1. GERD and PUD Flashcards
What are the medications that target esophageal clearance?
Bethanechol
Cisapride
What are the medications that target esophageal mucosal resistance?
Alginic Acid
Sucralfate
What are the medications that target LES tone?
Bethanechol
Metoclopramide
Cisapride
What are the medications that target gastric emptying?
metoclopramide
cisapride
What are the medications that target gastric acid?
antacids
H2R Antagonist
proton pump inhibitors
What targets does bethanechol work on?
esophageal clearance
LES tone
What targets does cisapride work on?
esophageal clearance
LES tone
gastric emptying
What targets does Alginic acid work on?
esophageal mucosal resistance
What targets does sucralfate work on?
esophageal mucosal resistance
What targets does metoclopramide work on?
gastric emptying
LES tone
What targets do antacids, H2RAs, and PPIs work on?
reducing gastric acid
What are the typical symptoms of GERD?
heartburn/retrosternal pain
acid or food regurgitation
dyspepsia or belching
What are the Atypical symptoms of GERD?
pulmonary symptoms
dental erosions
hoarseness
chest pain
What are the alarm symptoms of GERD?
GI bleeding early satiety dysphagia or odynophagia unexplained weight loss iron deficiency anemia vomiting
What are some diet choices that can precipitate GERD?
alcohol obesity peppermint caffeine chocolate carbonated drinks tomato based products
What are some lifestyle choices that can precipitate GERD?
tobacco use pregnancy running weight lifting tight clothing
What are some medications that decrease LES tone?
anticholinergics dihydropyridine CCBs barbiturates estrogen and progesterone opioids
What are some medications that are direct contact irritants to the stomach?
aspirin iron NSAIDS K Cl bisphosphonates
What are the 2 main classifications of esophagitis?
erosive (ERD)
non-erosive (NERD)
What is esophageal stricture?
inflammation and scar tissue that causes the narrowing of the esophagus
What are some treatments for esophageal stricture?
PPIs
intralesional corticosteroids
What is Barrett’s esophagus?
normal squamous epithelium is replaced with specialized columnar epithelium
What are some diagnostic tests for GERD?
endoscopy upper GI radiography H. pylori testing pH testing barium swallow test
What are the goals of therapy for GERD?
relieve symptoms
heal esophagitis
avoid complications
What are the recommendations for lifestyle modifications to relieve GERD symptoms?
weight loss elevate head of bed by 6-8 inches avoid late evening meals tobacco and alcohol cessation *cessation of chocolate, caffeine, spicy food, citrus, soda *not recommended in guidlines
What is the MOA of antacids?
neutralize stomach acid to maintain intragastric pH of >4
How does decreasing gastric pH help with GERD?
decreases activation of pepsinogen to pepsin
leads to increase of LES tone
What are some adverse effects of antacids?
constipation
acid rebound with Ca based products
bone demineralization with Al products
What is the MOA for H2RAs?
decrease gastric acid secretion by blocking the interaction of histamine and H2 receptor on parietal cell - this ultimately decreases gastric acid secretion
What are some adverse effects of H2RAs?
tachyphylaxis with prolonged use GI effects headache anticholinergic somnolence fatigue dizziness
Which H2RA has the most significant drug interactions?
cimetidine
H2RAs are pregnancy category ___.
B
What is the MOA of PPIs?
Irreversibly blocks the H/K/ATPase pump of the parietal cell - this is the terminal step in acid secretion
What are adverse effects of PPIs?
headache
diarrhea
constipation
abdominal pain
What are the long term effects of PPI use?
pneumonia possible fracture risk 2x risk of C. diff decreased Ca absorption hypomagnesemia
What time of day should H2RAs be administered?
30 minutes prior to meals
What time of day should PPIs be administered?
30 minutes prior to the first meal of the day
If there is not substantial effect PPIs can be titrated to ____.
BID
PPIs are pregnancy category __ except for omeprazole which is category __.
B
C
Metoclopramide is a __-_______ agent?
pro motility
What is the MOA of metoclopramide?
D2 antagonist, 5HT-3/4 antagonist, muscarinic antagonist
This increases LES pressure
increases GI emptying
enhances esophageal paristalsis
What are the steps of treatment for GERD?
- lifestyle changes + OTC
- low dose H2RA, PPI
- surgical
What are some surgical interventions to GERD?
Nissen fundoplication
LINX
What is Peptic Ulcer Disease?
defect in the gastric or duodenal wall that extends through the muscularis mucosa
Where can PUD ulcers be located?
stomach
duodenum
What are the 3 common causes of PUD?
H. pylori infection
NSAID induced
stress related damage
___-___% of ulcers reoccur within 1 year.
60 - 100
How is H. pylori transmitted?
fecal-oral
What are some anti-ulcer agents?
PPIs
H2RAs
Sucralfate
Prostaglandins
What is the MOA of sucralfate?
forms a protective coating that adheres to damaged mucosal area
Misoprostol is a _________ that is pregnancy category __.
protaglandin
X
What are the 2 treatment therapies for PUD and what are their durations?
triple therapy - 14 days
quadruple therapy - 10 days
What agents are included in triple therapy for PUD?
PPI
clarithromycin
amoxicillin or metronidazole
What agents are included in quadruple therapy for PUD?
PPI or H2RA
bismuth
tetracycline
metronidazole
How is treatment confirmed for PUD?
8 weeks from completion of therapy:
fecal antigen test
urea breath test
How is NSAID induced PUD treated?
discontinue nonselective NSAID
PPI (4 weeks)
H2RA
sucralfate
