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815 > Ch. 13 - Heartburn/Dyspepsia > Flashcards

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
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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)
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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
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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

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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
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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
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7
Q

GERD Symptoms

A
  • Globus sensation
  • Substernal pain
  • Belching

Atypical

  • Chest pain
  • Laryngitis
  • Chronic cough
  • Wheezing
  • Dental erosions
  • Pharyngitis
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8
Q

GERD Complications

A
  • Esophageal ulcers/strictures
  • Barrett’s esophagus
  • Esophageal cancer
  • Bleeding
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9
Q

PUD

A
  • Peptic Ulcer Disease
  • H. pylori cause
  • NSAID use increases likelihood
  • Gastric - worse with food
  • Duodenal - worse several hours after eating
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10
Q

PUD Symptoms

A
  • Pain
  • Anorexia
  • N/V
  • Belching
  • Bloating
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11
Q

PUD Complications

A
  • Bleeding
  • Perforation
  • Gastric outlet obstruction
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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
-

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13
Q

Regurgiation

A
  • Bitter acidic fluid in back of throat

- More common when laying down or bending over

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14
Q

Water Brash

A

-Sudden filling of mouth with clear, slightly salty fluid from salivary glands

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15
Q

Dyspepsia Symptoms

A
  1. Postprandial fullness - unpleasant sensation of prolonged food persistence in stomach
  2. Early satiation - feeling full abnormally soon after eating
  3. Epigastric pain - unpleasant sensation between umbilicus and lower end of sternum
  4. Epigastric burning - unpleasant subjective sensation of heat

Other symptoms: bloating, N/V, belching

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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
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17
Q

HB/Dyspepsia Treatment Goals

A
  1. Provide complete relief of symptoms
  2. Decrease recurrence of symptoms
  3. Prevent/manage unwanted effects of medications
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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
Q

Aluminum Salts

A
  • Hydroxide, carbonate, phosphate, aminoacetate
  • Slower onset, longer duration
  • ASE: dose-related constipation, accumulation in renal impairment, hypophosphatemia
26
Q

Calcium Carbonate

A
  • Slower onset, longer duration

- ASE: belching, flatulence, constipation, acid rebound, hypercalcemia, kidney stones, renal failure

27
Q

Antacid Drug Interactions

A
  • 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
Q

Antacid Summary

A
  • 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
Q

H2RA Common Ingredients

A
  • Famotidine
  • Ranitidine
  • Cimetidine
  • Nizatidine (not available in US)
30
Q

H2RA

A
  • 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
Q

H2RA Precautions

A
  • ASE: headache, diarrhea/constipation, drowsiness, dizziness, thrombocytopenia (rare)
  • Cimetidine inhibits CYP450s, caution if using theophylline, warfarin, phenytoin
32
Q

H2RA Summary

A
  • 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
Q

PPI Common Ingredients

A
  • Omeprazole
  • Esomeprazole
  • Lansoprazole
34
Q

PPIs

A
  • 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
Q

PPI Precuations

A
  • ASE: Headache, abdominal pain, diarrhea, constipation

- Omeprazole inhibits CYP2C19, so caution when also taking clopidogrel, diazepam, phenytoin, and warfarin

36
Q

PPI Summary

A
  • 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
Q

Heartburn Complementary Therapy

A

-No evidence that botanicals increase gastric pH or relieve heartburn

38
Q

Dyspepsia Complementary Therapy

A
  • 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
Q

Elderly HB/D Treatment

A
  • 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
Q

Children HB/D Treatment

A
  • > 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
Q

Preggo & BF HB/D Treatment

A
  • 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
Q

HB/D Counseling

A
  • 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
Q

HB/D Evaluation

A
  • 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

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