1. Mr. Jorgan Case # 1

2. Mr. H. Jorgan  40 y/o w/m here for initial evaluation  CC: “sour stomach & acid back-up” This started about 3-4 years ago and only occurred about 1x week. It has progressively increased in frequency and severity.  During the past year it has occurred daily after most meals. He has a feeling of fullness and bloating with nausea for about 2 hrs. post-prandially. There are times, especially after eating a late snack, when it may wake him from sleep. He avoids spicy foods because it makes him worse.

3. Mr. H. Jorgan  PMH:  Fractured left leg six years ago  Hypertension for three years  Medications:  Aspirin as needed for left leg pain  Tagamet-HB twice daily  Procardia  Allergies:  None

4. Mr. H. Jorgan  Social History:  Works as a loan officer for a large suburban bank  Denies tobacco use  Has 1 or 2 glasses of wine at dinner  Family History:  Mother 68 y/o with hypertension  Father 70 y/o with chronic stable angina  Two daughters age 18 and 16, both healthy

5. Mr. H. Jorgan  ROS:  Twenty pound weight gain over the past 6 years, which he attributes to a more sedentary life-style than he had previously  He denies dysphagia, odynophagia, chest pain, shortness of breath, hoarseness, and sore throat.

6. Develop a differential diagnosis for Mr. Jorgan’s problem Stop Here and Discuss

7. Differential Diagnosis Developed by the Gastroenterology Panel:  Gastroesophageal Reflux Disease (GERD)  Delayed Gastric Emptying  Esophageal Motility Disorder

8. What workup, if any, would you order at this time? Stop Here and Discuss

9. Our panel of Gastroenterologists recommends no diagnostic studies at this point.

10. Now, what is your treatment plan for Mr. Jorgan? Stop Here and Discuss

11. Treatment Plan Recommended by our Gastroenterologists:  Lifestyle modification - including dietary change and weight loss  Consider change in anti-hypertensive medication  Trial of prokinetic therapy  Change aspirin to acetaminophen if tolerated

12. With what Prokinetic agent did you choose to treat Mr. Jorgan? Stop Here and Discuss

13. Prokinetics Considered by the Gastroenterologists:  Metoclopramide - Cheap; frequent side effects (acute and long-term)  Bethanechol - Cheap; modest effect; cholinergic side-effects  Cisapride - Expensive; generally well tolerated; rare ventricular arrhythmias  Erythromycin - Investigational; antibiotic side-effects

14.  The Gastroenterologists chose toplace Mr. Jorgan on Cisapride 10 mg QID taken twenty minutes before meals and before bed.  He is instructed to double the dose if no better in a week and to return in two weeks. He is also switched from Procardia to Inderal. Treatment Chosen by Gastroenterologists :

15. Mr. Jorgan Returns Two Weeks Later  He has been adhering to the lifestyle modifications with avoidance of late meals, elevation of the head of the bed, working at weight loss and a low fat diet.  Symptoms:  Postprandial bloating and nausea virtually gone  Substernal burning once in past 2 weeks  Some loose stools for three days

16. Week Two Follow-up Visit (continued.)  Medications:  Cisapride 20 mg ac & hs  Propranolol Hydrochloride  Physical Exam:  BP = 134/80 P = 68  Weight = 187 lbs.  Abdominal exam: Normal

17. Now, what do you recommend to Mr. Jorgan? WHY? Stop Here and Discuss

18. The Gastroenterologists chose to continue the current regimen along with a PRN antacid.

19. When do you want to see Mr. Jorgan again? Stop Here and Discuss

20. The Gastroenterology panel wants to see Mr. Jorgan in four months

21. Mr. Jorgan Returns  Mr. Jorgan finally returns eight months later  He ran out of Cisapride four (4) months ago  His heartburn continues to be a problem 4-5 days and 1 night/week  No postprandial bloating or nausea as long as he followed his low fat diet & avoided large meals  His weight is down to 180 lbs  No new symptoms

22. What would you do next? Stop Here and Discuss

23. The Gastroenterologists recommend beginning an H2 Receptor Antagonist

24. Which H2 Receptor antagonist drug would you choose? Stop Here and Discuss

25. H2 Antagonist options (equivalent): Cimetidine800 mg BID Ranitidine150 mg BID Famotidine 20 mg BID Nizatidine150 mg BID

26. The Gastroenterology Panel Suggests:  Generic Cimetidine 800 mg BID  Continue lifestyle modifications  Call in ten days to report

27.  Continue Cimetidine 800 mg BID  Inform Mr. Jorgan about Laparoscopic Fundoplication as an alternative if he is interested Our Gastroenterologists Would:

28. Ten Days Later  Six Months Later  He is still symptom free  Tolerating the Cimetidine well & following the anti-reflux routine  Symptom free

29. GERD is a Chronic Relapsing Condition Effective Maintenance Therapy is the Key!