Causes of Gastroesophageal Reflux Disease

• Inflammatory
  –Allergy
  –Gastroesophageal reflux disease
  –Sinusitis resulting in postnasal drainage
• Tumors
  –Leukemia
  –Rhabdosarcomas
  –Squamous cell carcinoma secondary to oral ulcerations
• Trauma
  –Foreign body ingestion
  –Caustic ingestion
  –Soft tissue injury from accidental and nonaccidental trauma
• Systemic/rheumatologic disorders
  –Kawasaki disease: Mucocutaneous lymph node syndrome may have sore throat at presentation (other oral findings include strawberry tongue, fissured lips, mucosal erythema, fever, and lymphadenopathy)
  –Behçet syndrome
  –Reiter syndrome
  • Others
    –Cigarette smoke
    –Environmental pollutants
    –Pharyngeal drying: Mouth and pharynx can be dry from mouth breathing, more common in the winter months

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Dyspepsia: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Cholelithiasis.

Cirrhosis

Duodenal ulcer

Gastric dilation (acute)

Gastric ulcer

Gastritis (chronic)

GI cancer

Heart failure

Hepatitis

Hiatal hernia

Pulmonary embolism

Pulmonary tuberculosis

Uremia

Other causes

Drugs

Surgery

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Gastroesophageal reflux: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The function of the LES — a high-pressure area in the lower esophagus, just above the stomach — is to prevent gastric contents from backing up into the esophagus. Normally, the LES creates pressure, closing the lower end of the esophagus, but relaxes after each swallow to allow food into the stomach. Reflux occurs when LES pressure is deficient or when pressure within the stomach exceeds LES pressure. (See Influences on LES pressure, page 690.)

Studies have shown that a patient with symptom-producing reflux can’t swallow often enough to create sufficient peristaltic amplitude to clear gastric acid from the lower esophagus. This results in prolonged periods of acidity in the esophagus when reflux occurs.

Predisposing factors include:

❑ pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice

❑ long-term nasogastric (NG) intubation (more than 4 days)

❑ any agent that lowers LES pressure, such as food, alcohol, cigarettes; anticholinergics (atropine, belladonna, and propantheline); or other drugs (morphine, diazepam, calcium channel blockers, and meperidine)

❑ hiatal hernia with an incompetent sphincter

❑ any condition or position that increases intra-abdominal pressure, such as straining, bending, coughing, pregnancy, obesity, and recurrent or persistent vomiting.

About 25% to 40% of Americans experience symptomatic GERD at some point in their lives, while 7% to 10% of Americans experience symptoms on a daily basis. True incidence figures may be even higher because many people with GERD take over-the-counter remedies without reporting their symptoms.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Dyspepsia: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Cholelithiasis

Dyspepsia may occur with gallstones, commonly after intake of fatty foods. Biliary colic, a more common symptom of gallstones, causes acute pain that may radiate to the back, shoulders, and chest. The patient may also have diaphoresis, tachycardia, chills, low-grade fever, petechiae, bleeding tendencies, jaundice with pruritus, dark urine, and clay-colored stools.

Cirrhosis

In this chronic disorder, dyspepsia varies in intensity and duration and is relieved by ingestion of an antacid. Other GI effects are anorexia, nausea, vomiting, flatulence, diarrhea, constipation, abdominal distention, and epigastric or right-upper-quadrant pain. Weight loss, jaundice, hepatomegaly, ascites, dependent edema, fever, bleeding tendencies, and muscle weakness are also common. Skin changes include severe pruritus, extreme dryness, easy bruising, and lesions, such as telangiectasis and palmar erythema. Gynecomastia or testicular atrophy may also occur.

Duodenal ulcer

A primary symptom of duodenal ulcer, dyspepsia ranges from a vague feeling of fullness or pressure to a boring or aching sensation in the middle or right epigastrium. It usually occurs 1½ to 3 hours after eating and is relieved by food or an antacid. The pain may awaken the patient at night with heartburn and fluid regurgitation. Abdominal tenderness and weight gain may occur; vomiting and anorexia are rare.

Gastric dilation (acute)

Epigastric fullness is an early symptom of this life-threatening disorder. Accompanying dyspepsia are nausea and vomiting, upper abdominal distention, a succussion splash, and apathy. The patient may display signs and symptoms of dehydration, such as poor skin turgor and dry mucous membranes, and of electrolyte imbalance, such as irregular pulse and muscle weakness. Gastric bleeding may produce hematemesis and melena.

Gastric ulcer

Dyspepsia and heartburn after eating may occur in the early stages of a gastric ulcer. The cardinal symptom, however, is epigastric pain that may occur with vomiting, fullness, and abdominal distention and may not be relieved by food. Weight loss and GI bleeding are also characteristic.

Gastritis (chronic)

In this disorder, dyspepsia is relieved by antacids; lessened by smaller, more frequent meals; and aggravated by spicy foods or excessive caffeine. It occurs with anorexia, a feeling of fullness, vague epigastric pain, belching, nausea, and vomiting.

GI cancer

This type of cancer usually produces chronic dyspepsia. Other features include anorexia, fatigue, jaundice, melena, hematemesis, constipation, and abdominal pain.

Heart failure

Common in right-sided heart failure, transient dyspepsia may occur with chest tightness and a constant ache or sharp pain in the right upper quadrant. Heart failure also typically causes hepatomegaly, anorexia, nausea, vomiting, bloating, ascites, tachycardia, jugular vein distention, tachypnea, dyspnea, and orthopnea. Other findings include dependent edema, anxiety, fatigue, diaphoresis, hypotension, cough, crackles, ventricular and atrial gallops, nocturia, elevated diastolic blood pressure, and cool, pale skin.

Hepatitis

Dyspepsia occurs in two of the three stages of hepatitis. The preicteric phase produces moderate to severe dyspepsia, fever, malaise, arthralgia, coryza, myalgia, nausea, vomiting, an altered sense of taste or smell, and hepatomegaly. Jaundice marks the onset of the icteric phase, which also includes continued dyspepsia, anorexia, irritability, and severe pruritus. As jaundice clears, dyspepsia and other GI effects also diminish. In the recovery phase, only fatigue remains.

Hiatal hernia

In this disorder, dyspepsia results when the lower portion of the esophagus and the upper portion of the stomach rise into the chest as abdominal pressure increases.

Pancreatitis (chronic)

Dyspepsia is usually accompanied by severe continuous or intermittent epigastric pain that radiates to the back or through the abdomen. Anorexia, nausea, vomiting, jaundice, dramatic weight loss, hyperglycemia, and steatorrhea may also occur. The patient may have Turner’s or Cullen’s sign.

Pulmonary embolism

Sudden dyspnea characterizes this potentially fatal disorder; however, dyspepsia may occur as an oppressive, severe, substernal discomfort. Other findings include anxiety, tachycardia, tachypnea, cough, pleuritic chest pain, hemoptysis, syncope, cyanosis, jugular vein distention, and hypotension.

Pulmonary tuberculosis

Vague dyspepsia may occur along with anorexia, malaise, and weight loss. Common associated findings include high fever, night sweats, palpitations on mild exertion, a productive cough, dyspnea, adenopathy, and occasional hemoptysis.

Uremia

Of the many GI complaints associated with uremia, dyspepsia may be the earliest and most important. Others include anorexia, nausea, vomiting, bloating, diarrhea, abdominal cramps, epigastric pain, and weight gain. As the renal system deteriorates, the patient may experience edema, pruritus, pallor, hyperpigmentation, uremic frost, ecchymoses, sexual dysfunction, poor memory, irritability, headache, drowsiness, muscle twitching, seizures, and oliguria.

Other causes

Drugs

Nonsteroidal anti-inflammatory drugs, especially aspirin, commonly cause dyspepsia. Diuretics, antibiotics, antihypertensives, corticosteroids, and many other drugs can also cause dyspepsia, depending on the patient’s tolerance of the dosage.

Surgery

After GI or other surgery, postoperative gastritis can cause dyspepsia, which usually disappears in a few weeks.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Sore Throat: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Rhinovirus

❑ Group A streptococci

❑ Ebstein-Barr virus

❑ Adenovirus

❑ Influenza

❑ Candida/thrush

❑ Herpes simplex virus

❑ Peritonsillar abscess

❑ Mycoplasma pneumoniae

❑ Coxsackievirus

❑ Primary HIV

❑ Neisseria gonorrhea

❑ Epiglottitis

❑ Corynebacterium diphtheriae

❑ Leukemia

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Gastroesophageal reflux: Causes
(Handbook of Diseases)

The function of the LES — a high-pressure area in the lower esophagus, just above the stomach — is to prevent gastric contents from backing up into the esophagus. Normally, the LES creates pressure, closing the lower end of the esophagus, but relaxes after each swallow to allow food into the stomach.

Reflux occurs when LES pressure is deficient or when pressure within the stomach exceeds LES pressure.

The amount of time the reflux is in contact with the esophagus as well as the potency of the reflux relates to esophageal damage. Gastroesophageal reflux can also be related to delayed gastric emptying resulting from partial gastric outlet obstruction or gastroparesis. It may also be attributed to an abnormal esophageal clearance. In this instance, acid isn’t cleared and neutralized by esophageal peristalsis and salivary bicarbonates, as it is normally.

Clinical tip  Gastroesopha-geal reflux may also be related to atypical symptoms, such as chronic cough, sore throat, asthma, and laryngitis, and atypical chest pain.

Predisposing factors include the following:

❑ pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice

❑ long-term nasogastric (NG) intubation (more than 5 days)

❑ any agent that lowers LES pressure, such as food, alcohol, cigarettes, anticholinergics (atropine, belladonna, and propantheline), and other drugs (morphine, diazepam, and meperidine)

❑ hiatal hernia (especially in children)

❑ any condition or position that increases intra-abdominal pressure.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Dyspepsia: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cholelithiasis

Dyspepsia may occur with cholelithiasis (the formation of gallstones), commonly after intake of fatty foods. Biliary colic, a more common symptom of cholelithiasis, causes acute pain that may radiate to the back, shoulders, and chest. The patient may also have diaphoresis, tachycardia, chills, low-grade fever, petechiae, bleeding tendencies, jaundice with pruritus, dark urine, and clay-colored stools.

Cirrhosis

With cirrhosis, dyspepsia varies in intensity and duration and is relieved by ingestion of an antacid. Other GI effects are anorexia, nausea, vomiting, flatulence, diarrhea, constipation, abdominal distention, and epigastric or right-upper-quadrant pain. Weight loss, jaundice, hepatomegaly, ascites, dependent edema, fever, bleeding tendencies, and muscle weakness are also common. Skin changes include severe pruritus, extreme dryness, easy bruising, and lesions, such as telangiectasis and palmar erythema. Gynecomastia or testicular atrophy may also occur.

Duodenal ulcer

A primary symptom of duodenal ulcer, dyspepsia ranges from a vague feeling of fullness or pressure to a boring or aching sensation in the middle or right epigastrium. It usually occurs 1½ to 3 hours after eating and is relieved by intake of food or ingestion of an antacid. The pain may awaken the patient at night with heartburn and fluid regurgitation. Abdominal tenderness and weight gain may occur; vomiting and anorexia are rare.

Gastric dilation (acute)

Epigastric fullness is an early symptom of acute gastric dilation, a life-threatening disorder. Accompanying dyspepsia are nausea and vomiting, upper abdominal distention, succussion splash, and apathy. The patient with acute gastric dilation may display signs and symptoms of dehydration, such as poor tissue turgor and dry mucous membranes, and of electrolyte imbalance, such as irregular pulse and muscle weakness. Gastric bleeding may produce hematemesis and melena.

Gastric ulcer

Typically, dyspepsia and heartburn after eating occur early in a gastric ulcer. The cardinal symptom, however, is epigastric pain that may occur with vomiting, fullness, and abdominal distention and may not be relieved by food. Weight loss and GI bleeding are also characteristic.

Gastritis (chronic)

With chronic gastritis, dyspepsia is relieved by antacids; lessened by smaller, more frequent meals; and aggravated by spicy foods or excessive caffeine. It occurs with anorexia, a feeling of fullness, vague epigastric pain, belching, nausea, and vomiting.

GI cancer

GI cancer usually produces chronic dyspepsia. Other features include anorexia, fatigue, jaundice, melena, hematemesis, constipation, and abdominal pain. The patient may also experience pain after eating that isn’t relieved by antacids. Syncope, weakness, and weight loss may also occur.

Heart failure

Common with right-sided heart failure, transient dyspepsia may occur with chest tightness and a constant ache or sharp pain in the right upper quadrant. Heart failure also typically causes hepatomegaly, anorexia, nausea, vomiting, bloating, ascites, tachycardia, jugular vein distention, tachypnea, dyspnea, and orthopnea. Other findings include dependent edema, anxiety, fatigue, diaphoresis, hypotension, cough, crackles, ventricular and atrial gallops, nocturia, diastolic hypertension, and cool, pale skin.

Hepatitis

Dyspepsia occurs in two of the three stages of hepatitis. The preicteric phase produces moderate to severe dyspepsia, fever, malaise, arthralgia, coryza, myalgia, nausea, vomiting, an altered sense of taste or smell, and hepatomegaly. Jaundice marks the onset of the icteric phase, along with continued dyspepsia and anorexia, irritability, and severe pruritus. As jaundice clears, dyspepsia and other GI effects also diminish. In the recovery phase, only fatigue remains.

Hiatal hernia

With hiatal hernia, dyspepsia results when increased abdominal pressure causes the lower portion of the esophagus and the upper portion of the stomach to rise into the chest. Other signs and symptoms include heartburn and retrosternal or substernal chest pain. Signs and symptoms of possible complications include dysphagia, bleeding, and severe pain and shock.

Pancreatitis (chronic)

With chronic pancreatitis, a feeling of fullness or dyspepsia is usually accompanied by severe continuous or intermittent epigastric pain that radiates to the back or through the abdomen. Anorexia, nausea, vomiting, jaundice, dramatic weight loss, hyperglycemia, and steatorrhea may also occur. The patient may have Turner’s or Cullen’s sign.

Uremia

Of the many GI complaints associated with uremia, dyspepsia may be the earliest and most important. Others include anorexia, nausea, vomiting, bloating, diarrhea, abdominal cramps, epigastric pain, and weight gain. As the renal system deteriorates, the patient may experience edema, pruritus, pallor, hyperpigmentation, uremic frost, ecchymoses, sexual dysfunction, poor memory, irritability, headache, drowsiness, muscle twitching, seizures, and oliguria.

Other causes

Drugs

Nonsteroidal anti-inflammatories, especially aspirin, commonly cause dyspepsia. Diuretics, antibiotics, antihypertensives, corticosteroids, and many other drugs can cause dyspepsia, depending on the patient’s tolerance of the dosage.

Surgery

After GI or other surgery, postoperative gastritis can cause dyspepsia, which usually disappears in a few weeks.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Sore Throat: Principal Causes of Sore Throat
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Infection
   1. Pharyngitis/tonsillitis
      1. Viral
      2. Bacterial
         1. Group A Streptococcus
         2. Other bacteria
   2. Peritonsillar, retropharyngeal, andlateral pharyngeal abscesses
2. Irritants
   1. Excessive dryness
   2. Dust
   3. Smoke
   4. Postnasal drip secondary to allergicrhinitis or sinusitis
3. Trauma
   1. Vocal abuse
   2. Thermal injury
4. Foreign body
5. Caustic substances
6. Psychogenic

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Dyspepsia: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Cholelithiasis.Dyspepsia may occur with gallstones, usually after eating fatty foods. Biliary colic, a more common symptom of gallstones, causes acute pain that may radiate to the back, shoulders, and chest. The patient may also have diaphoresis, tachycardia, chills, a low-grade fever, petechiae, bleeding tendencies, jaundice with pruritus, dark urine, and clay-colored stools.

Cirrhosis.With cirrhosis, dyspepsia varies in intensity and duration and is relieved by taking an antacid. Other GI effects are anorexia, nausea, vomiting, flatulence, diarrhea, constipation, abdominal distention, and epigastric or right upper quadrant pain. Weight loss, jaundice, hepatomegaly, ascites, dependent edema, a fever, bleeding tendencies, and muscle weakness are also common. Skin changes include severe pruritus, extreme dryness, easy bruising, and lesions, such as telangiectasis and palmar erythema. Gynecomastia or testicular atrophy may also occur.

Duodenal ulcer.A primary symptom of a duodenal ulcer, dyspepsia ranges from a vague feeling of fullness or pressure to a boring or aching sensation in the middle or right epigastrium. It usually occurs 11⁄2 to 3 hours after a meal and is relieved by eating food or taking an antacid. The pain may awaken the patient at night with heartburn and fluid regurgitation. Abdominal tenderness and weight gain may occur; vomiting and anorexia are rare.

Gastric dilation (acute).Epigastric fullness is an early symptom of gastric dilation, a life-threatening disorder. Accompanying dyspepsia are nausea and vomiting, upper abdominal distention, succussion splash, and apathy. The patient may display signs and symptoms of dehydration, such as poor tissue turgor and dry mucous membranes, and of electrolyte imbalance, such as an irregular pulse and muscle weakness. Gastric bleeding may produce hematemesis and melena.

Gastric ulcer.Typically, dyspepsia and heartburn after eating occur early in gastric ulcer. The cardinal symptom, however, is epigastric pain that may occur with vomiting, fullness, and abdominal distention and may not be relieved by eating food. Weight loss and GI bleeding are also characteristic.

Gastritis (chronic).With chronic gastritis, dyspepsia is relieved by antacids; lessened by smaller, more frequent meals; and aggravated by spicy foods or excessive caffeine. It occurs with anorexia, a feeling of fullness, vague epigastric pain, belching, nausea, and vomiting.

GI cancer.GI cancer usually produces chronic dyspepsia. Other features include anorexia, fatigue, jaundice, melena, hematemesis, constipation, and abdominal pain.

Heart failure.Common with right-sided heart failure, transient dyspepsia may occur with chest tightness and a constant ache or sharp pain in the right upper quadrant. Heart failure also typically causes hepatomegaly, anorexia, nausea, vomiting, bloating, ascites, tachycardia, jugular vein distention, tachypnea, dyspnea, and orthopnea. Other findings include dependent edema, anxiety, fatigue, diaphoresis, hypotension, a cough, crackles, ventricular and atrial gallops, nocturia, diastolic hypertension, and cool, pale skin.

Hepatitis.Dyspepsia occurs in two of the three stages of hepatitis. The preicteric phase produces moderate to severe dyspepsia, a fever, malaise, arthralgia, coryza, myalgia, nausea, vomiting, an altered sense of taste or smell, and hepatomegaly. Jaundice marks the onset of the icteric phase, along with continued dyspepsia and anorexia, irritability, and severe pruritus. As jaundice clears, dyspepsia and other GI effects also diminish. In the recovery phase, only fatigue remains.

Hiatal hernia.Dyspepsia is a result of the lower portion of the esophagus and the upper portion of the stomach rising into the chest when abdominal pressure increases.

Pulmonary embolism.Sudden dyspnea characterizes pulmonary embolism, a potentially fatal disorder; however, dyspepsia may occur as an oppressive, severe, substernal discomfort. Other findings include anxiety, tachycardia, tachypnea, a cough, pleuritic chest pain, hemoptysis, syncope, cyanosis, jugular vein distention, and hypotension.

Pulmonary tuberculosis.Vague dyspepsia may occur along with anorexia, malaise, and weight loss. Common associated findings include a high fever, night sweats, palpitations on mild exertion, a productive cough, dyspnea, adenopathy, and occasional hemoptysis.

Uremia.Of the many GI complaints associated with uremia, dyspepsia may be the earliest and most important. Others include anorexia, nausea, vomiting, bloating, diarrhea, abdominal cramps, epigastric pain, and weight gain. As the renal system deteriorates, the patient may experience edema, pruritus, pallor, hyperpigmentation, uremic frost, ecchymoses, sexual dysfunction, poor memory, irritability, headache, drowsiness, muscle twitching, seizures, and oliguria.

Other causes

Drugs.Nonsteroidal anti-inflammatory drugs, especially aspirin, commonly cause dyspepsia. Diuretics, antibiotics, antihypertensives, corticosteroids, and many other drugs can cause dyspepsia, depending on the patient's tolerance of the dosage.

Surgery.After GI or other surgery, postoperative gastritis can cause dyspepsia, which usually disappears in a few weeks.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Gastroesophageal Reflux: Gastroesophageal Reflux - risk factors
(The 5-Minute Pediatric Consult)

Neurologic disorders (cerebral palsy/quadriplegia), esophageal atresia, tracheoesophageal fistula, cystic fibrosis, asthma

Gastroesophageal Reflux - pathophysiology

Transient relaxation of the lower esophageal sphincter during episodes of increased abdominal pressure. Multifactorial process involving number of reflux events, acidity, emptying, mucosal barriers, visceral hypersensitivity, and airway responsiveness.

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

 » Next page: Risk Factors for Gastroesophageal Reflux Disease

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