This document presents a case report of a 43-year-old male patient presenting with symptoms of gastroesophageal reflux disease (GERD) including mid-epigastric pain, chest burning, dry cough, and occasional regurgitation. On physical examination, his vital signs and physical exam were normal. The document then provides questions and answers about differential diagnoses, definitions, and management approaches for GERD. Key points addressed include the spectrum of GERD, from symptoms to complications like esophagitis, stricture, and Barrett's esophagus. Empiric PPI therapy is discussed as an initial management strategy.
GERD is most common gastric problem in community affecting large number of people. Diagnosis and management is very simple with understanding.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
GERD is most common gastric problem in community affecting large number of people. Diagnosis and management is very simple with understanding.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
Evaluation and management of patients with Dyspepsia.pptxgarvitnanecha
Evaluation and management of patients with Dyspepsia.
Dyspeptic symptoms.
Causes of dyspepsia
Approach to adult with Dyspepsia.
Newer advancement about diagnosing dyspepsia causes.
GERD and peptic ulcer and many more organic diseases.
Functional Dyspepsia and organic dyspepsia
Gastroesophageal Reflux Disease (GERD) is a common disorder that has undergone many paradigm changes in the last 15 years. We discuss the current paradigms in the pathophysiology, diagnosis and management of GERD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Evaluation and management of patients with Dyspepsia.pptxgarvitnanecha
Evaluation and management of patients with Dyspepsia.
Dyspeptic symptoms.
Causes of dyspepsia
Approach to adult with Dyspepsia.
Newer advancement about diagnosing dyspepsia causes.
GERD and peptic ulcer and many more organic diseases.
Functional Dyspepsia and organic dyspepsia
Gastroesophageal Reflux Disease (GERD) is a common disorder that has undergone many paradigm changes in the last 15 years. We discuss the current paradigms in the pathophysiology, diagnosis and management of GERD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
3. Case Presentation
• 43-year-old male
• C/o One-month episodes of mid-epigastric pain, a
“burning” sensation in his chest, an associated dry cough,
and occasional regurgitation.
• Pain worsens after eating & when lying flat
• Increasing postprandial fullness and early satiety
• Waking up from the pain and burning, with a sore throat
and hoarse voice
• Also reports associated episodic, mid-thoracic, bilateral
back pain
• Symptoms partially relieved by adjusting from a lying to
sitting position & with the use of antacids
4. Physical Examination
• Weight 76 Kg
• Vitals:
• Temperature, 99.1° F
• BP 132/78 mmHg
• Respiratory Rate 18
• Pulse, 80/ min
• Throat: Oropharynx pink & moist; no erythema, tonsillar enlargement, lesions,
lingual erosion of teeth,no lymphadenopathy, or nodularity; thyroid normal size.
• CVS/ Lungs/ Abdomen/ Musculoskeletal/ Neuro/ Eyes: NAD
5. Q1. Which of the following are among the
Differential Diagnoses to consider when assessing
the patient with symptoms of GERD?
• Esophageal neoplasm
• H pylori infection
• Coronary artery disease
• Cholelethiasis
• All of the above
6. DD of Chest Pain of GI origin
Condition Differentiating signs/symptoms Differentiating investigations
CAD (Coronary Artery
Disease)
•Cardiac aetiology must be ruled out before considering a diagnosis of
GERD in people with chest pain.
•Cardiac chest pain is typically substernal, precipitated by exertion,
and relieved by rest.
•ECG may show ST changes or Q waves.
•Exercise stress testing may abnormal.
Functional
oesophageal
disorder/functional
heartburn
• No reliable differentiating signs or symptoms. •Functional heartburn denotes endoscopy-negative
heartburn by definition. A normal oesophageal pH study
differentiates between non-erosive GERD and
functional heartburn.
Achalasia • Dysphagia is typically prominent. • Oesophageal manometry and/or oesophagram are
abnormal and consistent with achalasia.
Biliary colic • Right upper quadrant or epigastric pain usually increasing in intensity
and lasting several hours.
• USG may show gallstones.
Non-ulcer dyspepsia • At least 3 months of recurrent upper abdominal pain, bloating, and
nausea, with no obvious structural cause.
• No definitive differentiating tests. Oesophagitis is
absent on endoscopy for both non-erosive GERD &
non-ulcer dyspepsia, while peptic ulcer disease was
excluded.
Peptic ulcer disease • Burning pain in the epigastrium, which occurs hours after meals or
with hunger.
• The pain often wakes the patient at night and is relieved by food and
antacids.
• Endoscopy demonstrates ulcer.
• Testing for H pylori infection is often positive (not
diagnostic)
PPI-responsive
oesophageal
eosinophilia
• Should be diagnosed when patients have oesophageal symptoms &
histological findings of oesophageal eosinophilia, but demonstrate
symptomatic & histological response to proton-pump inhibition.
• This entity is considered distinct from eosinophilic oesophagitis, but
is not necessarily a manifestation of GERD.
• Therapeutic response to PPI
Malignancy • Suspected in older adults presenting with alarm symptoms: anaemia,
acute or progressive dysphagia, hematemesis, melena, persistent
vomiting, or involuntary weight loss.
•Laboratory tests may show anaemia or abnormal
LFTs.
•Tissue biopsies diagnostic.
http://bestpractice.bmj.com/best-practice/monograph/82/diagnosis/differential.html
7. Q2. When characterizing
gastroesophageal reflux disease (GERD),
which of the following statements is true?
• Chief symptoms that GERD patients experience are associated with
esophageal injury
• Patients with reflux symptoms are likely to have erosive esophagitis
• GERD is defined as symptoms or mucosal damage produced by the
abnormal reflux of gastric contents into the esophagus
• GERD is not typically associated with extraesophageal symptoms
8. GERD
• American College of Gastroenterology (ACG)
• GERD as symptoms or mucosal damage produced by the abnormal reflux of
gastric contents into the esophagus
Recent global evidence-based consensus added "troublesome
symptoms or complications" to the definition of GERD (affects
individual well being)
Most patients with GERD symptoms have no visible signs of erosive
esophagitis on endoscopy, thus diagnosed with non-erosive reflux
disease
Experience typical symptoms associated with esophageal injury as well as
atypical extra-esophageal syndromes
9. Q3. Which of the following are generally associated with
the spectrum of GERD & its accompanying
complications?
• GERD symptoms without endoscopically visible esophageal
injury
• Stricture formation
• Barrett's esophagus and esophageal adenocarcinoma
• Esophagitis and hemorrhage
• All of the above
10. The Global Montreal Definition and Classification
of GERD Consensus
Formal classification of esophageal and extra-esophageal
syndromes
Esophageal Syndromes Extra-esophageal Syndromes
Symptomatic
Syndromes
Syndromes With
Esophageal Injury
Established
Associations
Proposed
Associations
Typical reflux
syndrome
Reflux chest pain
syndrome
Reflux esophagitis
Reflux stricture
Barrett's
esophagus
Esophageal
adenocarcinoma
Reflux cough
syndrome
Reflux laryngitis
syndrome
Reflux asthma
syndrome
Reflux dental
erosion syndrome
Pharyngitis
Sinusitis
Idiopathic
pulmonary fibrosis
Recurrent otitis
media
11. GERD – Spectrum of Disease
• Important concept from the Montreal consensus -
GERD should be considered a spectrum of
disease
• Spectrum of GERD begins with GERD symptoms
(without endoscopically visible esophageal injury) &
moves to GERD-associated esophageal complications
• Reflux esophagitis
• Hemorrhage
• Stricture
• Barrett's esophagus
• Esophageal adenocarcinoma
12. Q4. Which of the following should not be considered
an Alarm symptom prompting endoscopy?
• Laryngitis or hoarseness of the voice
• Dysphagia (difficulty swallowing) or Odynophagia (painful
swallowing)
• Gastrointestinal tract bleeding or Anaemia
• Involuntary and significant weight loss
• Persistent vomiting
13. Alarm Symptoms of Gastroesophageal
Reflux Disease
DeVault KR, Castell DO. Am J Gastroenterol. 1999;94:1434–42.
Weight Loss Bleeding
Choking
Chest Pain
Dysphagia
14. Q5. What information is the least useful for initial
assessment of a patient with symptoms of GERD?
• Assessment of extraesophageal symptoms
• Timing of symptoms (day time and/or night time)
• Duration of symptoms (months, years)
• Endoscopy results
• Information on medications previously used by the patient
to treat GERD symptoms
15. Diagnostic Options for Patients with Suspected
GERD
• Endoscopy
• Ambulatory monitoring
(pH, impedance/pH)
• Therapeutic trial of Acid
suppression + Prokinetic
Vaezi MF. Clin Cornerstone. 2003;5(4):32-38.
16. • Routine:
• Test CBC: Haemoglobin and haematocrit
within normal range; not showing microcytic
indices.
• Upper GI Endoscopy: Mild inflammation at
GE junction.
• Special Diagnostics:
• Diaphragmatic tightness noted
• Rib motion decreased
• Rotation measured at 40 degrees bilaterally
Diagnostic tests
17. Diagnosing GERD
• No gold standard diagnostic test for uncomplicated GERD
• Initial diagnosis obtained via clinical symptoms & confirmed via
empiric PPI treatment
• Endoscopy: – Reserved for patients with alarm symptoms or disease
complications – To screen for Barrett’s oesophagus in patients with
long-standing GERD
• pH Monitoring: patients not responsive to medical or surgical
treatment
DeVault KR, Castell DO. Am J Gastroenterol. 2005;100:190-200.
19. Management of GERD
• Non-Pharmacologic (Life-style changes)
• Pharmacologic treatment
• Anti-reflux surgery
20. Q6. In regard to response to empiric PPI therapy,
which of the following statements is not correct?
• EGD is not helpful in PPI nonresponders
• Even if a patient does not respond to initial empiric
therapy with a PPI, a diagnosis of GERD may be made on
increased PPI dose response
• GERD symptoms very often (70% to 80%) return
following discontinuation of a PPI
• The PPI dosage may be increased to twice a day if the
patient does not experience complete relief
21. Management – Practical tips
• Patients with a probable diagnosis of GERD treated
empirically with PPI (approx. 4 wks) should return for a
follow-up
• Patients may experience complete relief, partial relief, or
no relief of symptoms
• Complete discontinuation of therapy - not advised for
patients with relief of symptoms
• Up to 80% of GERD patients experience symptom recurrence
when medication is stopped
22. Practical tips :– On Demand or Intermittent
treatment
• 60% of patients could benefit from on-demand or intermittent
treatment
• Initially diagnosed and treated, these patients are classified as having
mild disease with relatively infrequent symptom relapses
• Such patients are ideal for on-demand or intermittent treatment to
reduce symptoms and improve QOL
23. Practical tips :– No relief from symptoms
• In cases patient receives no relief from symptoms or is dissatisfied with
symptom relief, the clinician should revisit the patient's history
• Check whether the patient is able to adhere to the timing and dosing
• If the medication is being taken correctly, increasing the dosage to twice a
day may be considered. Doubling the dose of may provide symptom relief
• Scheduling an endoscopy (especially if there has been a complete lack of
response to initial treatment)
24. Q7. Which of the following statements is not of key
importance when discussing GERD treatment and
management?
• Understanding how GERD symptoms affect a patient's
QOL
• Night time disturbances related to GERD and affecting a
patient
• Risk factors for GERD and expectations from therapy
• Exercise regimen changes
• Testing for H pylori
25. American Gastroenterological Asso. Survey
• Nationwide survey of 1000 adults experiencing heartburn at least once
a week, conducted by the Gallup Organization for the American
Gastroenterological Association
• 79% of respondents reported night time heartburn
• Of these, 75% reported that symptoms affected their sleep
• 63% believed that heartburn negatively affected their ability to sleep well
• 40% believed that nocturnal heartburn impaired their ability to function the
following day
• Researchers concluded that night time heartburn in a majority of adults
with GERD results in sleep disturbances and impaired next-day function
• However, sleep disturbances improve substantially with medications
26. Q8. Which of the following statements in regard to long-term
management of patients with GERD is not correct?
• Once symptoms have improved, yearly visits are recommended
• Long-term treatment and monitoring can prevent complications and
progression of disease
• Patients are likely to adhere to therapy when symptoms are relieved
• Alarm symptoms are unlikely to develop on PPI or therapy
27. Q9. In your experience, which of the following is the most
important barrier to the optimal management of GERD?
• Lack of diagnosis of GERD in patients presenting with atypical
symptoms of GERD
• Not distinguishing uncomplicated from complicated GERD
• Lack of consensus on duration of pharmacotherapy
• Lack of consensus on appropriate time for surgical treatment
29. Other formulations of Rabeprazole & Domperidone SR have the following
disadvantages:
1. SR Domperidone is released in duodenum (alkaline pH) where it is not soluble,
therefore can not produce desired pharmacological response.
2. The entire domperidone is in SR form, so there is no drug available for
immediate action.
Combination therapy in gastric disorders
30. Rabemac-DSR Technology ensures that the SR domperidone released in
alkaline pH of duodenum has good solubility – Ensures excellent
pharmacological response
31. Technology in making the right combination
Rabemac-DSR
Domperidone the recommended daily dosage is 10-20 mg
3-4 times daily
Yet the available formulations gives the same dosage as
once or twice daily
Less conc. of drug in blood for less time, hence less relief
Less therapeutic utility in diabetic gastroparesis, asthmatic
and ENT indications
32. Only Rabemac-DSR provides with a 3 way
release technology
Immediate
release of
Domperidone to
control Nausea
and Vomiting
Rabeprazole
released to
control acid
reflux
Slow sustained
release of
Domperidone
over 24 hours
for action
34. Summary of Rabemac-DSR
• Rabemac- DSR is an advanced formulation of Domperidone once a day and
Rabeprazole once a day with unique Three Way Release Technology
Rabeprazole in Rabemac- DSR is the best acid suppressant that:
• Maintains intragastric pH of 4 for all 24 hours.
• Better control of night time heartburn compared to all PPIs
• Fastest resolution of symptoms compared to all PPIs.
• Has gastro-protective action
• No drug-drug interactions.
• The only PPI effective even in acidic medium
• Once a day dosage
35. Domperidone in Rabemac-DSR is the best GI prokinetic that:
• Increases GI motility
• Increases LES pressure
• Controls nausea & vomiting
• Promotes healing in erosive esophagitis
• No neurological / cardiac side effects
Summary of Rabemac-DSR