Ch. 13 - Heartburn/Dyspepsia Flashcards
1
Q
Heartburn
A
- One of the most common gastrointestinal complaints
- AKA indigestion, acid regurgitation, sour stomach, bitter belching
- Common symptom of GERD but also related to other disease states
- Pain can reach all the way to the back of the throat and down the esophagus
2
Q
Dyspepsia
A
- Origin in gastroduodenal area
- Induces bothersome postprandial fullness, early satiation, epigastric pain/burning as well as anorexia, belching, N/V, and bloating
- Can occur with heatburn
- Can be organic (form a cause) or function (not a specific cause)
3
Q
HB/Dyspepsia
A
- Decrease quality of life by limiting diet choices, increasing medication costs, and nocturnal symptoms
- Nocturnal symptoms: interrupted sleep, decreased health related quality of life, decreased work productivity, increased daytime sleepiness, increased complications like erosive esophagus/stricture
- Predominant in white population (especially when considering esophagitis), equally effects both genders
- More GERD complications in elderly, less sensitive to regurgitated acid
- 30-80% complain of heartburn in first trimester
- Dyspepsia w/o heartburn occurs in ~5-15% and affects women more
4
Q
Esophageal Defenses
A
-Esophageal defense mechanisms: antireflux barriers, esophageal acid clearance, and tissue resistance
-Help protect esophageal mucosa from acid
Antireflux barriers - intrinsic lower esophageal sphincter (LES), diaphragmatic crura, phrenoesophageal ligaments, and acute angle of His
-Together provide physical barrier to acid reflux
-Major component: LES, 3-4 cm, contracted at rest, transient relaxations allow stomach contents into the esophagus
-Diaphragmatic crura extrinsically squeezes LES
-Acute angle of His creates a flap-like barrier to block acid
-When reflux DOES occur, physiologic mechanisms help protect mucosa
-Esophageal acid clearance occurs when reflux happens and saliva/esophageal secretions neutralize acid
-Epithelial cells can also buffer/extrude H+ that don’t penetrate their cells
-Tissue resistance is further aided by gravity and esophageal blood supply which can remove acid and normalize pH
5
Q
HB Pathophysiology
A
- Heartburn is likely related to stimulation of esophagus chemoreceptors
- Can arise from acid, weak acid, bile reflux
- No clear reason why some reflux causes symptoms and others don’t
- Mucosal disruption, decreased acid clearance, inflammaiton, decreased salivary bicarbonate concentrations, volume refluxate, heartburn frequency can all contribute to HB symptoms
- Esophageal hypersensitivity, hypotensive LES, hiatal hernias can all increase HB
- Increased reflux exposure or volumes can damage tight intercellular junctions of esophagus which can increase H+ penetration and damage the cells
- Pepsin and/or bile salts with acid is more damaging than acid alone
- Helicobacter pylori decreased gastric acidity and can protect against HB/GERD complications
- Foods and drugs can decreased LES pressure and increase reflux
- Spicy foods, citrus, tomato-based foods, smoking, anxiety, fear, worrying, obesity all increase reflux
6
Q
Dyspepsia Pathophysiology
A
- Dyspepsia caused by various GI disorders (GERD, PUD, celiac disease, etc.)
- Certain foods and medications can also increase dyspepsia
- No firm pathological understanding or reasoning why they experience symptoms
- Psychosocial factors may play a role too (depression, anxiety, sex abuse
7
Q
GERD Symptoms
A
- Globus sensation
- Substernal pain
- Belching
Atypical
- Chest pain
- Laryngitis
- Chronic cough
- Wheezing
- Dental erosions
- Pharyngitis
8
Q
GERD Complications
A
- Esophageal ulcers/strictures
- Barrett’s esophagus
- Esophageal cancer
- Bleeding
9
Q
PUD
A
- Peptic Ulcer Disease
- H. pylori cause
- NSAID use increases likelihood
- Gastric - worse with food
- Duodenal - worse several hours after eating
10
Q
PUD Symptoms
A
- Pain
- Anorexia
- N/V
- Belching
- Bloating
11
Q
PUD Complications
A
- Bleeding
- Perforation
- Gastric outlet obstruction
12
Q
Alarm Symptoms
A
-Difficulty (dysphagia) or painful (odynophagia) swallowing
-Unexplained weight loss
-Signs of GI bleeding (hematemesis, melena, occult bleeding)
-Blood loss
-Anemia
-
13
Q
Regurgiation
A
- Bitter acidic fluid in back of throat
- More common when laying down or bending over
14
Q
Water Brash
A
-Sudden filling of mouth with clear, slightly salty fluid from salivary glands
15
Q
Dyspepsia Symptoms
A
- Postprandial fullness - unpleasant sensation of prolonged food persistence in stomach
- Early satiation - feeling full abnormally soon after eating
- Epigastric pain - unpleasant sensation between umbilicus and lower end of sternum
- Epigastric burning - unpleasant subjective sensation of heat
Other symptoms: bloating, N/V, belching
16
Q
HB/Dyspepsia Exclusions
A
- Frequent symptoms >3 months
- Persistent after 2 weeks with H2RA or PPI treatment
- Severe symptoms
- Nocturnal HB
- Chest pain with sweating, raidating, or SOB
- Adults >45 y.o. with new onset dyspepsia
- Chronic hoarseness, wheezing, coughing, or choking
- Continuous nausea, vomiting, or diarrhea
- Children
17
Q
HB/Dyspepsia Treatment Goals
A
- Provide complete relief of symptoms
- Decrease recurrence of symptoms
- Prevent/manage unwanted effects of medications
18
Q
HB/Dyspepsia Nonpharmacologic
A
- Avoid trigger foods
- Encourage weight loss if obese
- Avoid eating within 3 hours of lying down
- Elevate head of bed
- Eat smaller meals
- Decrease dietary fat
- Encourage tobacco, alcohol, and caffeine cessation
- Go over medication use and advise switching if medication is possible cause of HB/Dyspepsia
19
Q
HB/Dyspepsia General Treatment
A
- Recommend specific nondrug measures THEN recommend nonRx drug if appropriate
- Antacids and H2RAs for mild/infrequent HB and dyspepsia; quick relief but short duration
- H2RAs can also e used for mild to moderate episodic HB with prolonged relief, can combine with antacid or take in advance when expecting an episode
- Lower doses for mild/infrequent HB and higher doses for moderate HB
- Don’t use for > 14 days
- PPIs can be used for frequent heartburn, may have slow onset and may take several days before relief is achieved but better symptomatic relief and duration
20
Q
HB/Dyspepsia Pharmacologic Selection
A
Base on:
- Frequency, duration, and severity of symptoms
- Cost of the medication
- Drug-drug interactions
- Other conditions
- Adverse effects
- Patient preference
21
Q
Antacids-HB/D
A
Mechanism
- Neutralize acid in the stomach through chemical reactions
- Increase gastric pH to reduce injury to the stomach and esophagus
Indication
- Relief of mild, infrequent symptoms of heartburn, sour stomach, and acid indigestion
- NOT for treatment or prevention
22
Q
Antacid Common Ingredients
A
- Sodium bicarbonate
- Calcium carbonate
- Aluminum salts
- Magnesium salts
23
Q
Sodium Bicarbonate
A
- Rapid acting, shortest duration
- ASE: belching, flatulence, sodium overload, renal failure, milk-alkali syndrome
- Caution in elderly, heart failure, hypertension, cirrhosis, pregnany
24
Q
Magnesium Salts
A
- Hydroxide, oxide, carbonate, trisilicate
- Rapid acting, short duration
- ASE: Dose-related diarrhea, accumulation in renal impairment (CrCl < 30mL/min), CNS depression
25
Aluminum Salts
- Hydroxide, carbonate, phosphate, aminoacetate
- Slower onset, longer duration
- ASE: dose-related constipation, accumulation in renal impairment, hypophosphatemia
26
Calcium Carbonate
- Slower onset, longer duration
| - ASE: belching, flatulence, constipation, acid rebound, hypercalcemia, kidney stones, renal failure
27
Antacid Drug Interactions
- Chelation in all except sodium bicarbonate: tetracyclines, azithromycin, fluoroquinolones
- Urinary alkalization that increase salicylate excretion and decreases amphetamine and quinidine excretion
- Medications needed acidic environments like itraconzole, ketoconazole, and iron
- Enteric-coated products - may increase gastric v.s. intestinal absorption
28
Antacid Summary
- Mild, infrequent symptoms
- Chelator, acid neutralizer,
- Inexpensive
- Some can be used in pregnancy
- Diarrhea v.s. constipation, renal failure considerations
- Quick relief, but short duration
29
H2RA Common Ingredients
- Famotidine
- Ranitidine
- Cimetidine
- Nizatidine (not available in US)
30
H2RA
- Indication: treatment and prevention of mild-moderate infrequent heartburn
- Onset: 30 minutes to 1 hour
- Duration of action: Famotidine > Ranitidine/Nizatidine> Cimetidine (also dose dependent)
- Renally adjusted
- Maximum duration of use is 2 weeks
- May be more effected when used prn
31
H2RA Precautions
- ASE: headache, diarrhea/constipation, drowsiness, dizziness, thrombocytopenia (rare)
- Cimetidine inhibits CYP450s, caution if using theophylline, warfarin, phenytoin
32
H2RA Summary
- Mild to moderate symptoms, prevention
- Acid neutralizer, CYP inhibition
- Diarrhea, constipation, CNS effects
- Typically more expensive
- Refer for preggo
- Slower onset but longer duration
33
PPI Common Ingredients
- Omeprazole
- Esomeprazole
- Lansoprazole
34
PPIs
- Indications: symptoms >2 days/week, unresponsive to H2RAs
- NOT for immediate relief
- Takes 1-4 days for symptomatic relief
- Take every morning for 14 days
- Can be repeated in 4 months
35
PPI Precuations
- ASE: Headache, abdominal pain, diarrhea, constipation
| - Omeprazole inhibits CYP2C19, so caution when also taking clopidogrel, diazepam, phenytoin, and warfarin
36
PPI Summary
- For treatment of frequent symptoms
- Acid neutralizer, CYP inhibition
- Diarrhea, constipation, headache
- Typically more expensive
- Refer for preggo
- Not for immediate relief (can take days for full effect)
37
Heartburn Complementary Therapy
-No evidence that botanicals increase gastric pH or relieve heartburn
38
Dyspepsia Complementary Therapy
- Peppermint oil alone or in combination with other products may be helpful for dyspepsia
- Artichoke leaf extract showed to have efficacy for dyspepsia too
39
Elderly HB/D Treatment
- More likely to be on medications that cause HB/D and at increased risk for complications
- Renal impairment: avoid aluminum/magnesium antacids, decreased doses of H2RAs
- CV medications: avoid sodium bicarbonate
40
Children HB/D Treatment
- >2 y.o. can use children forms of calcium carbonate
- Refer to doctor if symptoms recur or don't resolve quickly
- Calcium intake for children: 2-3 y.o. - 700 mg, 4-8 y.o. - 1000 mg, 9-18 y.o. - 1300 mg (daily)
- H2RAs okay for 12 y.o.+
- PPIs okay for 18 y.o.+
41
Preggo & BF HB/D Treatment
- Mild/infrequent - use nonpharmacologic first
- Calcium and magnesium safe at recommended doses but watching calcium intake (1000-1300mg/day)
- Cimetidine and rantidine are compatible for preggo
- Omeprazole, esomeprazole, famotidine are likely low risk for preggo
- Cimetidine considered safe for preggo but famotidine may be better since it enters breast milk less
- Aluminum, calcium, and magnesium antacids are considered safe for BF
- PPIs should be avoided for BF
42
HB/D Counseling
- OTC products are for symptomatic relief, can't treat underlying condition
- Heartburn and dyspepsia can be chronic and recurring
- Keep a journal to help identify triggers
- OTC medications should be used in combination with nonpharmacologic interventions
- Include how to treat symptoms and when to see PCP
- Avoid duplication therapy and screen for H2RA and PPI use
43
HB/D Evaluation
- Antacids/H2RA should get relief within 30 minutes to an hour
- PPIs may take up to 4 days for relief but most are asymptomatic within 1-2 days
- Encourage contacting PCP about effectiveness of therapy or any SE that have arised
- If therapy is inadequate, reevaluate to see if another therapy is suitable or if referral is needed
- SE may be managed by adjusting dose or drug
- Atypical/alarm symptoms should be referred for medical evaluation
