapy is directed toward the specific cause.

Immune responses of the host

ELISA-based serological tests are used routinely for detection of infection in patients with dyspepsia and for seroepidemiological surveys. The antigens used vary in complexity but all include the urease. Most recently tests for salivary IgG antibodies have been introduced which are noninvasive and particularly useful in children. In general, tests to monitor the success of treatment have not been useful because of the persistence of the circulating antibodies.

Psychology in Medicine in the 1800s

Concrete examples of perhaps some of the earliest markers of the need for the emerging field of behavioral medicine arose in the study of digestive dysfunctions. Walter Cannon, a Harvard physiologist, postulated, based on his research, that digestive dysfunctions were largely due to persons' nervous character (Shorter, 1991, p. 143). Other developments in the 1880s and 1890s occurred in Germany. German internists recognized that stomach pain or vomiting could result from either physical irritation or nervous symptoms. The term neurasthenic dyspepsia or emotional dyspepsia was labeled by a Berlin internist to describe digestive problems of psychological origin. Recognizing the brevity of this review, and the attempt only to highlight historical routes of behavioral medicine, it follows that the early 1900s was a particularly progressive point in the telling of this history.

Clinical Manifestations Diagnosis and Treatment

The classic symptom of ulcer is dyspepsia, a burning epigastric pain usually occurring 2-3 h after meals and at night (between 11.00 p.m. and 2.00 a.m.) when acid secretion is maximal. Relief often occurs with ingestion of food and alkali. Although suggestive of peptic ulcer, dyspepsia is not a sensitive or specific measure of peptic ulcer. Only about 50 of DU patients have the typical symptom of dyspepsia. Some ulcer patients develop a stomach that is easily irritated by food, mechanical distention, or other chemical stimuli.

Chapter References

Talley NJ, Weaver AL, Tesmer DL, Zinsmeister AR Lack of discriminant value of dyspepsia subgroups in patients referred for upper endoscopy. Gastroenterology 105 1378, 1993. 7. Talley NJ, McNeil D, Piper DW Discriminant value of dyspeptic symptoms A study of the clinical presentation of 221 patients with dyspepsia of unknown cause, peptic ulceration, and cholelithiasis. Gut 28 40, 1987. 17. Ofman JJ, Etchason J, Fullerton S, et al Management strategies for Helicobacter pylori seropositive patients with dyspepsia Clinical and economic consequences. Ann Intern Med 126 280, 1997.

Developmental Disability Mental Retardation

Children with mental retardation have a wide variety of associated medical problems. With increasing severity of mental retardation, there is increased incidence of associated problems. Cerebral palsy, visual deficits, seizure disorders, failure to thrive, hypotonia, gastroesophageal reflux, aspiration, and psychiatric disorders have all been seen in the general population with mental retardation. Mental retardation associated with known syndromes may have diagnosis-specific medical problems such as in Down syndrome, the best known of these syndromes. Listings of diagnosis-specific medical problems can be found in Table 131-5

Postoperative Intestinal Lesions

The blind loop syndrome, one of the malabsorption syndromes, is a collective name for pathological conditions manifesting as diarrhea, dyspepsia, malabsorption, and anemia that are caused by abnormal growth of intestinal bacterial flora associated with abnormal retention of intestinal contents in the intestinal tract 1 . Evidence suggests that the anemia in this syndrome is due to vitamin B12 deficiency, which may be caused by the use of vitamin B12 by intestinal bacteria and the binding of intestinal bacteria to the intrinsic factor-vitamin B12 complex.

Selected Motor Lesions Causing Dysphagia

Nutcracker esophagus is a motility disorder in which there are high-amplitude, long-duration peristaltic contractions in the distal esophagus. Manometric criteria require readings of 180 mmHg. The cause of nutcracker esophagus is unknown and the prevalence of this disease is debated in the literature. 12 Patients with this disorder frequently have associated psychiatric disorders and about one-third have GERD.

Physiologic Changes Of Pregnancy

The gastrointestinal tract demonstrates diminished motility, and there is delayed gastric emptying during pregnancy. This increases the likelihood of gastroesophageal reflux and the potential for aspiration from acute injuries as well as from resuscitative interventions, including endotracheal intubation. The small bowel is moved upward in the abdomen by the enlarging uterus, protecting the small bowel to some degree from lower abdominal injuries. It does, however, increase the chance of complex bowel injuries in penetrating trauma of the upper abdomen.4 The liver is typically unaffected by pregnancy, and the most common etiology of abdominal hemorrhage remains splenic injury, as in nonpregnant patients.

Cerealbased Fermented Food

(a) Chinese Minchin This is made from wheat gluten and used as a solid condiment. The fungal species involved in fermentation include Aspergillus sp., Chadosporium sp., Fusarium syncephalastum, and Paecilomyces sp. (Padmaja and George 1999) (b) Chinese red rice (Anka) This is produced by fermenting rice with various strains of M. purpureus Went. It is used to color foods such as fish, rice wine, red soybean cheese, pickled vegetables, and salted meats. To make Anka, polished rice is washed, steamed, cooled, inoculated with M. purpureas, and allowed to ferment for a few weeks. Anka has been reported to be effective in treating indigestion and dysentery (Su and Wang 1977) (c) Jalabies These are syrup-filled confectionery available in India, Nepal, and Pakistan made from wheat flour. Saccharomyces bayanus and bacteria are involved in fermentation (Padmaja and George 1999) (d) Indian Kanji This is made from rice and carrots. It is a sour liquid added to vegetables. H. anomala is involved...

TABLE 1128 Differential Diagnosis of Acute Life Threatening Episodes

An ALTE may be caused by anything that could give the impression that the infant is extremely ill and in danger of dying. The most common general categories of the causation for ALTEs and their prevalence among ALTE infants are infection (5 to 40 percent, depending on the season), gastroesophageal reflux (GER) and other causes of laryngeal chemoreceptor stimulation (20 percent), seizures and other neurologic disorders (15 to 20 percent), and idiopathic (40 to 60 percent). Because most infants who have significant GER do not experience ALTEs, establishing the diagnosis of GER does not prove that it is the cause of ALTE. An unusually strong laryngeal chemoreceptor reflex can significantly increase an infant's susceptibility to ALTE due to GER, even with only minor reflux. This reflex is stimulated by acid or nonisotonic fluids, and the reflex response is apnea, bradycardia, and central pooling of blood.

Definition and Clinical Aspects

Cardial incompetence, hiatal hernia, and gastroesophageal reflux are relatively common endoscopic findings. Often these findings are causally related to one another, but they may also occur independently. They are not consistently associated with typical clinical complaints.

Resection of Epiphrenic Diverticulum

Epiphrenic diverticulum is an uncommon entity that most frequently occurs on the right side of the distal 10 cm of the esophagus. The pathogenesis of esopha-geal diverticula remains controversial 9 . The most common symptoms are dysphagia, heartburn, and regurgitation of undigested food particles. Surgery is indicated in symptomatic patients, and a myotomy at the time of the excision is recommended when abnormal motility is present. Longer instruments and reticulating wrists allow surgeons to extend the dissection deep into the thorax for more proximal diverticula and to operate in tight quarters, manipulating the esophagus without causing undue tension or torque on this structure. The robotic system clearly facilitates the dissection of the neck of the diverticulum when compared with conventional laparoscopic instruments. Once the diverticulum neck is identified and dissected free, the diverticulum is resected using an endoscopic linear stapler. Endoscopy is used to aid in...


INFLAMMATORY ESOPHAGITIS GERD may induce an inflammatory response in the lower esophageal mucosa. Over time, this can progress to esophageal ulcerations, scarring, and stricture formation. The presence of esophagitis due to reflux warrants aggressive pharmacologic therapy with acid-suppressive medications. If this treatment regimen is not sufficient, surgical options are considered.17 Barrett's esophagus, mentioned above, can develop as well.

Infantile Spasms

There are many causes of infantile spasm (secondary type), including migrational defects, prior CNS trauma, hypoxia, neurocutaneous disorders, and infectious and metabolic disorders. The idiopathic type is the most alarming because it affects children with no prior neurologic disorder and no etiology is identified. Differential diagnosis includes benign myoclonus, dyskinesia due to gastroesophageal reflux, and tics.

Pulmonary Problems

Respiratory tract symptoms are seen commonly in children with severe forms of cerebral palsy. They include chronic congestion, recurrent wheezing pneumonia, microaspiration, and aspiration.1 The respiratory tract problems are generally related to oral motor dysfunction and gastroesophageal reflux. Oral motor dyspraxia presents with exaggerated gag and retained bite reflexes, tongue thrust, and oral hypersensitivity, which can lead to choking, gagging, and aspiration.12 Oropharyngeal incoordination manifests early with poor feeding and failure to thrive and contributes to aspiration. Gastroesophageal reflux is associated with aspiration of food and chemical fumes that may be damaging to pulmonary tissues and can be associated with the development of pneumonia. Lack of head control may lead to pooling of secretions in the posterior pharynx with spillage of contents into the vallecula and then into the trachea. at risk for reactive airways triggered by microaspiration of saliva, food, or...

Barretts Metaplasia

One of the proposed mechanisms for development of Barrett's metaplasia is gastroesophageal reflux. It is assumed that prolonged acid reflux from the stomach (generally with bile acids) promotes damage to the epithelia at the end of the esophagus. Presumably, in the early stages of the disease, the normal stratified squamous epithelium is replaced. Eventually, reepithelialization results in the formation of columnar as opposed to stratified squamous epithelium, most likely because of repeated exposure to an acid environment. It is not clear whether the different intestinal cell types formed in the esophagus arise from the same stem cell in the basal layer or whether there is a transdifferentiation of columnar cells to goblet cells. It is also not understood why some patients with efflux disease do not go on to develop Barrett's metaplasia.


Vomiting is a common childhood problem and may be a specific or nonspecific manifestation of a benign process or a serious, life-threatening illness or injury. Vomiting or regurgitation may be a manifestation of a relatively minor problem (e.g., a nervous parent, poor feeding habits, or gastroesophageal reflux) or it may be a sign of a more serious illness. Bilious vomiting is always a serious manifestation in an infant or a child. Vomiting may be a sign of obstructive or nonobstructive GI diseases, or of infections or metabolic disorders (Table 123-3).


Autonomic neuropathy represents the clinical entities of gastroesophageal reflux disease (GERD), gastroparesis, neurogenic bladder, impotence and sexual dysfunction, autonomic diarrhea (nocturnal, often with incontinence), and orthostatic hypotension. Symptoms of GERD include dysphagia, chest pain, and heartburn. Distinction from myocardial ischemia in the emergency department is often impossible, unless GERD has been previously diagnosed. Gastroparesis is the nonprogressive and nonrhythmic contraction of the gastric antrum, often with pylorospasm. Symptoms include epigastric pain, bloating, anorexia, nausea, early satiety, or vomiting.21 Gastroparesis has been shown to respond to erythromycin, cisapride, and metoclopramide, all of which decrease gastric emptying time. Severe cases may not respond to medication.

Midepigastric Pain

Other causes of midepigastric pain include gastroesophageal reflux disease (GERD), gastric and duodenal ulcer disease with or without perforation, and cardiac symptoms. All diseases should be ruled out per the risk factors seen in that patient. For example, if a 65-year-old gentleman with a known history of reflux presents to the ED complaining of midepigastric pain, even though the pain may be recurrent reflux, he should still get at the least an ECG to ensure that there is no cardiac ischemia occurring. GERD is treated surgically under specific criteria, including patients who are refractory to medical therapy, people who are noncompliant with their medications, and people with pathologic changes of dysplasia or malignancy secondary to reflux seen during esophagogastroduodenoscopy (EGD) evaluation. Reflux surgery is rarely done urgently. Ulcer disease has been seen to be highly correlated with Helicobacter pylori infection, which is treated initially with medical therapy. Patients...

Metabolic Alkalosis

Metabolic alkalosis may be caused either by the excessive loss of acid or intake of alkali. The latter may be iatrogenic or factitious, with the excessive intake of prescribed antacids (such as sodium bicarbonate for heartburn or peptic ulcer disease) - the 'milk-alkali' syndrome. The loss of acid-rich gastric secretions in severe vomiting, for example, in cases of gastric outlet obstruction (due to pyloric stenosis, or a consequence of peptic ulcer disease), also leads to alkalosis. Compensation is by reducing ventilation to promote retention of CO2 and thus balance the Henderson-Hasselbalch equation. Treatment is of the underlying condition rather than by administration of acid.

Risk Factors

Gastroesophageal reflux disease (GERD) is strongly associated with adenocarcinoma of the esophagus. In the process of gastroesophageal reflux, acid fluid regurgitates into the gastroeso-phageal junction and causes a sensation of heartburn. GERD can be caused by hiatal hernia, esophageal ulcer, and use of drugs that relax the lower gastroesophageal sphincter and increase reflux. Alcohol, tobacco, obesity, and pregnancy may also contribute to GERD. 5-10 of people with GERD and is associated with a 30- to 125-fold increased risk for esophageal adenocarcinoma. In the United States, the incidence of adenocar-cinoma of the esophagus has increased more than 350 since the 1970s. Obesity has been hypothesized to be one of the factors responsible for this increase by augmenting abdominal pressure and gastroesophageal reflux frequency. However, evidence has not been consistent to support this hypothesis.

Disease and Illness

Ideally) invokes an explanatory etiology, a prognostic picture, and a set of treatment options, all drawing upon the theories and knowledge base of medical science. Since the eighteenth century, disease classifications have progressively moved from a basis in the patient's reported symptoms to one grounded on the pathological lesions and processes exposed after death or, by medical technologies, in the living (Engelhardt, 1986 Foucault). Hence, dyspepsia has become peptic ulcer disease. This shift has greatly advanced the explanatory and therapeutic powers of modern medicine, but it has also diminished the attention paid to the patient's experience.

Cerebral Palsy

Children with cerebral palsy may have associated medical problems as a direct effect or complication of motor dysfunction or underlying brain damage. Seizures, oral motor dysfunction, gastroesophageal reflux, constipation, urinary tract infections, pneumonia, wheezing, hearing loss, strabismus, visual impairments, scoliosis, contractures, and hip dislocation or subluxation are all seen with increased frequency in children with cerebral palsy. Children with less severe presentations have minimal associated medical problems (i.e., the child with spastic diplegia may have only issues related to spasticity). As the severity of impairment increases to spastic quadriplegia, the incidence and severity of associated problems and need for emergency medical treatment also increase.

Fibre in the Diet

Although diverticular disease of the colon is viewed as a disease of western civilization and ascribed to inadequate dietary fibre intake, there is a strong clinical impression by the medical profession that increased dietary fibre intake will relieve the symptoms of diverticular disease (Ornstein et al., 1981). In a controlled clinical study, 58 patients with uncomplicated diverticular disease of the colon ingested a bran crispbread, an ispaghula drink (Psyllium) and a placebo for 4 months each in a randomized, cross-over, double-masked, controlled trial. Subjective assessments were made monthly using a self-administered questionnaire. Objective studies were made by examination of a 7-day stool collection from each patient at the end of each treatment period. Using a pain and lower bowel symptom score, which included incomplete sensation of emptying the bowel, straining, stool consistency, aperients taken and nausea, and a total symptom score, which included nausea, belching,...

Bulimia Nervosa

Jill was a 23-year-old administrative assistant who had been binge eating and purging since the age of 16. Although her mother was slim and even glamorous, her father's side of the family tended to be obese and Jill seemed to have inherited those tendencies. Throughout Jill's teen years her mother constantly urged her to watch her weight, to avoid getting too chubby, so that she would be socially popular. Jill did everything she could to diet, and she exercised rigorously. However, all of her efforts seemed inadequate to prevent a gradual increase in her weight, and she become demoralized at the seeming futility of her battle with the scale. When she was 16, discovering that she could keep her weight down by purging seemed an easy out. Over the next few years the binge eating and purging pattern increased, and she became progressively ashamed and secretive about her eating patterns. Gradually, binge eating and purging seemed to take on a life of their own and Jill became demoralized...


The oesophagus runs from the pharynx to the cardia and has a short cervical part, a longer intrathoracic part and a short upper abdominal part. It runs behind and is closely approximated to the trachea as far as the bifurcation, and the arch of the aorta crosses it. The least protected part of the oesophagus is the lower intrathoracic section and this is where spontaneous rupture generally occurs. The entrance to the abdomen is controlled by slips of the diaphragm called crurae and if these become lax then a sliding or paraoe-sophageal hernia may occur. Sliding hernias are associated with dysfunction of the natural valve occurring at the cardia and are often associated with acid reflux leading to reflux oesophagitis and sometimes stricture formation.

Spinal Cord Injury

Spinal cord injury may result in complete or partial loss of neurologic function below the level of the lesion. Pain, heterotopic bone ossification, hypercalcemia, renal calculi, and depression are frequent issues for all children with spinal cord injury. 17 Other associated medical problems are similar to those encountered by children with meningomyelocele. Neurogenic bowel and bladder, decubitus ulcers, spasticity or hypotonicity, gastroesophageal reflux, esophagitis, aspiration, impaired sensation, ureterovesical reflux, scoliosis, contractures, and osteoporosis are common. For children with cervical or thoracic level lesions, respiratory compromise due to impaired phrenic nerves and or abnormal innervation of abdominal musculature may be present. Autonomic dysreflexia and oral motor dysfunction also may be present. Since many of the issues are well covered in the section on meningomyelocele, this section will cover only the issues specific to spinal cord injuries.

M Pathophysiology

Peptic strictures have a reported incidence of up to 15 in patients with reflux disease. Strictures develop as a result of longstanding gastroesophageal reflux and chronic, deep inflammation (extending into the submucosa) with fibrosis and scarring. They are found in the region of the gastroesophageal junction. Most strictures are short, but some may extend for several centimeters in the distal esophagus. The earliest change is usually a thickening of the Z-line, followed by concentric luminal narrowing that may later become eccentric and may be associated with a diverticulum-like outpouching of the esophagus proximal to the stricture.

Oesophageal Diseases

If there is obstruction to swallowing it is called dysphagia, but if there is just pain on swallowing it is known as odonypha-gia. Oesophageal pain may be characteristic such as heartburn associated with acid reflux and associated hiatal hernia, but can also be quite obscure and mimic cardiac disease.

Medical History

One specific focus of medical history in a nutritional assessment context is the exploration of gastrointestinal function. Conditions such as chronic diarrhea, gastroesophageal reflux, and colonic disorders may be associated with reduced nutrient absorption or food avoidance that result in impaired nutritional status. Past history of gastrointestinal problems and or surgery may also point to current alterations in nutrient digestion or absorption. Other important components of the medical history are history of weight loss or gain, past and present use of medications, use of special foods or formulas, changes in taste or smell, and food allergies and intolerances.

Gastric carcinoma

The main, and often only, symptom of an early gastric cancer is dyspepsia. As the cancer becomes more advanced symptoms include anorexia, weight loss, vomiting, and anaemia. Unfortunately, dyspepsia is a very common symptom, and is often treated by patients and doctors alike with a variety of ant-acid therapies. Guidelines have been produced to encourage referral of patients with dyspepsia who Table 12.7. Referral guidelines for suspected upper GI cancers (patients with dyspepsia). Patient 55 years old, with dyspepsia Dyspepsia with alarm symptoms - Anorexia Dyspepsia with risk factors are at risk, and these are shown in Table 12.7. Even so, it is uncommon to see early gastric cancers and it is often the case that when advanced cancers are diagnosed patients have often had a long history of dyspepsia prior to diagnosis. Although barium studies have been used to investigate dyspepsia, and diagnose gastric cancer, the investigation of choice is endoscopy, which allows visualisation of...


TOXIC EFFECTS OF THEOPHYLLINE Theophylline has a direct central nervous system effect, leading to nausea and vomiting. In addition, theophylline increases gastric acid secretion. Nausea and vomiting can be seen with therapeutic levels, although the incidence of nausea and vomiting increases markedly with levels above 15 Mg mL. Approximately 25 percent of patients with levels greater than 20 Mg mL have nausea or vomiting. Gastrointestinal bleeding, with epigastric pain, may also occur. Esophageal reflux has also been reported.


Dystress is taken from the Greek root dus (bad), which has a notion of hard or bad or unlucky and removes the good sense of a word or increases its bad sense (e.g., dyspepsia, dysentery). Dystress means stress* with which the animal cannot cope (see ANIMAL WELFARE, Coping) and is usually a result of long-term (chronic) stress. It is to be differentiated from stress with which an animal can cope, sometimes referred to as eustress. It often involves activation of the hypothalamus with its connections to the pituitary gland, which controls many of the endocrine glands in the body. The adrenal cortex is often involved, and this leads to a rise in circulating corticosteroids. On other occasions, compromised functioning of

Reflux Esophagitis

Reflux esophagitis refers to the gross or histological inflammatory changes that occur in the esophageal mucosa in response to reflux. The clinical picture is characterized by retro-sternal or epigastric pain, heartburn, and dysphagia that periodically recur. Periods of remission with very mild clinical symptoms are followed by acute exacerbations. In many cases the complaints progress over time, eventually leading to complications such as chronic ulcers, scarring, strictures, columnar metaplasia, and adenocarcinoma. Fig. 3.22 Gastroesophageal reflux Fig. 3.22 Gastroesophageal reflux Heartburn


Biliary duct injury and successful repair of the injury, patients can have normal laboratory findings but permanently impaired QoL 45, 82 , This reinforces the question as to whether we are measuring what is relevant for the patients, Furthermore, the experts pointed out the importance of the preop-erative QoL assessment for patient selection for laparoscopic surgery in specific diseases, This is especially true for GERD, for example, when deciding on surgery for depressed patients 55 ,


Patients with gastroesophageal reflux disease, gastric ulcer, and duodenal ulcer. Gastrointestinal motility is influenced by sex hormones (51,52), implying that gender-based disparity in motility may exist and that the transit time in women may vary throughout pregnancy and the menstrual cycle. Estrogen and its equivalents may inhibit gastric emptying (53,54), whereas the effects of progesterone depends on its concentration (55,56). Gastric transit time has been demonstrated by many researchers to be slower in females than males (57-61).


A patient with FOC may present in a number of ways. The peak incidence of sporadic ovarian cancer is 40-60 years of age. Familial ovarian cancer has an earlier average age of onset, but cancers under 40 years of age are still uncommon (Bewtra et al., 1992 Boyd et al., 2000). Ovarian tumours rarely give rise to specific symptoms at an early stage, the commonest being vague gastrointestinal disturbance such as dyspepsia or increased abdominal girth. A result of this is that the majority of patients still present as stage III disease with spread to the abdominal cavity. It is the aim of screening to be able to identify the disease before it has spread from its primary site of origin, i.e. stage 1A, as one is then able to cure the majority of patients. More and more patients with FOC are presenting via some sort of screening programme.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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