10.2 SFGH pearls: GERD, Asthma and SBO!

  • Surgery for reflux is typically considered in those with GERD symptoms who are young and would require lifelong medical therapy. However, it is not recommended for those who fail PPI therapy, as efficacy is population is controversial
  • GERD and asthma are commonly associated conditions, with 30-90% of those with asthma also have GERD (quite the range, but definitely common)
    • There are a few proposed mechanisms for this relationship:
      • Increased vagal tone – infusing saline into the esophagus in animals àincreased respiratory resistance. The reaction is eliminated with vagotomy
      • Bronchial reactivity – in some studies, methacholine test positivity correlated with reflux symptoms!
      • Microaspiration – small amounts of acidic reflux materials is aspirated and causes bronchoconstriction
    • Upper GI series can be helpful to characterize the post-operative anatomy in the esophagus, stomach and duodenum in a patient with an unclear surgical history. A small bowel follow through with the study also can help confirm a small bowel obstruction and determine whether the obstruction is partial vs complete
    • Post-operative adhesions are the most common cause of intestinal obstruction in Western countries! They should be suspected in any patient with h/o prior abdominal surgery who present with obstructive symptoms, and lysis of adhesions should be performed if they fail conservative management.
    • This patient was somewhat undifferentiated on admission, but there is evidence that SBO patients do better on a surgical service even if management is non-operative, with shorter length of stay, lower cost, shorter time to surgery (if needed) and lower mortality. (Oyasiji et al below), so consider discussing this with our surgical colleagues for your SBO patients.

Evernote link: https://www.evernote.com/shard/s300/sh/cee7adf4-022b-4f6a-a160-c4d00a6b6dcc/1a6256e4ae79f3663a3c58d35e71a56c

Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013; 108:308.

Simpson WG. Gastroesophageal reflux disease and asthma. Diagnosis and management. Arch Intern Med 1995; 155:798.

Karbasi A, Ardestani ME, Ghanei M, Harandi AA. The association between reflux esophagitis and airway hyper-reactivity in patients with gastro-esophageal reflux. J Res Med Sci 2013; 18:473.

Oyasiji T, Angelo S, Kyriakides TC, Helton SW. Small bowel obstruction: outcome and cost implications of admitting service. Am Surg 2010. Jul;76(7):687-91

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