Surgery

Conservative medical management usually successful; surgery is indicated in the following

situations:

Persistent or recurrent symptoms not responding to medical treatment

Complete mechanical incompetence of the sphincter (less than 6 mm Hg)
Strictures
Strangulation or incarceration (paraesophageal hiatal hernia)
Type of Procedure

Nissen fundoplication: The fundus of the stomach is wrapped around the lower
3 to 4 cm of esophagus, creating an area of higher pressure; procedure may be done
laparoscopically
Belsey fundoplication: The fundus is wrapped around 270 degrees of the lower
esophagus, and the operation is performed through a left thoracotomy
Medications

Antacids: 1 ounce taken 1 and 3 h after eating and at bedtime

H2 receptor blockers: Ranitidine (Zantac), 300 mg at dinnertime or bid. If no
symptomatic response after 2 weeks, increase dose or begin treatment with proton pump
inhibitors.
Proton pump inhibitors
Omeprazole, 20 mg qd
Lansoprazole, 15 mg qd

Gastrointestinal stimulants: Metoclopramide (Reglan), 10 to 20 mg/day; will

increase the rate of gastric and esophageal emptying by stimulating the smooth muscles of the
intestine; monitor for signs of acute agitation with metoclopramide
Cisapride (Propulsid), 10 to 20 mg qid before meals and at bedtime; improves
esophageal peristalsis, increases LES tone, and promotes gastric emptying
General Management

Instruct patient to use 4- to 10-inch bed blocks to raise the head of the bed so
that he or she lies on an incline; pillows are not effective
Avoid eating foods that are irritating
Avoid wearing tight belt, corset, or girdle, which increases intraabdominal
pressure
Avoid eating 1 to 2 hours before bedtime; avoid lying down after eating
Walk around after eating
Weight reduction
Take medications with an ample amount of water; always take medications in
an upright position
NURSING CARE
NURSING ASSESSMENT

Pain
Reflux esophagitis: Symptoms include heartburn or pain; the condition is
worsened by lying down or stooping over; pain is relieved by sitting up or by antacids
Epigastric pain
Pattern of discomfort in relation to food ingestion

Nutritional status: History of foods that irritate or worsen symptoms; dysphagia

Gastrointestinal status: Gaseous eructations, water brash (mouth filling with
fluid from esophagus), regurgitation; sudden onset of vomiting, pain, and complete dysphagia
indicates incarceration of paraesophageal hiatal hernia
Respiratory status: Chronic lung disease after nocturnal regurgitation and
aspiration; may include hoarseness, chronic laryngitis, bronchospasm
POTENTIAL COMPLICATIONS
Incarceration, hemorrhage, obstruction, strangulation, aspiration

PATIENT PROBLEMS/NURSING DIAGNOSES & INTERVENTIONS

NUTRITION SUPPORT

Imbalanced nutrition: less than body requirements, related to postprandial pain and dysphagia

Provide small meals; avoid gastric distention.

Provide a bland diet, avoiding foods that are irritating. Chocolate is associated
with relaxation of esophageal sphincter and is contraindicated.

Have patient avoid eating 1 to 2 hours before bedtime to reduce heartburn of

reflux esophagitis.

Have patient sip a half glass of water after a meal to cleanse the esophagus.

Consult with nutritionist for meal planning, as well as weight reduction for those
who are obese.

PHYSICAL COMFORT PROMOTION

Chronic pain related to gastroesophageal reflux

Provide 4-inch blocks to elevate head of bed (and help patient find out where
they can be purchased for home use); this will maintain patient in an inclined plane, reducing
abdominal pressure.

Provide antacids at bedside for frequent use during acute phase. Administer
antacids to patients with poor memory or who are confused.

Explain relationship between food and pain patient is experiencing; that is, that
pain is related to reflux of gastric contents.

Administer H2 blockers and gastrointestinal stimulants as ordered.

PATIENT EDUCATION/CONTINUUM OF CARE PLAN

1.
Discuss with patient the relationship between hiatal hernia, reflux esophagitis,
and treatment plan.
2.
Provide instructions on use of prescribed medications. If patient has other
medical problems and is taking other medications, check with pharmacist before choosing
antacid to be used.
3.
Provide information on use of 4- to 10-inch blocks under head of bed; patient
may also need help to prevent sliding out of bed.

4.
Other substances that reduce pressure in lower esophageal sphincter and
should be avoided include chocolate, peppermint, nicotine, anticholinergics, calcium channel
blockers, nitrates, diazepam, beta-adrenergic agonists (Isuprel; Alupent), dietary fat, caffeine,
and alcohol.
EVALUATION/PATIENT OUTCOMES
Nutrition Support: Nutrition is maximized. Patient takes in small, frequent, low-fat, high-protein
meals, avoiding irritating substances. Patient's weight remains stable.

Physical Comfort Promotion: Pain is minimized. Patient understands medication regimen and
importance of raising head of bed; patient reports a decrease in pain associated with eating and
sleeping.

Screening for GERD in Hospitalized Patients

Last Revised: Jul 20, 2012

Contributed by: Patricia O'Malley, RN, PhD, CNS

Abstract
GERD is a chronic condition with frequent relapses that negatively impacts quality of life. This
update explores the prevalence of GERD with current interventions for diagnosis and
management. Nursing care of the patient with GERD includes screening, preventing
complications, monitoring responses to therapies, and patient education.

Back to Top
Table of Contents
Objectives
Introduction
Pathophysiology of GERD
Symptoms
Diagnosis
Nursing Care in Hospital Setting
Management of GERD

Patient Education
Emerging Information in the Literature
Summary
About the Author
References
Additional Resources
Back to Top
Objectives
Discuss how the diagnosis of GERD is made.
Describe the management plan and related nursing care for a patient with GERD.
Discuss teaching needs for a patient with GERD.
Back to Top
Introduction
Gastroesophageal reflux disease (GERD) is a chronic relapsing illness that affects millions world
wide and is a significant source of morbidity and economic burden.1 At least once a week, 15%
of the US population experience GERD and many self-medicate with over-the-counter (OTC)
antacids, assuming that the recurring symptoms do not require medical attention.2 GERD is a
potentially serious physiological abnormality that negatively affects quality of life and, if left
untreated, can result in life-threatening esophageal injury.2 Increasing age, male gender, and
Caucasian ethnicity are associated with the development of GERD.3

Back to Top
Pathophysiology of GERD
GERD is the reflux of gastric contents including acid and pepsin into the esophagus. Esophageal
damage is a function of the degree of reflux and duration of mucosa exposure. Reflux can result
from gastric distension associated with a large meal. However, the most common cause is
inappropriate relaxation of the lower esophageal sphincter (LES) that does not maintain proper
pressure to prevent retrograde flow of gastric contents after swallowing (Figure 1).4 This
retrograde flow, which can last seconds to minutes, may reach the larynx and upper airways,
which can result in laryngitis and asthma symptoms.4

Figure 1.

Endoscopic view of the distal end of the esophagus in a patient with gastroesophageal reflux
disease.
Endoscopic view of the distal end of the esophagus in a patient with gastroesophageal reflux
disease. Source: Goldman's Cecil Medicine, 24th ed.
Often associated with LES weakness are problems with esophageal clearance and motility.4
Delayed gastric and esophageal emptying combined with a low LES pressure result in an
unguarded esophagus. If the patient has concomitant hiatal hernia, the reflux is even larger.

Chronic reflux can result in ulcerations and mucosal inflammation, which lead to fibrosis,
scarring, and stricture. Over time, patients may develop Barrett's esophagus (Figure 2) in which
normal squamous cells are replaced by mucin-filled columnar cells, increasing the risk of
adenocarcinoma.2

Figure 2.

Severe reflux esophagitis (left) with mucosal erythema and linear ulcers with yellow exudates (*).
It is thought that such changes eventually lead to Barrett's esophagus (right).
Severe reflux esophagitis (left) with mucosal erythema and linear ulcers with yellow exudates (*).
It is thought that such changes eventually lead to Barrett's esophagus (right), in which the
normal white squamous epithelium (SE) is replaced by red columnar epithelium (BE). These
pictures are from different patients. Source: Goldman's Cecil Medicine, 24th ed.
Back to Top
Symptoms
Occasional heartburn does not indicate a diagnosis of GERD, but the absence of heartburn does
not rule out GERD.5 While heartburn symptoms occur for everyone from time to time, recurring
symptoms more than twice a week indicate that medical attention is needed.5 Patient
outcomes vary depending on age, the degree of reflux, and the time of esophageal exposure.
Despite the increasing prevalence of GERD in the United States, there are generally low
numbers of patients seen by primary care providers, which is probably related to the high
volume of OTC antacids and H2-receptor antagonists (H2RAs) that patients use to self-treat.6

Typical signs and symptoms include heartburn, epigastric pain, nausea, and vomiting. Pain is
often described as a burning sensation behind the sternum or rising to the neck and is
associated with meals, supine position, sleep, and exercise.4 Extraesophageal symptoms include
wheezing, hoarseness, chronic cough, sore throat, frequent throat clearing, dental erosions, and
sleep apnea. Alarm symptoms include difficulty swallowing, atypical chest pain, gastrointestinal
bleeding, weight loss, shortness of breath, and sensations of choking.2

The prevalence of GERD increases with age, and symptoms in elderly people are very different
from those in young and middle-aged adults. While middle-aged persons often present with
typical symptoms, elderly individuals more often present with dysphasia, vomiting, weight loss,
anemia, and anorexia.3 The severity of GERD is often under-appreciated in elderly patients and
subsequently undertreated.3 GERD exerts a significant negative effect on quality of life. Patients
with GERD report more negative consequences than do patients with diabetes, angina, and
heart failure.2

Back to Top
Diagnosis
Reduction of symptoms with pharmacological therapy is the beginning of diagnosis. However,
signs and symptoms alone are not predictive of the severity of GERD.6 Current guidelines do not
require endoscopic assessment for every patient. However, endoscopy is the only reliable
method to diagnose erosive esophagitis or Barrett's esophagus. Patient history is important,
especially OTC use of antacids and H2RAs.2

Further medical evaluation can include:

An upper gastrointestinal series or a barium swallow under fluoroscopy can detect severe
esophagitis but cannot determine if the patient has Barrett's esophagus.
Ambulatory pH monitoring may be helpful for patients who have a negative endoscopy
evaluation with continuing symptoms by measuring how often acid reflux occurs and how long it
lasts. Generally this evaluation is expensive and requires extensive training for the safe
placement of probes.
Esophageal manometry can help determine whether the patient has adequate peristalsis and
can assess pressures within the esophagus.2,4
The gold standard for evaluation is endoscopy because 50% to 65% of all patients with GERD
have erosive esophagitis.3 An exam with no visible injury of the esophagus is diagnosed as
endoscopy-negative reflux disease (ENRD) or nonerosive reflux disease (NERD).2 Exams that
show esophageal ulcerations or erosions are described by a variety of classification systems
including Los Angeles Classification, Savary-Miller Classification, MUSE, AFP Scale, and HetzelDent Classification.2

Back to Top
Nursing Care in Hospital Setting

Screen every patient who is hospitalized, particularly elderly patients, for signs and symptoms of
GERD. This recommendation is made in light of the low numbers of patients who seek medical
evaluation and the increasing OTC use of antacids and H2RAs. Refer patients with findings
suggestive of GERD for further evaluation.4

Nursing care should focus on minimizing the risk of regurgitation and aspiration. Nasogastric
tubes can reduce the risk of aspiration but cannot eliminate the risk. Patients with endotracheal
tubes are also at risk if cuff pressures are low, leaving the lungs open for injury. Frequent
checking of cuff pressure, maintaining elevation of the head of the bed greater than 30 degrees
for all patients, and appropriate suctioning can prevent aspiration.4

If vomiting does occur, place the patient in a lateral position with the head down and provide
suctioning and oxygen as necessary. Chest x-rays can help confirm if pulmonary aspiration has
occurred. Aspiration pneumonia may be treated with antibiotics and steroids to decrease
inflammation.3

An algorithm for the management of patients with heartburn symptoms can be found in
Goldman's Cecil Medicine, 23rd ed.

Back to Top
Management of GERD
Management of GERD is based on treatment goals: relieving symptoms, increasing gastric pH to
greater than 4, healing esophagitis, and preventing stricture and other complications.2 Initial
interventions focus on medication therapies.

Antacids are used to increase the pH of the esophagus. Use of antacids must be monitored
particularly in heart patients because of the high sodium content of these agents. Antacid use
may also mask serious symptoms.7

H2RAs used since the 1970s (cimetidine, ranitidine, famotidine, nizatidine) inhibit gastric
secretions without affecting LES pressure or esophageal clearance. H2RAs can be used alone or
in combination with other therapies and are generally effective in patients with ENRD.6 H2RAs
have low-risk side effects, which may include diarrhea, headache, drowsiness, fatigue, muscle
pain, and constipation.8

Proton pump inhibitors (PPIs) are the most effective agents because they promote esophageal
healing and prevent the recurrence of erosive esophagitis. First-generation PPIs omeprazole and
lansoprazole are metabolized by the CYP2C19 hepatic enzyme system and should not be used by
patients receiving diazepam, warfarin, phenytoin, or theophylline therapies. Second-generation
PPIs (rabeprazole, pantoprazole, esomeprazole, dexlansoprazole) should be prescribed for these
patients because these newer agents are processed through a different hepatic cytochrome.
PPIs are the preferred therapy if H2RAs are ineffective or erosive esophagitis is present. PPIs are
not without adverse effects, which may include nausea, abdominal pain, constipation, flatulence,
and diarrhea.8

However, recent studies have shown a possible interaction between the PPIs (particularly
omeprazole) and clopidogrel, in which the effectiveness of clopidogrel is reduced.9,10 These
studies prompted an FDA warning for health care providers to avoid concomitant use.(FDA).11
However, some researchers believe the evidence is lacking, calling for more studies and clinician
decisions based on individual patients.12,13

Finally, prokinetic agents such as metoclopramide may be helpful. Prokinetic agents tighten the
LES and decrease belching and bloating. Carefully monitor patients receiving prokinetics for
adverse side effects, particularly diarrhea and associated electrolyte disturbances.3

Carefully evaluate all patient medications in terms of potential effect on GERD symptoms.
Medications associated with LES relaxation and increased reflux include theophylline, nitrates,
calcium channel blockers, alpha- and beta-adrenergic blockers, benzodiazepines,
anticholinergics, progestin, estrogen, transdermal nicotine, and tricyclic antidepressants.14

Poor adherence to prescribed therapies is common. In one study, only 55% adhered to the
prescribed agent over a 1-month period, and 37% adhered fewer than 12 days a month.15,16 A
retrospective study of adherence to medication therapy of 10,159 patients with Barrett's
esophagus (BE) and 48,965 patients with GERD alone found similar low adherence and
persistence with medication use. The absence of BE and recent diagnosis was associated with
even poorer compliance.17 Further research is needed to determine what factors enhance
adherence. Such factors may be related to follow-up after treatment begins, education, or
monitoring, as well as patient response to the side effects of therapy.

Back to Top
Patient Education
Lifestyle modifications can have a significant influence on the signs and symptoms of GERD. Box
1 describes important interventions patients can take to reduce the symptoms of GERD. Also

included are precautions patients should use during medication therapy.18 Instruct patients to
take medications as directed and report any adverse effects. Also teach patients to seek medical
attention promptly if alarm symptoms occur at anytime.

Box 1. Lifestyle Modifications That May Reduce GERD Symptoms

Eat smaller meals to reduce pressure on the lower esophageal sphincter.

Lose weight. Increased weight is associated with motility disorders and reduces the
effectiveness of drug therapy.
Stop smoking to reduce esophageal irritation/inflammation and improve salivation.
Avoid caffeine, fatty foods, chocolate, onions, citrus fruits and juices peppermint, spearmint,
tomatoes, hot spices, garlic, coffee, tea (including decaffeinated), alcohol, and carbonated
drinks. These foods can relax the lower esophageal sphincter and promote gastric backflow.
Wear loose clothing. Avoid belts and girdles that increase external obstruction.
Sleep with the head of the bed up 6 to 8 inches on blocks to reduce backflow and esophageal
acid exposure.
Do not lie down, vigorously exercise, lift heavy objects, bend, or strain for 2 to 3 hours after
meals to reduce reflux during stomach digestion of food.
Educate patients that GERD is a chronic condition and relapses are common with
discontinuation of medication therapy. If symptoms do not improve with lifestyle and
medication therapy, surgery may be necessary. Although esophageal cancer is a rare outcome
associated with GERD (about 0.5% per year for those with Barrett's esophagus),19 it remains
unknown whether medication therapy can prevent cancer. Therefore, advise patients to
continue with frequent follow-up and evaluation. Finally, instruct patients to report any changes
in medication therapies to their primary care provider.5

Simple and precise educational materials for patients and nursing staff can be found at the
Agency for Healthcare Research and Quality website. For patients, the publication titled
Treatment Options for GERD or Acid Reflux Disease- A Review of the Research for Adults
provides a wealth of information regarding therapy and drug options, side effects of
medications, and sample questions patients can use when seeing their physician. The
publication titled Managing Chronic Gastroesophageal Reflux Disease provides an excellent
review for clinicians of recent research findings and provides ratings for the strength of the
available evidence.
Back to Top
Emerging Information in the Literature

The following points can be made based on new studies in the treatment and management of
GERD:

Treatment of GERD may also reduce GERD-related dental erosions.20

For patients with obstructive sleep apnea (OSA), aggressive treatment of GERD may enhance
favorable outcomes in the treatment of OSA.21,22
Treatment of reflux may also significantly improve signs and symptoms of chronic obstructive
pulmonary disease.23
Reduction of GERD symptoms results in long-lasting improvement in quality of life.24
Long-term PPI therapy is associated with hypomagnesemia related to malabsorption.
Magnesium levels should be monitored and supplements prescribed as necessary.25
Long-term PPI therapy is also associated with increased risk of hip fracture, probably related to
calcium malabsorption.26
PPIs may help the cough but not the hoarseness associated with GERD.10
Whether PPIs reduce the incidence of GERD related asthma is still unknown.10
Obesity attenuates the effectiveness of drug therapies.10
Back to Top
Summary
GERD is a common problem that affects millions worldwide. Increasing use of OTC antacids and
medications suggests that many persons are undiagnosed, particularly elderly people who are at
higher risk for GERD because of aging and medication therapies. Screen every hospitalized
patient for GERD. Lifestyle modifications and medication therapies can significantly improve the
quality of life for patients with GERD.

Back to Top
About the Author
Patricia O'Malley, RN, PhD, CNS, is a researcher at Miami Valley Hospital in Dayton, OH.

Gastroesophageal Reflux Disease, Adult

Gastroesophageal reflux disease (GERD) happens when acid from your stomach flows up into
the esophagus. When acid comes in contact with the esophagus, the acid causes soreness
(inflammation) in the esophagus. Over time, GERD may create small holes (ulcers) in the lining
of the esophagus.ExitCare Image

CAUSES
Increased body weight. This puts pressure on the stomach, making acid rise from the stomach
into the esophagus.
Smoking. This increases acid production in the stomach.
Drinking alcohol. This causes decreased pressure in the lower esophageal sphincter (valve or
ring of muscle between the esophagus and stomach), allowing acid from the stomach into the
esophagus.
Late evening meals and a full stomach. This increases pressure and acid production in the
stomach.
A malformed lower esophageal sphincter.
Sometimes, no cause is found.

SYMPTOMS
Burning pain in the lower part of the mid-chest behind the breastbone and in the mid-stomach
area. This may occur twice a week or more often.
Trouble swallowing.
Sore throat.
Dry cough.
Asthma-like symptoms including chest tightness, shortness of breath, or wheezing.
DIAGNOSIS
Your caregiver may be able to diagnose GERD based on your symptoms. In some cases, X-rays
and other tests may be done to check for complications or to check the condition of your
stomach and esophagus.

TREATMENT
Your caregiver may recommend over-the-counter or prescription medicines to help decrease
acid production. Ask your caregiver before starting or adding any new medicines.

HOME CARE INSTRUCTIONS

Change the factors that you can control. Ask your caregiver for guidance concerning weight loss,
quitting smoking, and alcohol consumption.

Avoid foods and drinks that make your symptoms worse, such as:
Caffeine or alcoholic drinks.
Chocolate.
Peppermint or mint flavorings.
Garlic and onions.
Spicy foods.
Citrus fruits, such as oranges, lemons, or limes.
Tomato-based foods such as sauce, chili, salsa, and pizza.
Fried and fatty foods.
Avoid lying down for the 3 hours prior to your bedtime or prior to taking a nap.
Eat small, frequent meals instead of large meals.
Wear loose-fitting clothing. Do not wear anything tight around your waist that causes pressure
on your stomach.
Raise the head of your bed 6 to 8 inches with wood blocks to help you sleep. Extra pillows will
not help.
Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed
by your caregiver.
Do not take aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
SEEK IMMEDIATE MEDICAL CARE IF:
You have pain in your arms, neck, jaw, teeth, or back.
Your pain increases or changes in intensity or duration.
You develop nausea, vomiting, or sweating (diaphoresis).
You develop shortness of breath, or you faint.
Your vomit is green, yellow, black, or looks like coffee grounds or blood.
Your stool is red, bloody, or black.
These symptoms could be signs of other problems, such as heart disease, gastric bleeding, or
esophageal bleeding.

MAKE SURE YOU:

Understand these instructions.

Will watch your condition.

Will get help right away if you are not doing well or get worse.
Document Released: 09/27/2006 Document Revised: 03/11/2013 Document Reviewed:
07/06/2012

ExitCare Patient Information 2014 ExitCare, LLC

Gastroesophageal Reflux Disease, Child

Almost all children and adults have small, brief episodes of reflux. Reflux is when stomach
contents go into the esophagus (the tube that connects the mouth to the stomach). This is also
called acid reflux. It may be so small that people are not aware of it. When reflux happens often
or so severely that it causes damage to the esophagus it is called gastroesophageal reflux
disease (GERD).ExitCare Image

CAUSES
A ring of muscle at the bottom of the esophagus opens to allow food to enter the stomach. It
closes to keep the food and stomach acid in the stomach. This ring is called the lower
esophageal sphincter (LES). Reflux can happen when the LES opens at the wrong time, allowing
stomach contents and acid to come back up into the esophagus.

SYMPTOMS
The common symptoms of GERD include:

Stomach contents coming up the esophagus even to the mouth (regurgitation).

Belly pain usually upper.
Poor appetite.
Pain under the breast bone (sternum).
Pounding the chest with the fist.
Heartburn.
Sore throat.
In cases where the reflux goes high enough to irritate the voice box or windpipe, GERD may lead
to:

Hoarseness.
Whistling sound when breathing out (wheezing). GERD may be a trigger for asthma symptoms in
some patients.
Long-standing (chronic) cough.
Throat clearing.
DIAGNOSIS
Several tests may be done to make the diagnosis of GERD and to check on how severe it is:

Imaging studies (X-rays or scans) of the esophagus, stomach and upper intestine.
pH probe A thin tube with an acid sensor at the tip is inserted through the nose into the lower
part of the esophagus. The sensor detects and records the amount of stomach acid coming back
up into the esophagus.
Endoscopy A small flexible tube with a very tiny camera is inserted through the mouth and
down into the esophagus and stomach. The lining of the esophagus, stomach, and part of the
small intestine is examined. Biopsies (small pieces of the lining) can be painlessly taken.
Treatment may be started without tests as a way of making the diagnosis.

TREATMENT
Medicines that may be prescribed for GERD include:

Antacids.
H2 blockers to decrease the amount of stomach acid.
Proton pump inhibitor (PPI), a kind of drug to decrease the amount of stomach acid.
Medicines to protect the lining of the esophagus.
Medicines to improve the LES function and the emptying of the stomach.
In severe cases that do not respond to medical treatment, surgery to help the LES work better is
done.

HOME CARE INSTRUCTIONS

Have your child or teenager eat smaller meals more often.

Avoid carbonated drinks, chocolate, caffeine, foods that contain a lot of acid (citrus fruits,
tomatoes), spicy foods and peppermint.
Avoid lying down for 3 hours after eating.
Chewing gum or lozenges can increase the amount of saliva and help clear acid from the
esophagus.
Avoid exposure to cigarette smoke.
If your child has GERD symptoms at night or hoarseness raise the head of the bed 6 to 8 inches.
Do this with blocks of wood or coffee cans filled with sand placed under the feet of the head of
the bed. Another way is to use special wedges under the mattress. (Note: extra pillows do not
work and in fact may make GERD worse.
Avoid eating 2 to 3 hours before bed.
If your child is overweight, weight reduction may help GERD. Discuss specific measures with
your child's caregiver.
SEEK MEDICAL CARE IF:
Your child's GERD symptoms are worse.
Your child's GERD symptoms are not better in 2 weeks.
Your child has weight loss or poor weight gain.
Your child has difficult or painful swallowing.
Decreased appetite or refusal to eat.
Diarrhea.
Constipation.
New breathing problems hoarseness, whistling sound when breathing out (wheezing) or
chronic cough.
Loss of tooth enamel.
SEEK IMMEDIATE MEDICAL CARE IF:
Repeated vomiting.
Vomiting red blood or material that looks like coffee grounds.
Document Released: 03/09/2005 Document Revised: 03/11/2013 Document Reviewed:
01/08/2010

ExitCare Patient Information 2014 ExitCare, LLC.

(Buttaro, 2012) (Goldman, 2011) (Chernecky, 2012) (Haugen, 2010) (Brunner & Suddarth's, 2010)

(Brunner & Suddarth's, 2010)

(Buttaro, 2012)
(Chernecky, 2012)
(Mayo Clinic, 2014)
(Goldman, 2011)
(Haugen, 2010)
(Patrick, 2011)
(U.S. Departmentof Health and Human Services, 2007)

References
Brunner & Suddarth's, 2010. Medical Surgical Nursing. 11 ed. USA, Philadelphia: Lippincott
Williams And Wilkins.
Buttaro, 2012. Primary Care. 4th ed. USA,Riverport Ln, Maryland Heights: Mosby.
Chernecky, 2012. Laboratory Tests and Diagnostic Procedures. 6 ed. USA,Riverport Ln, Maryland
Heights: W.B. Saunders.
Ferri, 2013. Ferri's Clinical Advisor 2014. USA,Riverport Ln, Maryland Heights: Mosby.
Goldman, 2011. Goldman's Cecil Medicine. 24th ed. USA,Riverport Ln, Maryland Heights: W.B.
Saunders.
Haugen, 2010. Ulrich & Canale's Nursing Care Planning Guides. 7th ed. USA,Riverport Ln,
Maryland Heights: Saunder.
Patrick, L., 2011. Gastroesophageal Reflux Disease (GERD):. Alternative Medicine Review, 16(2),
pp. 116-133.
U.S. Departmentof Health and Human Services, 2007. Heartburn, Gastroesophageal Reflux (GER),
and Gastroesophageal Reflux Disease (GERD). National Digestive Diseases Information
Clearinghouse, I(2), pp. 1-7.