Ard

ACID RELATED DISORDERS
ADMITTING CONFERENCE AND TOPIC DISCUSSION

MENG MADDUMBA
THE PT.
GENERAL DATA
This is the case of DZG,

13/F, born on May 23 2001
BP: LMC, San Fernando City, La Union,
POR: Dontogan, Baguio City,
Student
Roman Catholic
Filipino
HISTORY
OF PRESENT ILLNESS
Admissio
n
7 DAYS
PTA pain
(+) Epigastric
after skipping meals, burning in nature

rated 5/10, localized, non-radiating
aggravated by an empty stomach, minimally relieved by
food intake
(+) Dysuria and Increase in frequency of voiding

(-) associated: N/V, Anorexia,
diarrhea, febrile episodes, chest
pains or DOB.
HISTORY
OF PRESENT ILLNESS
Admissio
n
7 DAYS
PTA
Consult
at a private
clinic
Dx: ARD + UTI
Meds Given:
CEFIXIME BID (dosage
unrecalled)
OMEPRAZOLE 20mg/tab OD
HISTORY
OF PRESENT ILLNESS
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
Admissio
n
(+) Dysuria and frequency of voiding decreasing

up to
two days PTA
(+) Epigastric pain, same characteristics
Decreasing pain rating from 6 to 2-3/10
Decreasing
in frequency from 3 to 1
(-) associated: N/V, Anorexia,
episodes
diarrhea, febrile episodes, chest
pains or DOB.
HISTORY
OF PRESENT ILLNESS
(+) Epigastric pain

(+) Dysuria
(+) Consult
(-) associated
S/Sx
Medications
continued
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
Admissio
n
HISTORY
OF PRESENT ILLNESS
(+) Epigastric pain

(+) Dysuria
(+) Consult
(-) associated
S/Sx
Medications
continued
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
Admissio
n
1 DAY PTA
(+) continuous epigastric pain after missing a
meal.
Burning in nature, Rated 6-7/10,

Radiating to anterior chest area; left
Aggravated by intense training and minimally relieved by
rest and
(+) medications.
Associated DOB and weakness
(-) associated: N/V, Anorexia, diarrhea,
febrile episodes, .
HISTORY
OF PRESENT ILLNESS
(-) associated
S/Sx
Medications
continued
6 DAYS 2 DAYS
PTA
7 DAYS
PTA pain
(+) Epigastric
(+) Dysuria
(+) Consult
Dx: ARD + UTI
(-) associated
S/Sx
1 DAY PTA
(+) Epigastric pain
(+) Associated
DOB and
weakness
Admissio
n
FEW HRS
PTA Pain
(+) Epigastric
Same
characteristics
Rated 8-9/10
HISTORY
FEEDING HISTORY
At present, the diet is slightly below the

patients daily calorie requirement
Based on a 2,500 kcal RENI of 13 year old female

adolescent.
HISTORY
GROWTH AND DEVELOPMENTAL
Weight and Height:
Weight= 46 kg
Height= 1.57m
BMI: 18.66 = Normal
Physical growth:
No reported delays in growth
and Development.
No observed impairments
HISTORY
Psychological and Cognitive

Development
(HEADS)
HOME
good interaction with family
members
with occasional fights with
siblings.
Still respectful of
authorities and nonrebellious.
More concerned about his
looks, clothes and body
image.
HISTORY

Development
EDUCATION (HEADS)
More influenced by her
peer groups in school
though not rebellious
towards authority.
Verbalized having hard
time in more challenging
academic requirement.
At present the patients
developmental
milestone is at par for
age.
HISTORY

Development
ACTIVITIES (HEADS)
Physically Active
Member of the National
Wushu Team
Competes at
International
competition
DRUGS
No history of use or
plans of using
SUICIDE
No grave problems
that would warrant
suicidal ideologies
HISTORY
IMMUNIZATION STATUS
Claims to have complete immunization status

PAST MEDICAL
2001
2004
BETHANY
HOSPITAL
LA UNION
- Innocent Heart
Murmurs
- Anemia
D/C WELL
SLU-HSH
- Pneumonia
- Benign Febrile
Convulsions
D/C WELL
2007
SLU-HSH
- Pneumonia
D/C WELL
Childhood illness: measles, mumps, UTI, and occasional cough

and colds
Allergies: No known allergies
HISTORY
FAMILY DISEASES
Diseases in the Family:

Both parents are presently well. Patient has a
family history of HPN, Diabetes Mellitus,
Arthritis, Colon cancer, CVD, and CAD.
No reported history of other heredofamilial diseases and
other communicable diseases. No other persons residing in
their home was noted to have illness.
REVIEW
OF SYSTEMS
General: (-) weight loss, (-) fever, (-) chills, (-) sweats, (-) irritability, (+)
poor oral intake,
(+) weakness
Head and Neck: (-) trauma, (-) lesions, (-) swelling, (+) headache, (-)
pain, (-) stiffness
Respiratory: (-) productive cough, (-) pain, (+) DOB, (-) hemoptysis, (-)
cyanosis, (-) TB/PPKI
Cardiovascular: (-) edema, (-) cyanosis, (-) palpitation, (+) chest pains
(-) murmur, (-) known CHD
GIT: (+) good oral intake; (-) anorexia, (+) abdominal pain, (-)
vomiting, (-) nausea, (-) diarrhea, (-) constipation, (-) flatulence, (-)
melena, (-) hematochezia,
(-) change in bowel habits, (-) hernia, (+) use of laxatives or antacids,
PHYS.EX
PERTINENT FINDINGS
General Survey:
Awake, conscious, coherent, afebrile, not in cardiorespiratory
distress.
Vital Signs and Anthropometric

Measurements
CR= 98 bpm
Weight= 46 kg
RR= 24 cpm
Height= 1.57m
T= 36.6 C per axilla
BMI: 18.66 = Normal
No signs of Dehydration
Chest/Lungs and Heart:
SCWE (-)retractions, (-) lagging , clear breath sounds,
PHYS.EX
PERTINENT FINDINGS
Abdomen:
Flat, non-distended
(+) normoactive bowel sounds
(+) tympanitic on all four quadrants
Soft
(+) tenderness on epigastric area upon deep
palpation,
(-) masses palpated
(-) organomegaly
IMPRESSION
DIAGNOSIS OF THE PT
HISTORY (S)
Previous Dx:
Acid related
disorder
Under
gastric
medications
History of:
(+) Epig Pain (89/10)
Burning in nature
Radiating to chest
Precipitated by an
empty stomach
Aggravated by
activity
Relieved by food
intake and
medication
(-) Febrile episode
PHYS.EX (O)
Flat, non-distended
Normoactive bowel
sounds
(-) Visible Mass and
Pulsation
(-) Palpated Mass
Direct tenderness on
Epigastric area
(-) pathologic
gallbladder/
appendyceal signs
IMPRESSION
DIAGNOSIS OF THE PT
DAY10
Initial Impression: ARD
Gastroesophageal Reflux
Disease (GERD)
PLAN
DIAGNOSTICS
URINALYSIS
Unremarkable Results
PLAN
DIAGNOSTICS
CBCP
Normochromic, normocytic
RBCs
Normal: Hgb, Hct, Platelets,
WBC (neutrophilic
predominance)
*Essentially normal
PLAN
DIAGNOSTICS
Hook to D5NM 1li x 21

gtts/min computed at M%
Omeprazole 20 mg every 12
hours
Al + Mg Hydroxide (Maalox) 15
mL every after meals
DISCUSSION
'Acid-related disorders' is a term used

to describe a whole range of conditions,
where acid is entirely responsible for the
problems. Careful evaluation of the
patient's symptoms is required to establish
the basis for the
gastric
problem
Acid-related disorders: what are they? By: Colin-Jones D
Five Components of the Evaluation of

Children with Abdominal Pain
1. History
2. Physical Examination
3. Laboratory Tests
4. Imaging Studies
5. Empiric Interventions
Chronic Abdominal Pain in Childhood: Diagnosis and Management

ALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimo
Maryland
Am Fam Physician.
Five Components of the Evaluation of

Children with Abdominal Pain
1. History
2.
3.
4.
5.
Physical Examination
Laboratory Tests
Imaging Studies
Empiric Interventions
ALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore,
Maryland
Am Fam Physician.
More than one third of children complain of

abdominal pain lasting two weeks or
longer. The diagnostic approach to
abdominal pain in children relies heavily
on the history provided by the parent
and child to direct a step-wise approach to
investigation.ALAN M. LAKE, M.D., Johns Hopkins University School of Medicine, Baltimore,
Maryland
Am Fam Physician.
PHYSIO
REVIEW
Two primary functional zones:
A) oxyntic gland area (80% of the organ)
B) pyloric gland area (remaining 20%)
Parietal cells (oxyntic glands) = hydrochloric acid
and intrinsic factor
Chief cells (oxyntic glands) = pepsinogen.
Neuroendocrine cells = regulate the activity of
the parietal cell.
D cells
enterochromaffin-like (ECL) cells
A-like cells
enterochromaffin (EC) cells.
PHYSIO
REVIEW
The principal stimulants for acid secretion are:
a) Histamine
major paracrine stimulator of acid secretion
b)
Gastrin
main stimulant of acid secretion during meal

stimulation
c) Acetylcholine
directly stimulates acid secretion by binding to
muscarinic (M3)
receptors
**released from postganglionic enteric neurons
PHYSIO
REVIEW
The principal stimulants for acid secretion are:
a) Histamine
major paracrine stimulator of acid secretion
b)
Gastrin
main stimulant of acid secretion during meal

stimulation
c) Acetylcholine
directly stimulates acid secretion by binding to
muscarinic (M3)
receptors
**released from postganglionic enteric neurons
Inflammation of the gastric and

duodenal mucosa is the end result of
an imbalance between mucosal
defensive and aggressive factors. The
degree of inflammation and imbalance
between defensive and aggressive factors
can then result in varying degrees
of
Pediatric gastritis and peptic ulcer disease.
Blecker U1, Mehta DI, Gold BD.
gastritis and/or mucosal ulceration.
GERD
GERD
DISCUSSION
Gastroesophageal reflux disease is the

exposure of esophageal mucosa to
a) acidic gastric contents
b) Pepsin
c) bile acids.
Can lead to: Esophageal mucosal injury:
Erosive Esophagitis
GERD
DISCUSSION
Gastroesophageal reflux disease is the

exposure of esophageal mucosa to
a) Acidic gastric contents
b) Pepsin
c) Bile acids.
Can lead to: Esophageal mucosal injury:
Erosive Esophagitis
GERD
CLINICAL PRESENTATION
DISCUSSION
Signs and symptoms (Infants Younger

Children):
Typical or atypical crying and/or irritability

Apnea and/or bradycardia
Poor appetite; weight loss or poor growth (failure to thrive)
Apparent life-threatening event
Vomiting
Wheezing, stridor
Abdominal and/or chest pain
Recurrent pneumonitis
Sore throat, hoarseness and/or laryngitis
Chronic cough
Water brash
GERD
CLINICAL PRESENTATION
DISCUSSION
Signs and symptoms (Older Children):

Signs and symptoms in older children include all
of the mentioned plus:
Heartburn and a history of vomiting
Regurgitation
Unhealthy teeth
Halitosis
GERD
DIAGNOSIS
DISCUSSION
a)History and physical

examination
b) Esophageal pH monitoring
c) Combined multiple intraluminal impedance (MII)
and pH recording
d) Endoscopy and biopsy
e) Empiric trial of acid-suppressive
Pediatric gastroesophageal
as reflux
a diagnostic
clinical practice
guidelines: joint recommendations of the North American
Society for Pediatric Gastroenterology, Hepatology, and
test
Nutrition (NASPGHAN) and the European Society for
Pediatric Gastroenterology, Hepatology, and Nutrition
(ESPGHAN).
GERD
DIAGNOSIS
DISCUSSION
In infants and toddlers, there is no

symptom or group of symptoms that
can reliably diagnose GERD or predict
treatment response.(B)
Pediatric gastroesophageal reflux clinical practice
(ESPGHAN).
GERD
DIAGNOSIS
DISCUSSION
In older children and adolescents a history

and physical examination are generally
sufficient to reliably diagnose GERD and
initiate management.
(ESPGHAN).
GERD
MANAGEMENT
DISCUSSION
Treatment
Parental education, guidance, and support
Lifestyle changes
Pharmacologic therapies
Surgical therapy
(ESPGHAN).
GERD
MANAGEMENT
DISCUSSION
Conservative measures:
Providing small, frequent feeds thickened
with cereal
Upright positioning after feeding
Elevating the head of the bed
Prone positioning (infants >6 months)
GERD
MANAGEMENT
DISCUSSION
Older Children:
Diet that avoids tomato and citrus products,
fruit juices, peppermint, chocolate, and
caffeine-containing beverages
Smaller, more frequent feeds
Relatively lower fat diet (lipids retards gastric
emptying)
Proper eating habits
Weight loss
Avoidance of alcohol and tobacco, when
applicable
GERD
MANAGEMENT
DISCUSSION
Older Children:
Diet that avoids tomato and citrus products,
fruit juices, peppermint, chocolate, and
caffeine-containing beverages (?)
Smaller, more frequent feeds
Relatively lower fat diet (lipids retards gastric
emptying)
Proper eating habits
Weight loss
Avoidance of alcohol and tobacco, when
applicable
GERD
MANAGEMENT
DISCUSSION
In older children and adolescents, there is

no evidence to support specific dietary
restrictions to decrease symptoms of
GER. In adults, obesity and late-night eating
are associated with GER.
(A)
(ESPGHAN).
GERD
MANAGEMENT
DISCUSSION
In older children and adolescents, there is

no evidence to support specific dietary
restrictions to decrease symptoms of
GER. In adults, obesity and late-night eating
are associated with GER.
(A)
(ESPGHAN).
GERD
MANAGEMENT
DISCUSSION
In adolescents with GERD, left-side

sleeping positioning and elevation of the
head of the bed may decrease symptoms
and GER. (A)
(ESPGHAN).
GERD
MANAGEMENT
DISCUSSION
PHARMACOLOGY
Antacids :
aluminum hydroxide, magnesium hydroxide
Histamine H2 antagonists :
nizatidine, cimetidine, ranitidine, famotidine
Proton pump inhibitors:

lansoprazole, omeprazole, esomeprazole,
dexlansoprazole, rabeprazole sodium,
pantoprazole
GERD
MANAGEMENT
DISCUSSION
Histamine-2receptor antagonists
(H2RAs) produce relief of symptoms and
mucosal healing.(A)
Proton pump inhibitors (PPIs) are
superior to H2RAs in relieving symptoms
and healing esophagitis.(A)
(ESPGHAN).
GERD
MANAGEMENT
DISCUSSION
SURGICAL INTERVENTION
gastrostomy or fundoplication is required in only a
very small minority of patients with
gastroesophageal reflux
The goal of surgical antireflux procedures is to
"tighten" the region of the lower esophageal
junction and, if possible, to reduce hiatal herniation
of the stomach
GERD
MANAGEMENT
DISCUSSION
SURGICAL INTERVENTION
gastrostomy or fundoplication is required in only a
very small minority of patients with
gastroesophageal reflux
The goal of surgical antireflux procedures is to
"tighten" the region of the lower esophageal
junction and, if possible, to reduce hiatal herniation
of the stomach
GERD
MANAGEMENT
DISCUSSION
Antireflux surgery should be considered

only in children with GERD and failure of
optimized medical therapy,orlong-term
dependence on medical therapy where
compliance or patient preference preclude
ongoing use,orlife-threatening
gastroesophageal reflux clinical practice
complications.(C) Pediatric
(ESPGHAN).
THANK YOU FOR LISTENING

ADMITTING CONFERENCE AND TOPIC DISCUSSION
MENG MADDUMBA

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ACID RELATED DISORDERS

ADMITTING CONFERENCE AND TOPIC DISCUSSION

This is the case of DZG,

after skipping meals, burning in nature

(+) Dysuria and Increase in frequency of voiding

(+) Dysuria and frequency of voiding decreasing

(+) Epigastric pain

(+) Epigastric pain

Burning in nature, Rated 6-7/10,

At present, the diet is slightly below the

Based on a 2,500 kcal RENI of 13 year old female

GROWTH AND DEVELOPMENTAL

Weight and Height:

GROWTH AND DEVELOPMENTAL

Psychological and Cognitive

GROWTH AND DEVELOPMENTAL

Psychological and Cognitive

GROWTH AND DEVELOPMENTAL

Psychological and Cognitive

Claims to have complete immunization status

Childhood illness: measles, mumps, UTI, and occasional cough

Diseases in the Family:

Vital Signs and Anthropometric

Hook to D5NM 1li x 21

'Acid-related disorders' is a term used

Five Components of the Evaluation of

Chronic Abdominal Pain in Childhood: Diagnosis and Management

Five Components of the Evaluation of

More than one third of children complain of

main stimulant of acid secretion during meal

**released from postganglionic enteric neurons

main stimulant of acid secretion during meal

**released from postganglionic enteric neurons

Inflammation of the gastric and

Gastroesophageal reflux disease is the

Gastroesophageal reflux disease is the

Signs and symptoms (Infants Younger

Typical or atypical crying and/or irritability

Signs and symptoms (Older Children):

a)History and physical

In infants and toddlers, there is no

In older children and adolescents a history

In older children and adolescents, there is

In older children and adolescents, there is

In adolescents with GERD, left-side

Proton pump inhibitors:

Antireflux surgery should be considered

THANK YOU FOR LISTENING

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