ISSN 0857 - 5630⌫ ⌫

CHULA JOURNAL OFINTERNALMEDICINEVOLUME 20 NO.2 APR-JUN. 2007

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ปจจัย

Resting LES pressure Increased Decreased

Hormones

Gastrin Secretin

Motilin Cholecystokinin

Substance P Glucagon

Gastric inhibin polypeptide

Vasoactive intestinal peptide (VIP)

Progesterone

Neural agents

α- adrenergic agonists α- adrenergic antagonists

β- adrenergic antagonists β- adrenergic agonists

Cholinergic agonists Cholinergic antagonists

Serotonin

Medications

Metoclopramide Nitrates

Domperidone Calcium channel blockers

Prostaglandin F-2∝ Theophilline

Cisapride Morphines

Meperidine

Diazepam

Barbiturate

Foods Protein Fat

Chocolate

Ethanol

Peppermint

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Characteristics Endoscopy neg reflux disease

Erosive esophagitis

Columnar lined esop.(metaplasia)

Prevalence 50% 40% 10%

Extent of exposure acid Mild to moderate Mild to severe Moderate to severe

Response of mucosa Highly sensitive and

reactive to acid reflux

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or grade of

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Increasing length of

metaplastic columnar lined

esophagus with increasing

exposure to acid

Presentation High burden of typical

and atypical

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Typical symptoms

of reflux, prominent

heartburn

Delayed presentation or

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symptoms due to relative

insensitivity to acid

Response of acid suppression Often incomplete

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symptoms)

Good symptomatic

response and

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Prompt symptomatic

response but little or no

regression of columnar

lined esophagus

Complication Associated with

functional bowel

disease

Risk of peptic

stricture with

severe disease

Ulceration and stricture

with severe disease

Malignant potential Low Low Relatively high

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Non-cardiac Pulmonary Laryngeal Oral cavity Others chest pain conditions conditions conditions Bronchial asthma Pharyngitis Dental erosions Otalgia

Lung fibrosis Dysphonia Oral burning Otitis media

Stridor/croup Chronic cough Oral ulcers Chronic sinusitis

Chronic bronchitis Hoarseness Dysgeusia/ageusia Posterior nasal drip

Bronchectasis Chronic laryngitis

COPD Globus sensation

Pneumonia Vocal cord ulcers

Laryngospasm

Laryngeal stenosis

Tracheal stenosis

Laryngeal cancer

Torticollis (Sandifer’s

syndrome)

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Highest efficacy

Lowest efficacy

Double does PPI + Bed time H2RA

Double does PPI

Full (standard) dose PPI

Half dose PPI

Standard dose H2RA + Prokinetics

Standard dose H2RA or Prokinetics

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Regimen Advantages Disadvantages

Step-down therapy Rapid symptom relief Potential over-treatment

(high initial therapy) Efficient for doctor Higher initial drug cost

Avoid overinvestigation

and associated costs

Step-up Rx therapy Avoid overtreatment Patient may continue with symptoms (minimun initial

Lower initial drug cost therapy)

unneccessarily Takes too long period of treatment

Inefficient for doctor

May lead to overinvestigations

Uncertain end point (partial symptom relief)

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⌧ Kamal M.F. Itani, M.D., Samuel E. Wilson, M.D., Samir S. Awad, M.D., Erin H. Jensen, M.S., Tyler S. Finn, B.A., and

Murray A. Abramson, M.D., M.P.H.

AbstractBACKGROUNDErtapenem, a long-acting carbapenem, may be an alternative to the recommended prophy-lactic antibiotic cefotetan.METHODSIn this randomized, double-blind trial, we assessed the efficacy and safety of antibiotic pro-phylaxis with ertapenem, as compared with cefotetan, in patients undergoing elective colorectalsurgery. A successful outcome was defined as the absence of surgical-site infection, anasto-motic leakage, or antibiotic use 4 weeks postoperatively. All adverse events were collecteduntil 14 days after the administration of antibiotic prophylaxis.RESULTSOf the 1002 patients randomly assigned to study groups, 901 (451 in the ertapenem groupand 450 in the cefotetan group) qualified for the modified intention-to-treat analysis, and672 (338 in the ertapenem group and 334 in the cefotetan group) were included in the per-protocol analysis. After adjustment for strata, in the modified intention-to-treat analysis, therate of overall prophylactic failure was 40.2% in the ertapenem group and 50.9% in thecefotetan group (absolute difference, -10.7%; 95% confidence interval [CI], -17.1 to -4.2); inthe per-protocol analysis, the failure rate was 28.0% in the ertapenem group and 42.8% inthe cefotetan group (absolute difference, -14.8%; 95% CI, -21.9 to -7.5). Both analyses ful-filled statistical criteria for the superiority of ertapenem. In the modified intention-to-treatanalysis, the most common reason for failure of prophylaxis in both groups was surgical-siteinfection: 17.1% in the ertapenem group and 26.2% in the cefotetan group (absolute differ-ence, -9.1%; 95% CI, -14.4% to -3.7). In the treated population, the overall incidence ofClostridium difficile infection was 1.7% in the ertapenem group and 0.6% in the cefotetangroup (P=0.22).CONCLUSIONSErtapenem is more effective than cefotetan in the prevention of surgical-site infection inpatients undergoing elective colorectal surgery but may be associated with an increase in C.difficile infections. (ClinicalTrials.gov number, NCT00090272.)

N Engl J Med 2006;355:2640-51.

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⌦⌫ ⌦ ⌫ ⌦⌦⌫⌫⌫ ⌫ ⌫ ⌦⌦⌫⌫ ⌫ ⌫ ⌫

⌦⌫ ⌦ ⌦⌫⌫ ⌦⌫

⌦ ⌫⌫⌦⌫ ⌫⌫⌫ ⌫ ⌫ ⌫ ⌫ ⌫ ⌫

⌦⌫⌦ ⌦ ⌦⌫⌫⌫ ⌫ ⌦⌦⌫⌫

⌫⌫⌫ ⌦⌫ ⌫⌫⌫ ⌦⌫ ⌫ ⌦⌦ ⌫⌫⌦ ⌦⌫⌫ ⌦⌫ ⌦ ⌦ ⌦⌫ ⌦⌫⌫⌫ ⌦⌫⌫⌫⌫⌫⌫ ⌫⌫⌫⌫⌫ ⌦⌦⌫ ⌦⌫⌫ ⌦

⌫⌦ ⌦ ⌫ ⌦⌦⌫⌫ ⌦⌫⌫⌦⌫⌦ ⌦ ⌦⌫ ⌫⌫

⌦ ⌫

⌫ ⌫

⌦ ⌫⌫ ⌫ ⌦⌦⌫⌫

⌦ ⌫⌫⌫⌦ ⌦⌫⌫ ⌦

⌫ ⌦⌫⌫⌫⌫ ⌫⌫⌫⌫⌫⌫ ⌦⌫⌫ ⌫ ⌫ ⌫⌦ ⌫⌫ ⌫⌦ ⌫ ⌦ ⌦ ⌫⌫⌫ ⌦⌦⌫ ⌫⌫ ⌫⌫ ⌫ ⌫⌦

⌫ ⌫ ⌫ ⌫⌫⌫⌦⌫ ⌦ ⌫⌫⌦⌫ ⌫⌫ ⌫⌫⌫ ⌫ ⌦⌫ ⌫⌦⌫⌫⌫⌫ ⌫⌫ ⌫⌫ ⌦⌫⌫ ⌫⌫⌫⌫

⌦ ⌦⌫⌫⌫⌫

☺

☺

⌧ ☺

☺

☺

☺ ☺ ☺ ⌧

☺ ⌧

⌫⌫⌫⌫ ⌫ ⌫⌫⌫ ⌫⌦⌫⌫ ⌫⌫⌫⌫

⌫ ⌫

*

⌫

⌫⌫

⌫ ⌫

⌫ ⌫ ⌫ ⌦

⌫ ⌫ ⌫⌦⌦

⌧ ⌫⌦ ⌫ ⌫⌫

⌫⌫ ⌫ ⌫ ⌫⌫⌫⌫ ⌫⌫⌦ ⌫⌫

Interdepartmental conference

⌦ ⌫ ⌫ ⌫ ⌫ ⌫

⌫

⌫

⌫ ⌦⌫⌫⌫ ⌫ ⌫ ⌫

⌫ ⌫⌫ ⌫ ⌫ β ⌦ ⌫

⌫

⌫ ⌫

⌧

⌦ ⌫ ⌦

⌫ ⌫ ⌫ ⌫

⌦ ⌫ ⌫ ⌫⌫⌫

⌫ ⌫ ⌧ ⌫⌫⌫

⌫⌦⌦ ⌫ ⌫

⌫

⌫ ⌫ ⌫⌫

⌫

⌫⌫

⌫ ⌫

⌫⌫⌫ ⌫

⌧

α

⌫ ⌫ ⌫

⌦

⌫

⌫ ⌫ ⌧ ⌫⌫⌫⌫

⌫⌫⌫ ⌫

⌫⌫

⌫ ⌫

⌫⌫ ⌫ ⌫ ⌫ ⌫ ⌫

⌧

⌧

EKG quiz

⌫ ⌫

⌫ ⌫ ⌫ ⌫ ⌧ ⌫⌫ ⌫ ⌫⌫

⌫

⌦⌫⌫

⌦ ⌫⌫

⌫

⌫ ⌫⌫⌦ ⌫

⌫ ⌫⌫⌫⌫ ⌫ ⌦⌫ ⌫⌫ ⌫⌫ ⌫⌫

⌫⌫ ⌫⌫⌫ ⌫⌫⌫ ⌫⌫⌫ ⌫⌫ ⌫⌫ ⌦⌫

⌫⌫ ⌫

⌧

⌧

⌫ ⌫ ⌫

⌫⌫

⌫

⌫ ⌫ ⌫

ประเภทฉุกเฉิน การรักษา กลไกการออกฤทธ์ิ เวลาออกฤทธ์ิ ระยะเวลา

การรักษา ขนาดและวิธีบริหาร

ประเภทไมฉุกเฉิน

การรักษา กลไกการ ออกฤทธ์ิ

ระยะเวลา การรักษา

ขนาดและวิธีบริหาร

↑ ⌧

⌧

⌧

⌧

≥ ☯

⌧

⌫ ⌫

☺

☺

☺

☺

☺

☺

X-ray imaging

⌫

⌫ ⌫

⌫⌫ ⌧

⌦⌫ ⌫ ⌫⌫ ⌫

⌫ ⌫ ⌫⌫ ⌫⌫ ⌦⌦

⌫⌫ ⌫ ⌫

⌦ ⌫ ⌫ ⌦ ⌦ ⌦⌫

⌫ ⌫⌫ ⌦⌦

⌫ ⌫ ⌫⌫

⌫

⌫⌫ ⌫ ⌫ ⌫ ⌫

⌫ ⌫ ⌫ ⌫

⌧ ⌧ ⌫

⌫⌫ ⌫ ⌫⌫ ⌫⌫ ⌫

⌫ ⌫

⌫ ⌫⌫ ⌧ ⌫⌫

⌫⌫ ⌫ β

⌦ ⌧

⌦ ⌦ ⌦⌫⌫⌦⌫ ⌫⌦⌫ ⌫ ⌫⌫⌫

⌫ ⌫

⌫ ⌫

⌫⌫⌫

⌫

☯ ⌫⌫

☯ ⌫ ⌫ ⌫

☯ ⌫⌫ ⌫

☯

☯

☯ ⌫

☯

☯

⌫⌫⌫

⌫

⌫ ⌫

⌫

⌫

☯

☯ ⌫ ⌫ ⌧

☯ ⌫⌫ ⌫

☯ ⌫

☯ ⌧

☯

☯ ⌫

☯

☯ ⌫ ⌫

☯

⌫⌫⌫

⌫

⌫ ⌫ ⌫

⌫

☯ ⌧

☯

☯

☯ ⌧

☯ ⌧

☯

☯

☯

☯ ⌫

☯ ⌫ ⌫ ⌦

☯ ⌫ ⌫ ⌫

⌫⌫⌫

⌫

⌫ ⌫ ⌫

⌫

☯

☯

☯

☯ ⌫ ⌫ ⌫

☯

☯

⌫

☯ ⌫⌫ ⌫⌫⌫⌫

☯ ⌫

☯ ⌫

☯

⌫⌫⌫

⌫

⌫ ⌫ ⌫

⌫

☯ ⌧ ⌫

☯ ⌧ ⌫ ⌫

☯ ⌫ ⌫

☯ ⌫

☯ ⌫

☯

☯ ⌫

☯ ⌧

☯ ⌫⌫ ⌫

☯ ⌫

⌫⌫⌫

⌫

⌫ ⌫ ⌫

⌫

☯ ⌫

☯ ⌫ ⌫

☯ ⌫ ⌫ ⌫

☯ ⌫

☯

☯

☯ ⌫

⌫⌫⌫

⌫

⌫ ⌫ ⌫

⌫

☯ ⌫

☯ ⌧ ⌫ ⌫

☯ ⌫ ⌫ ⌫

☯

☯

☯ ⌫ ⌫

☯

☯ ⌫

☯ ⌫ ⌫

⌫⌫⌫

⌫

⌫ ⌫ ⌫

⌫

☯ ⌫ ⌫

☯ ⌫

☯

☯ ⌫ ⌫

☯

☯ ⌫

⌫⌫⌫

⌫

⌫ ⌫ ⌫

⌫

⌫

⌫

⌫

⌫ ⌫

⌫

⌫

⌫

⌫

⌫

⌫

⌫

⌫

⌫ ⌫ ⌫

⌫ ⌫

⌫⌫ ⌫⌫

⌫

⌫ ⌫⌦ ⌫

⌫

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

⌫⌫ ⌫

⌧ ⌧ ⌫ ⌫