GERDGERD

DR SREEJOY PATNAIKDR SREEJOY PATNAIK

EVENT SPONSORERS EVENT SPONSORERS

ALKEM PHARMAALKEM PHARMA

DT: 27/06/2012DT: 27/06/2012

Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease (GERD) (GERD)

• Any symptoms or esophageal mucosal damage Any symptoms or esophageal mucosal damage that results from reflux of gastric acid into the that results from reflux of gastric acid into the esophagusesophagus

• Classic GERD symptomsClassic GERD symptoms– Heartburn (pyrosis): substernal burning discomfortHeartburn (pyrosis): substernal burning discomfort– Regurgitation: bitter, acidic fluid in the mouth Regurgitation: bitter, acidic fluid in the mouth

when lying down or bending overwhen lying down or bending over

ObjectivesObjectives

• Definition of GERDDefinition of GERD

• Epidemiology of GERDEpidemiology of GERD

• Pathophysiology of GERDPathophysiology of GERD

• Clinical ManisfestationsClinical Manisfestations

• Diagnostic EvaluationDiagnostic Evaluation

• TreatmentTreatment

• ComplicationsComplications

DefinitionDefinition

– American College of American College of Gastroenterology (ACG)Gastroenterology (ACG)

– Symptoms OR mucosal damage Symptoms OR mucosal damage produced by the abnormal reflux of produced by the abnormal reflux of gastric contents into the esophagusgastric contents into the esophagus

– Often chronic and relapsingOften chronic and relapsing– May see complications of GERD in May see complications of GERD in

patients who lack typical patients who lack typical symptomssymptoms

Physiologic vs PathologicPhysiologic vs Pathologic

• Physiologic GERDPhysiologic GERD– PostprandialPostprandial

– Short livedShort lived

– AsymptomaticAsymptomatic

– No nocturnal sxNo nocturnal sx

• Pathologic GERDPathologic GERD– SymptomsSymptoms

– Mucosal injuryMucosal injury

– Nocturnal sxNocturnal sx

Locke et al. Gastroenterology 1997;112:1148.Locke et al. Gastroenterology 1997;112:1148.

High Prevalence of Gastroesophageal High Prevalence of Gastroesophageal Reflux Symptoms Reflux Symptoms

19.8%

59%

0%10%20%30%40%50%60%

Weekly Monthly

Frequency of heartburn and/or regurgitation

Important Reasons to Diagnose and Treat Important Reasons to Diagnose and Treat GERDGERD

• Negative impact on health-related quality of lifeNegative impact on health-related quality of life11

• Risk factor for esophageal adenocarcinomaRisk factor for esophageal adenocarcinoma22

1.1. Revicki et al. Am J Med 1998;104:252.Revicki et al. Am J Med 1998;104:252.2.2. Lagergren et al. N Engl J Med 1999;340:825.Lagergren et al. N Engl J Med 1999;340:825.

PathophysiologyPathophysiology

• Primary barrier to Primary barrier to gastroesophageal reflux is gastroesophageal reflux is the lower esophageal the lower esophageal sphinctersphincter

• LES normally works in LES normally works in conjunction with the conjunction with the diaphragmdiaphragm

• If barrier disrupted, acid If barrier disrupted, acid goes from stomach to goes from stomach to esophagusesophagus

Clinical Presentations of GERDClinical Presentations of GERD

• Classic GERD Classic GERD

• Extraesophageal/Atypical GERDExtraesophageal/Atypical GERD

• Complicated GERDComplicated GERD

Extraesophageal Manifestations Extraesophageal Manifestations of GERDof GERD

PulmonaryPulmonaryAsthmaAsthmaAspiration pneumoniaAspiration pneumoniaChronic bronchitisChronic bronchitisPulmonary fibrosisPulmonary fibrosis

OtherOther Chest painChest pain Dental erosionDental erosion

ENTENTHoarsenessHoarsenessLaryngitisLaryngitisPharyngitisPharyngitisChronic coughChronic coughGlobus sensationGlobus sensationDysphoniaDysphoniaSinusitisSinusitisSubglottic stenosisSubglottic stenosisLaryngeal cancerLaryngeal cancer

Potential Oral and Laryngopharyngeal Signs Potential Oral and Laryngopharyngeal Signs Associated with GERDAssociated with GERD

• Edema and hyperemia of Edema and hyperemia of larynxlarynx

• Vocal cord erythema, Vocal cord erythema, polyps, granulomas, polyps, granulomas, ulcersulcers

• Hyperemia and lymphoid Hyperemia and lymphoid hyperplasia of posterior hyperplasia of posterior pharynx pharynx

• Interarytenyoid changesInterarytenyoid changes

• Dental erosionDental erosion

• Subglottic stenosisSubglottic stenosis

• Laryngeal cancerLaryngeal cancer

Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.344.

Pathophysiology of Extraesophageal Pathophysiology of Extraesophageal GERDGERD

Symptoms of Complicated GERDSymptoms of Complicated GERD

• DysphagiaDysphagia– Difficulty swallowing: food sticks or hangs Difficulty swallowing: food sticks or hangs

upup

• OdynophagiaOdynophagia– Retrosternal pain with swallowingRetrosternal pain with swallowing

• BleedingBleeding

When to Perform Diagnostic TestsWhen to Perform Diagnostic Tests

• Uncertain diagnosisUncertain diagnosis

• Atypical symptomsAtypical symptoms

• Symptoms associated with complicationsSymptoms associated with complications

• Inadequate response to therapy Inadequate response to therapy

• Recurrent symptomsRecurrent symptoms

• Prior to anti-reflux surgeryPrior to anti-reflux surgery

Diagnostic Tests for GERDDiagnostic Tests for GERD

• Barium swallowBarium swallow

• EndoscopyEndoscopy

• Ambulatory pH monitoringAmbulatory pH monitoring

• Esophageal manometryEsophageal manometry

Barium SwallowBarium Swallow

• Useful first diagnostic test for Useful first diagnostic test for patients with dysphagiapatients with dysphagia– Stricture (location, length)Stricture (location, length)– Mass (location, length)Mass (location, length)– Bird’s beakBird’s beak– Hiatal hernia (size, type)Hiatal hernia (size, type)

• LimitationsLimitations– Detailed mucosal exam for erosive Detailed mucosal exam for erosive

esophagitis, Barrett’s esophagusesophagitis, Barrett’s esophagus

EndoscopyEndoscopy

• Indications for endoscopy Indications for endoscopy – Alarm symptomsAlarm symptoms– Empiric therapy failureEmpiric therapy failure– Preoperative evaluationPreoperative evaluation– Detection of Barrett’s Detection of Barrett’s

esophagusesophagus

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

• Physiologic studyPhysiologic study

• Quantify reflux in Quantify reflux in proximal/distal proximal/distal esophagusesophagus

– % time pH < 4% time pH < 4

– DeMeester scoreDeMeester score

• Symptom correlationSymptom correlation

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

NormalNormal

GERDGERD

Wireless, Catheter-Free Esophageal pH Monitoring

• Improved patient Improved patient comfort and acceptancecomfort and acceptance

• Continued normal work, Continued normal work, activities and diet studyactivities and diet study

• Longer reporting periods Longer reporting periods possible (48 hours)possible (48 hours)

• Maintain constant probe Maintain constant probe position relative to SCJposition relative to SCJ

Potential AdvantagesPotential Advantages

Esophageal ManometryEsophageal Manometry

• Assess LES pressure, Assess LES pressure, location and relaxationlocation and relaxation– Assist placement of 24 hr. Assist placement of 24 hr.

pH catheterpH catheter

• Assess peristalsisAssess peristalsis– Prior to antireflux surgery Prior to antireflux surgery

Limited role in GERDLimited role in GERD

GERD vs DyspepsiaGERD vs Dyspepsia

• Distinguish from DyspepsiaDistinguish from Dyspepsia– Ulcer-like symptoms-burning, epigastric painUlcer-like symptoms-burning, epigastric pain– Dysmotility like symptoms-nausea, bloating, Dysmotility like symptoms-nausea, bloating,

early satiety, anorexiaearly satiety, anorexia

• Distinct clinical entityDistinct clinical entity• In addition to antisecretory meds and an In addition to antisecretory meds and an

EGD need to consider an evaluation for EGD need to consider an evaluation for Helicobacter pyloriHelicobacter pylori

Treatment Goals for GERDTreatment Goals for GERD

• Eliminate symptomsEliminate symptoms

• Heal esophagitisHeal esophagitis

• Manage or prevent complicationsManage or prevent complications

• Maintain remissionMaintain remission

Lifestyle Modifications are Lifestyle Modifications are Cornerstone of GERD TherapyCornerstone of GERD Therapy

• Elevate head of bed 4-6 inches Elevate head of bed 4-6 inches • Avoid eating within 2-3 hours of bedtimeAvoid eating within 2-3 hours of bedtime• Lose weight if overweightLose weight if overweight• Stop smokingStop smoking• Modify dietModify diet

– Eat more frequent but smaller mealsEat more frequent but smaller meals

– Avoid fatty/fried food, peppermint, chocolate, Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and teaalcohol, carbonated beverages, coffee and tea

• OTC medications prnOTC medications prn

Better LivingBetter Living

• Lifestyle modificationsLifestyle modifications– Avoid large mealsAvoid large meals– Avoid acidic foods (citrus/tomato), alcohol, caffiene, Avoid acidic foods (citrus/tomato), alcohol, caffiene,

chocolate, onions, garlic, peppermintchocolate, onions, garlic, peppermint– Decrease fat intakeDecrease fat intake– Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal– Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches– Avoid meds that may potentiate GERD (CCB, alpha Avoid meds that may potentiate GERD (CCB, alpha

agonists, theophylline, nitrates, sedatives, NSAIDS)agonists, theophylline, nitrates, sedatives, NSAIDS)– Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist– Lose weightLose weight– Stop smokingStop smoking

Acid Suppression Therapy for GERDAcid Suppression Therapy for GERD

HH22-Receptor Antagonists-Receptor Antagonists

(H(H22RAs)RAs)

Cimetidine (TagametCimetidine (Tagamet®®))

Ranitidine (ZantacRanitidine (Zantac®®))

Famotidine (PepcidFamotidine (Pepcid®®))

NizatidineNizatidine (Axid (Axid®®))

Proton Pump InhibitorsProton Pump Inhibitors (PPIs)(PPIs)

Omeprazole (PrilosecOmeprazole (Prilosec®®))Lansoprazole (PrevacidLansoprazole (Prevacid®®))Rabeprazole (AciphexRabeprazole (Aciphex®®))Pantoprazole (ProtonixPantoprazole (Protonix®®))Esomeprazole (Nexium Esomeprazole (Nexium ®®) )

Better LivingBetter Living• Lifestyle modificationsLifestyle modifications

– Avoid large mealsAvoid large meals– Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic, Avoid acidic foods (citrus/tomato), alcohol, caffiene, chocolate, onions, garlic,

peppermintpeppermint– Decrease fat intakeDecrease fat intake– Avoid lying down within 3-4 hours after a mealAvoid lying down within 3-4 hours after a meal– Elevate head of bed 4-8 inchesElevate head of bed 4-8 inches– Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates, Avoid meds that may potentiate GERD (CCB, alpha agonists, theophylline, nitrates,

sedatives, NSAIDS)sedatives, NSAIDS)– Avoid clothing that is tight around the waistAvoid clothing that is tight around the waist– Lose weightLose weight– Stop smokingStop smoking

TreatmentTreatment• AntacidsAntacids

– Over the counter acid Over the counter acid suppressants and antacids suppressants and antacids appropriate initial therapyappropriate initial therapy

– Approx 1/3 of patients with Approx 1/3 of patients with heartburn-related symptoms heartburn-related symptoms use at least twice weeklyuse at least twice weekly

– More effective than placebo More effective than placebo in relieving GERD symptomsin relieving GERD symptoms

TreatmentTreatment

• Histamine H2-Receptor AntagonistsHistamine H2-Receptor Antagonists– More effective than placebo and antacids for More effective than placebo and antacids for

relieving heartburn in patients with GERDrelieving heartburn in patients with GERD– Faster healing of erosive esophagitis when Faster healing of erosive esophagitis when

compared with placebocompared with placebo– Can use regularly or on-demandCan use regularly or on-demand

TreatmentTreatment

AGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESCimetadine 400mg twice daily 400-800mg twice dailyCimetadine 400mg twice daily 400-800mg twice dailyTagametTagamet

Famotidine 20mg twice daily 20-40mg twice dailyFamotidine 20mg twice daily 20-40mg twice dailyPepcidPepcid

Nizatidine 150mg twice daily 150mg twice dailyNizatidine 150mg twice daily 150mg twice dailyAxidAxid

Ranitidine 150mg twice daily 150mg twice dailyRanitidine 150mg twice daily 150mg twice dailyzantaczantac

TreatmentTreatment

• Proton Pump InhibitorsProton Pump Inhibitors– Better control of symptoms with PPIs vs Better control of symptoms with PPIs vs

H2RAs and better remission ratesH2RAs and better remission rates– Faster healing of erosive esophagitis with PPIs Faster healing of erosive esophagitis with PPIs

vs H2RAsvs H2RAs

TreatmentTreatmentAGENT EQUIVALENT DOSAGEAGENT EQUIVALENT DOSAGE DOSAGESDOSAGESEsomeprazole 40mg daily 20-40mg dailyEsomeprazole 40mg daily 20-40mg dailyNexsiumNexsium

Omeprazole 20mg daily 20mg dailyOmeprazole 20mg daily 20mg dailyOmezOmez

Lansoprazole 30mg daily 15-10mg dailyLansoprazole 30mg daily 15-10mg dailyLanLan

Pantoprazole 40mg daily 40mg dailyPantoprazole 40mg daily 40mg dailyPantocidPantocid

Rabeprazole 20mg daily 20mg dailyRabeprazole 20mg daily 20mg dailyRazoRazo

TreatmentTreatment

• H2RAs vs PPIsH2RAs vs PPIs– 12 week freedom from symptoms12 week freedom from symptoms

• 48% vs 77%48% vs 77%

– 12 week healing rate12 week healing rate• 52% vs 84%52% vs 84%

– Speed of healingSpeed of healing• 6%/wk vs 12%/wk6%/wk vs 12%/wk

TreatmentTreatment

• Antireflux surgeryAntireflux surgery– Failed medical managementFailed medical management– Patient preferencePatient preference– GERD complicationsGERD complications– Medical complications attributable to a large Medical complications attributable to a large

hiatal herniahiatal hernia– Atypical symptoms with reflux documented on Atypical symptoms with reflux documented on

24-hour pH monitoring24-hour pH monitoring

TreatmentTreatment

• Antireflux surgery candidatesAntireflux surgery candidates– EGD proven esophagitisEGD proven esophagitis– Normal esophageal motilityNormal esophageal motility– Partial response to acid suppressionPartial response to acid suppression

TreatmentTreatment

• Antireflux surgeryAntireflux surgery– Tenets of surgeryTenets of surgery

• Reduce hiatal herniaReduce hiatal hernia

• Repair diaphragmRepair diaphragm

• Strengthen GE junctionStrengthen GE junction

• Strengthen antireflux barrier via gastric wrapStrengthen antireflux barrier via gastric wrap

• 75-90% effective at alleviating symptoms of 75-90% effective at alleviating symptoms of heartburn and regurgitationheartburn and regurgitation

TreatmentTreatment

• PostsurgeryPostsurgery– 10% have solid food dysphagia10% have solid food dysphagia– 2-3% have permanent symptoms2-3% have permanent symptoms– 7-10% have gas, bloating, diarrhea, nausea, 7-10% have gas, bloating, diarrhea, nausea,

early satietyearly satiety– Within 3-5 years 52% of patients back on Within 3-5 years 52% of patients back on

antireflux medicationsantireflux medications

TreatmentTreatment

• Endoscopic treatmentEndoscopic treatment– Relatively newRelatively new– No definite indicationsNo definite indications– Select well-informed patients with well-documented Select well-informed patients with well-documented

GERD responsive to PPI therapy may benefitGERD responsive to PPI therapy may benefit

• Three categoriesThree categories– Radiofrequency application to increase LES reflux barrierRadiofrequency application to increase LES reflux barrier– Endoscopic sewing devicesEndoscopic sewing devices– Injection of a nonresorbable polymer into LES areaInjection of a nonresorbable polymer into LES area

Effectiveness of Medical Therapies for Effectiveness of Medical Therapies for GERDGERD

TreatmentTreatment ResponseResponse

Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %

HH22-receptor antagonists-receptor antagonists 50 %50 %

Single-dose PPI Single-dose PPI 80 %80 %

Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %

Treatment Modifications for Treatment Modifications for Persistent SymptomsPersistent Symptoms

• Improve complianceImprove compliance

• Optimize pharmacokineticsOptimize pharmacokinetics

– Adjust timing of medication to 15 – 30 minutes Adjust timing of medication to 15 – 30 minutes before meals (as opposed to bedtime)before meals (as opposed to bedtime)

– Allows for high blood level to interact with Allows for high blood level to interact with parietal cell proton pump activated by the mealparietal cell proton pump activated by the meal

• Consider switching to a different PPI Consider switching to a different PPI

GERD is a Chronic Relapsing ConditionGERD is a Chronic Relapsing Condition

• Esophagitis relapses quickly after cessation Esophagitis relapses quickly after cessation of therapyof therapy– > 50 % relapse within 2 months> 50 % relapse within 2 months– > 80 % relapse within 6 months> 80 % relapse within 6 months

• Effective maintenance therapy is imperativeEffective maintenance therapy is imperative

Complications of GERDComplications of GERD

• Erosive/ulcerative esophagitisErosive/ulcerative esophagitis

• Esophageal (peptic) strictureEsophageal (peptic) stricture

• Barrett’s esophagusBarrett’s esophagus

• AdenocarcinomaAdenocarcinoma

Erosive EsophagitisErosive Esophagitis

Peptic StricturePeptic Stricture

Barium SwallowBarium Swallow EndoscopyEndoscopy

Esophageal Stricture: Dilating DevicesEsophageal Stricture: Dilating Devices

TTS Balloon Dilation of a Peptic StrictureTTS Balloon Dilation of a Peptic Stricture

Barrett’s EsophagusBarrett’s Esophagus

Esophageal CancerEsophageal Cancer

Barium SwallowBarium Swallow EndoscopyEndoscopy

ComplicationsComplications

• Erosive esophagitisErosive esophagitis– Responsible for 40-60% of GERD symptomsResponsible for 40-60% of GERD symptoms– Severity of symptoms often fail to match Severity of symptoms often fail to match

severity of erosive esophagitisseverity of erosive esophagitis

ComplicationsComplications• Esophageal strictureEsophageal stricture

– Result of healing of Result of healing of erosive esophagitiserosive esophagitis

– May need dilationMay need dilation

ComplicationsComplications

• Barrett’s EsophagusBarrett’s Esophagus– Columnar metaplasia of Columnar metaplasia of

the esophagusthe esophagus– Associated with the Associated with the

development of development of adenocarcinomaadenocarcinoma

ComplicationsComplications

• Barrett’s EsophagusBarrett’s Esophagus– Acid damages lining of Acid damages lining of

esophagus and causes esophagus and causes chronic esophagitischronic esophagitis

– Damaged area heals in a Damaged area heals in a metaplastic process and metaplastic process and abnormal columnar cells abnormal columnar cells replace squamous cellsreplace squamous cells

– This specialized This specialized intestinal metaplasia can intestinal metaplasia can progress to dysplasia and progress to dysplasia and adenocarcinomaadenocarcinoma

When to Discuss Anti-Reflux When to Discuss Anti-Reflux Surgery with PatientsSurgery with Patients

• Intractable GERD – rareIntractable GERD – rare– Difficult to manage stricturesDifficult to manage strictures– Severe bleeding from esophagitisSevere bleeding from esophagitis– Non-healing ulcersNon-healing ulcers

• GERD requiring long-term PPI-BID in a GERD requiring long-term PPI-BID in a healthy young patient healthy young patient

• Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms• Not Barrett’s esophagus aloneNot Barrett’s esophagus alone

Partial fundoplication techniquesPartial fundoplication techniques

• Thal 90 deg. Ant. Wrap Thal 90 deg. Ant. Wrap

• Watson 120 deg ant-lat. wrapWatson 120 deg ant-lat. wrap

• Dor 150-200 deg ant. wrap Dor 150-200 deg ant. wrap

• Toupet 270 deg posterior wrapToupet 270 deg posterior wrap

• Belsey Mark IV 270 deg transthoracic Belsey Mark IV 270 deg transthoracic ant- lat wrap.ant- lat wrap.

Indications for partial Indications for partial fundoplicationfundoplication

• 1.PRIMARY ESO. MOTILITY 1.PRIMARY ESO. MOTILITY DISORDERSDISORDERS

• Achalasia ( after myotomy)Achalasia ( after myotomy)

• SclerodermaScleroderma

• 2.SEC. ESOP. MOTILITY DISORDERS2.SEC. ESOP. MOTILITY DISORDERS

POOR MOTILITY SEC. TO CHRONIC POOR MOTILITY SEC. TO CHRONIC /BARRETS ESOP/BARRETS ESOP

• 3. Inability to tolerate complete 3. Inability to tolerate complete fundoplicationfundoplication

• Dysphagia, gas bloatingDysphagia, gas bloating

• Chronic nauseaChronic nausea

• AerophagiaAerophagia

• Revision of obstructing360 deg wraps Revision of obstructing360 deg wraps

Scores for heartburn (a) and acid regurgitation Scores for heartburn (a) and acid regurgitation (b) 12 months after an anterior or a posterior (b) 12 months after an anterior or a posterior

partial fundoplicationpartial fundoplication..

Endoscopic GERD Therapy Endoscopic GERD Therapy

• Endoscopic antireflux therapiesEndoscopic antireflux therapies– Radiofrequency energy delivered to the LESRadiofrequency energy delivered to the LES

• Stretta procedureStretta procedure– Suture ligation of the cardiaSuture ligation of the cardia

• Endoscopic plicationEndoscopic plication– Submucosal implantation of inert material in Submucosal implantation of inert material in

the region of the lower esophageal sphincterthe region of the lower esophageal sphincter• EnteryxEnteryx

Dr Craig Taylor-anterior Dr Craig Taylor-anterior fundoplication fundoplication

• This is how a laparoscopic fundoplication is This is how a laparoscopic fundoplication is performed to repair the antireflux valve in performed to repair the antireflux valve in patients with heartburn. It was performed by Dr patients with heartburn. It was performed by Dr Craig Taylor in Sydney. This type of anti-reflux Craig Taylor in Sydney. This type of anti-reflux procedure (anterior fundoplication) provides procedure (anterior fundoplication) provides excellent heartburn control whilst minimising excellent heartburn control whilst minimising the side effects that used to be common after the the side effects that used to be common after the older Nissen fundoplication, especially gas older Nissen fundoplication, especially gas bloating. bloating.

• This newer technique aims to restore the This newer technique aims to restore the function of the valve between stomach and function of the valve between stomach and oesophagus in a more natural and anatomical oesophagus in a more natural and anatomical way. Patients can expect to be free of their way. Patients can expect to be free of their heartburn and reflux and stop taking antireflux heartburn and reflux and stop taking antireflux medication- for many patients this can be quite medication- for many patients this can be quite life changing.As with all surgical procedures life changing.As with all surgical procedures there are risks, and patients need to be aware of there are risks, and patients need to be aware of these.these.

• The procedure took approximately 1 hour The procedure took approximately 1 hour under a general anaesthetic, and only under a general anaesthetic, and only requires an overnight stay in hospital. requires an overnight stay in hospital. Patients can generally return to work within Patients can generally return to work within a few days, and may resume all normal a few days, and may resume all normal physical activity including gym and lifting physical activity including gym and lifting within a monthwithin a month