GERD means that stomach acid refluxes into the esophagus. It is due to inappropriate intermittent relaxation of the lower esophageal sphincter.

Incidence is increased in patients with hiatal hernia.

The main complaint is usually heartburn. often related to eating and lying supine. GERD may also cause abdominal or chest pain.

Initial treatment is to elevate the head of the bed and to avoid coffee, alcohol,tobacco, spicy and fatty foods, chocolates and medicines with anticholinergic properties. If this approach fails, antacids, histamine 2 blockers, PPIs may be tried.

Surgery (Nissen fundoplication) is reserved for severe/ resistant cases

What is hiatal hernia? How is it different from paraesophageal hernia?

A hiatal hernia is a sliding hernia, which means the whole gastroesophageal junction moves above the diaphragm, pulling the stomach with it. This common and benign finding may predispose to GERD.

In a paraesophageal hiatal hernia, the gastroesophageal junction is below the diaphragm, but the stomach herniates through the diaphragm into the thorax. This  type of hernia is uncommon but serious, it may become strangulated, requires surgical repair.

PUD classically presents with chronic intermittent epigastric pain (burning, gnawing or aching) that is localized and relieved by antacids and milk. Look for epigastric tenderness.

Other signs: blood in stools, Nausea and vomiting

PUD is more common in men 

Two types: Gastric and Duodenal

Explain classic differences between gastric and duodenal ulcers.

                       Duodenal                      Gastric

Cases               75%                             25%

Acid secretion    Normal to high               Normal to low

Main Cause        H. Pylori                       NSAIDs, Aspirin

Peak age           Forties                          Fifties

Blood Type         O                                A

Eating food        Pain gets better,       Pain not relieved                         then worse after     or made worse

                        2-3 hours

Gold Standard: endoscopy (most sensitive)

but an upper GI  barium study is cheaper and less invasive.

Empirical treatment with medications maybe tried in the absence of diagnostic studies if symptoms are typical.

If endoscopy is done, a biopsy of the gastric ulcer is mandatory to rule out malignancy.

Doudenal ulcers do not have to be biopsied as malignancies are rare.

The most feared complication is perforation. Look for peritoneal signs, history of PUD, and free air on abdominal radiograph.

Treat with antibiotics, and laparotomy with repair of perforation.

If ulcers are severe, atypical(jejunum) or non healing, think about stomach cancer or Zollinger Ellison Syndrome (gastrinoma, check gastrin levels)

PUD is also a cause of GI bleeding, which can be severe in some cases.

How is PUD treated initially?

Diet changes are not thought to help ulcers, although reducing alcohol and tobacco use may speed healing .

Start treatment with antacids, H-2 Blockers, PPIs and antibiotics to eliminate Helicobacter Pylori.

Triple therapy: Amoxicillin+Bismuth+Metronidazole

Surgical options may be considered after medical treatment fails, or with complications (bleeding, perforation)

Commonly done procedures: Antrectomy, Vagotomy, Billroth 1 or 2.

After surgery, especially Billroth procedures, watch for dumping syndrome (weakness, dizziness, sweating, nausea, vomiting after eating)

Patients also develop hypoglycemia 2-3 hours after the meal, which causes recurrence of the same symptoms, as well as afferent loop syndrome,(bilious vomiting after a meal relieves abdominal pain), bacterial overgrowth and vitamin deficiencies (B12 and iron , causing anemia)

Achlorhydria is the absence of hydrochloric acid secretion. It is most commonly due to pernicious anemia, in which anti parietal antibodies destroy acid secreting parietal cells and thus cause achlorhydria and B12 deficiency.

It is associated with other endocrine