mr. jorgan case # 1. mr. h. jorgan 40 y/o w/m here for initial evaluation cc: “sour stomach...
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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!