Dyspepsia and GERD Flashcards
What is dyspepsia?
Symptoms are complex rather than a specific disease entity
Chronic or recurrent epigastric pain, postprandial fullness or early satiety of at least 3 months duration
Other symptoms include: bloating, nausea, anorexia and burping/belching
What are the two types of dyspepsia?
Functional and organic
What is functional dyspepsia?
Non-ulcer or idiopathic dyspepsia
Pathophysiology is not well understood
What is organic dyspepsia?
Actual pathological source
Common causes: PUD, GERD, gastric cancer, medications, herbals, etc.
What is GERD?
Defined as symptoms, esophageal damage or both resulting from reflux
The retrograde movement of stomach contents into the esophagus
GERD is the most prevalent acid-related disorder in Canada
Loosely referred to as “heartburn”
“Heartburn” may also be a symptom of other gastric disorders
What is the pathogensis or GERD?
It is multi-factorial and includes:
- defective/incompetent LES
- hiatal hernia
- impaired esophageal peristalsis
- delayed gastric emptying
- excessive gastric acid production
- bile reflux
What is the primary mechanism of GERD pathology? Why?
Defective LES
LES is usually constricted and resting tone of the LES is more than the intragastric pressure
When food is ingested, LES relaxes to allow bolus to enter stomach
For GERD to occur, pressure gradient between LES and stomach is less than normal or absent
What are the complications of GERD?
Esophagitis Strictures Barrett's esophagitis Esophageal cancer Worsening asthma or pneumonia Ulcers Hemorrhage Anemia Tooth decay Gingivitis Halitosis
What are factors that contribute to GERD and dyspepsia?
Food and beverages Pregnancy Lifestyle (obesity, smoking, diet) Increasing age (i.e., over 65) Medications Disease states (Hiatal hernia, Sjogren's syndrome, asthma possibly) Posture Stress and anxiet
What are the mechanisms by which foods can cause an intolerance?
Decreased LES tone Direct mucosal irritation Irritation of pre-existing ulcer Direct stimulation of mucosal sensory receptors Gastric over distention Delayed gastric emptying Gas production
What are foods that reduce the LES tone?
Alcoholic beverages (especially red wine) Carbonated beverages Chocolate Coffee, cola, tea, and other caffeinated beverages Food with a high fat content Foods with a high sugar content Garlic Onions (especially raw) Peppermint Spearmint
What are foods that exert a direct irritant effect?
Citrus products
Coffee
Spicy foods
Tomato products
What are medications that reduce LES tone?
Alpha adrenergic agonists and antagonists Anticholinergic agents Barbituates Beta adrenergic agonists Benzodiazepines (especially diazepam) CCBs Dopamine Estrogen Narcotics Nitrates Phentolamine Progesterone Theophylline Tricylic antidepressants
What are medications that exert a direct irritant effect?
Antibiotics (especially erythromycin and tetracyclines) Aspirin/NSAIDs Bisphosphonates Iron Potassium supplements Quinidine Zidovudine
What are symptoms of dyspepsia?
Reflux-like symptoms
Ulcer-like symptoms
Dismotility
Unspecified (can not be classified in other areas)
What are reflux-like symptoms of dyspepsia?
Heartburn and acid regurgitation
Belching and burping
What are ulcer-like symptoms of dyspepsia?
Epigastric pain or discomfort
Pain relieved by food
Pain wakens person from sleep
What are dismotility symptoms of dyspepsia?
Early satiety or post-prandial fullness N/V and/or retching Bloating with no visible distention Feeling of abnormal or slow digestion Worsened by food
What are symptoms of GERD?
Heartburn and acid regurgitation are most common symptoms
Worsens when bending over or lying down
Occurs within 1-2 hours after eating, especially after large or fatty meals
Burping and belching
What are symptoms classified?
Frequent: 2 or more days a week
Episodic: mild and sporadic symptoms which are usually predictable
Persistent or chronic: occurs over a long period of time (three or more months; referral)
What are red flags of GERD and dyspepsia (referral)?
Laryngitis Pharyngitis Choking Hiccups (not an automatic referral) Water brash (not an automatic referral Globus sensation Dental erosions Chronic cough or wheezing Cardiac chest pain Odynophagia and/or dysphagia Pain unrelated to meals Severe symptoms with or without sudden onset Nighttime symptoms Chest pain or pain radiating to the arm, neck, jaw or back (indicates MI) Anemia or jaundice Hematemesis and/or melena (blood in stool) Persistent N/V or diarrhea Unexplained or involuntary weight loss Respiratory symptoms Pediatric patients
When doing a differential diagnosis of GERD/dyspepsia, what other conditions should be considered?
Irritable bowel syndrome (IBS) Peptic ulcer Gastric or pancreatic cancer Angina Myocardial infarction Gallstones Asthma
What are the goals of therapy for dyspepsia/GERD?
Relieve symtoms Prevent recurrence or symptoms Heal esophageal mucosa Improve quality of life Prevent complications
What are the types of OTC products?
Antacids H2 blocker Combo products Foaming agents Anti-flatuents
What are some antacids?
Ca CO3 (Tums, Rolaids) AlOH (Amphogel) Mg salts (Milk of magnesia) Mg/Al complexes (Maalox, Diovol) Na bicarbonate (Alka-seltzer) Na citrate (Eno)
What are some H2 blockers?
Ranitidine (Zantac 75 and 150 mg)
Famotidine (Pepcid 10 mg)
What are some combo products?
Famitodine with CaCO3 and MgOH (Pepcid Complete)
Antacid/simethicone (Maalox Plus, Diovol Plus)
Antacid/Alginate (Maalox HRF)
What are some foaming agents?
Alginic acid or alginates (Gaviscon)
Na/K bicarbonate or Al/Mg may be added to the product
What are some anti-flatuents?
Simethicone (Ovol, GasX and Phazyme)
Mixture of inert silicon polymers
What is the indication for antacids?
Relieves symptoms of dyspepsia/GERD
What is the indication for H2B?
Prevents and relieves symptoms of dyspepsia/GERD
What is the indication for combo products?
Prevents and/or relieves symptoms of dyspepsia/GERD and it may or may not relieve symptoms of bloating and gas
What is the indication for foaming agents?
Relieves symptoms of dyspepsia/GERD
What is the indication for anti-flatuents?
Relieves symptoms of bloating and gas
What is the MOA of antacids?
Neutralize existing acid
Does not affect the amount or rate of GA secretions
Increases both gastric and duodenal pH
What is the MOA of H2B?
Competitively and reversibly binds to H2 receptors in gastric parietal cells
Dose-dependent inhibition of GA secretion
Inhibits basal and nocturnal GA secretion -> meal stimulated GA secretion
What is the MOA of foaming agents?
Alginates precipitates in acid medium of stomach to form sponge like matrix of align acid
Bicarbonate reacts with GA to form CO2 which is trapped in matrix and helps it float like a raft
Raft acts as a barrier between contents of stomach and esophagus (don’t lye down or it won’t work)
What is the MOA of anti-flatuents?
Decreases surface tension of gas bubbles in stomach and intestine
Gas bubbles are broken and eliminated more easily
No antacid effect but is often added to products containing antacids
What is ANC?
Acid neutralization capacity
The amount of acid buffered/dose over a specified period
Describe the potency of antacids and dosing
The ANC is influenced by ingredients, formulation and manufacturer
The ANC of CaCO3 is higher than Na bicarb, which is higher than Mg salts which are higher than AlOH
Common dose: 10-20 ml or 2-4 tablets after meals and at bedtime as needed
For GERD, doses can be higher
Describe the onset of action for antacids
Faster onset of action compared to other agents
Depends on the ability to solubilize in the stomach and react with GA
Formulation is very important
Describe the duration of action of antacids
Transient duration of action
Only lasts as long as antacid is in the stomach
DOA is less than an hour if given with food
DOA is 1-3 hours if given after fodo
What are the side effects of Mg antacids?
Dose-related diarrhea (osmotic)
Electrolyte disturbances
Hypermagnesemia
Kidney stones with trisilicate salt
What are the side effects of Al antacids?
Constipation, intestinal obstruction, hemorrhoids, fissures and fecal impaction
Hypophosphatemia and hypophosphaturia
Osteomalacia and osteoporosis
Long term can lead to Al toxicity especially in patients with end stage renal disease (including dementia)
What are the side effects of Ca antacids?
Constipation, belching, flatulence
Rebound acidity
High doses can cause hypercalcemia and milk-alkali syndrome
Chronic use by predisposed patients can lead to hypophosphatemia
Kidney stones (carbonate)
What are the side effects of Na bicarbonate antacids?
Ingestion after a large meal can lead to gastric distention and stomach wall perforation
Belching and flatulence
Metabolic alkalosis
What are precautions of Mg antacids?
Avoid in elderly
Avoid in renal failure
Not studied extensively in pregnancy; limited absorption (risk factor B)
Does not enter breast milk significantly
What are precautions of Al antacids?
Avoid long term use in renal dysfunction
Avoid in patients prone to constipation
Caution in elderly (intestinal obstruction)
Not studied extensively in pregnancy; limited absorption
Does not enter the breast milk significantly
What are the precautions with Ca antacids?
Preferred agent in renal dysfunction
Caution if patient uses Ca supplements and/or eats lots of foods with Ca
Moderate use appears to present minimal risk to fetus and may also enhance maternal nutrition (risk factor B)
Should be safe during breastfeeding
What are precautions of Na bicarbonate antacids?
Avoid in patients with restricted Na intake such as renal dysfunction, oedema, cirrhosis, heart failure or HTN
Avoid in pregnancy
Not recommended during breast feeding
What are factors to consider when choosing an antacid?
Practicality Palatability Potency of the product Cost Sodium, sugar and dye content
How do antacids interact with drugs?
They interfere with absorption by increasing gastric pH
They interfere with elimination by increasing urine pH
They bind to drug to form complexes (chelation)
Alterations of GI transit time
What medications do antacids interact with?
Enteric coated and buffered products
Antibiotics (tetracyclines, fluoroquinolones, azithromycine)
Iron and digoxin
Patients should be advised to not take any other oral medication within 2 hours of antacids (minimum)
When and how should H2B be taken for prevention?
Ranitidine 75-150 mg should be taken 30-60 minutes before meals
Famotidine 10 mg should be taken 10-15 minutes before meals
How should be H2B be taken for treatment?
1 tablet BID
Second dose can be taken one hour after first dose if the first dose was ineffective
Max: 2 tablets in 24 hours
What is the OOA and DOA or H2B
Onset: 30-60 minutes
Duration: 6-8 hours
Degree and DOA are dose dependent
How should alginates be taken for treatment?
2-4 tablets or 10-20 ml as needed after meals and at night
What is the OOA and DOA of alginates?
Onset: within minutes
DOA: 4 hours
How should simethicone be taken for treatment?
80-160 mg QID PRN
Max: 500 mg/day
What is the OOA and DOA of simeticone?
Onset: 15 minutes
DOA: few hours
What are the side effects of H2B?
Famotidine: headache, drowsiness, dizziness
Ranitidine: N/V, diarrhea and headache
What are the side effects of alginates?
N/V, flatulence and belching
What are the side effects of simethicone?
Not absorbed from GI tract; no known side effects
What are special instructions for H2B?
Bioavailability is not affected by food
What are special instructions for alginates?
Must chew tablets and drink a glass of water right after taking
Only works if patient is upright
Take after meals
What are special instructions for simethicone?
Take after meals and at bedtime
What are drug interactions for H2B?
They are modestly affected by antacids
Do not take antacids within 0.5-1 hour of H2B ingestion
H2B interacts with iron, intraconazole, ketoconazole and sulcralfate
What are drug interactions for alginates?
Simethicone
What are drug interactions for simethicone?
Do not use with alginates (causes bubbles to coalesce)
What are precautions for H2B?
Do not use ranitidine if under 16 years old
Do not use famotidine if under 12 years old
Pregnancy risk factor B for both
Famotidine is excreted less in breast milk than ranitidine
What are precautions for alginates?
Use in adults only
Not systemically absorbed
Considered compatible with pregnancy and lactation
What are precautions for simethicone?
Used in infants and adults
Do not use if suspected intestinal perforation or obstruction
Compatible with pregnancy
Probably compatible with breastfeeding
What is the MOA of bismuth subsalicylate (aka Peptobismol)?
Once called an antacid but is not used for this indication
Suppresses H. pylori
What is they indication for bismuth subsalicylate?
Treatment of overindulgence of food and alcohol, common and Traveler’s diarrhea
Eradication of H. pylori in combination with other agents
What are the directions for bismuth subsalicylate?
Adults and children over 12 years
Regular strength product: 2 tablets or 30 ml QID with meals and at bedtime
What are the side effects of bismuth subsalicylate?
Darkening of the tongue
Grayish-black stools
Bismuth toxicity with chronic use
Tinnitus (ringing in the ears)
What are precautions for bismuth subsalicylate?
Young children
Bleeding disorders
Salicylate sensitivity
Patients taking medications that may interact with salicylate
Do not use during pregnancy or breastfeeding
What is omeprazole?
Class of drugs known as proton pump inhibitors (PPI)
What is the MOA omeprazole?
Inhibits hydrogen potassium ATPase (the proton pump), which irreversibly blocks the final step in gastric acid secretion
The onset of symptom relief following an oral dose occurs in 2 to 3 hours, but complete relief may take 1 to 4 days
What is the indication for omeprazole?
OTC is indicated for the treatment of frequent heartburn in patients who have symptoms 2 or more days per week
Not intended for immediate relief of occasional or acute episodes of heartburn or for dyspepsia
What is the dosage for omeprazole?
Take one tablet (20mg) by mouth 30-60 minutes before eating every morning for 14 days
Treatment of heartburn may be repeated after 4 months if symptoms recur
If symptoms persist for more than 2 weeks or recur within 4 months, then must refer
What are the omeprazole drug interactions?
CYP 2C19
May decrease the absorption of pH-dependant drugs
What are the side effects of short term omeprazole use?
Diarrhea
Constipation
Headache
What are the side effects of long term omeprazole use?
Increased risk of osteoporosis, bone fracture, C. difficile infections and possibly hypomagnesaemia and vitamin B12 deficiency
What is the treatment approach for dyspepsia and GERD?
Combination of lifestyle modifications and pharmacological treatment
Depends on predictability and pattern of symptoms, desired onset of relief, comorbid illness, age, side effects, formulation, taste, drug interactions and cost
What can be used if a patient is pregnant or breastfeeding?
Non drug approaches or appropriate lifestyle modification
Antacids (calcium carbonate is preferred)
H2B (ranitidine has the most data available) under physician’s recommendation
PPI (omeprazole has most data available) is under physician’s recommendation
What is a non-drug advice?
Smaller, more frequent meals
Decrease or quit smoking
Decrease caffeine intake
Avoid or decrease drugs that precipitate symptoms
Decrease fat intake
Avoid foods that precipitate event
Decrease alcohol intake
Obtain ideal body weight
Avoid exercising 3 hours after eating or bending on a full stomach
Stress reduction management and other behavioural therapies
Avoid tight-fitting clothing around waist
Avoid lying down right after meals or eating before bed
Elevate head of bed roughly 10 cm using foam blocks or a wedge (not just adding pillows)
What are monitoring parameter for GERD and dyspepsia?
Side effects and hypersensitivity reactions daily while on therapy
Symptoms daily while on therapy and regularly over long term and refer if symptoms last over two weeks, symptoms worsen or are unrelieved by drug therapy, development of any alarm or atypical symptoms at any time
Symptoms recurring over 2-3 times/year
What are red flags?
Presence of any atypical or alarm symptoms
Recurring or prolonged symptoms (over three months)
Symptoms that occur while taking OTC treatment for 2 weeks
Symptoms that continue after 2 weeks of OTC treatment
Infants and children
Patients over 50 years old especially if new onset (this is debatable)
Patients taking long term NSAIDs
Personal or family history of upper GI tract cancer or PUD
