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Clinical 1 > Dyspepsia and GERD > Flashcards

Dyspepsia and GERD Flashcards

1
Q

What is dyspepsia?

A

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

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2
Q

What are the two types of dyspepsia?

A

Functional and organic

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3
Q

What is functional dyspepsia?

A

Non-ulcer or idiopathic dyspepsia

Pathophysiology is not well understood

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4
Q

What is organic dyspepsia?

A

Actual pathological source

Common causes: PUD, GERD, gastric cancer, medications, herbals, etc.

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5
Q

What is GERD?

A

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

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6
Q

What is the pathogensis or GERD?

A

It is multi-factorial and includes:

  • defective/incompetent LES
  • hiatal hernia
  • impaired esophageal peristalsis
  • delayed gastric emptying
  • excessive gastric acid production
  • bile reflux
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7
Q

What is the primary mechanism of GERD pathology? Why?

A

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

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8
Q

What are the complications of GERD?

A 
Esophagitis
Strictures
Barrett's esophagitis
Esophageal cancer
Worsening asthma or pneumonia
Ulcers
Hemorrhage
Anemia
Tooth decay
Gingivitis
Halitosis
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9
Q

What are factors that contribute to GERD and dyspepsia?

A 
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
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10
Q

What are the mechanisms by which foods can cause an intolerance?

A 
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
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11
Q

What are foods that reduce the LES tone?

A 
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
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12
Q

What are foods that exert a direct irritant effect?

A

Citrus products
Coffee
Spicy foods
Tomato products

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13
Q

What are medications that reduce LES tone?

A 
Alpha adrenergic agonists and antagonists
Anticholinergic agents
Barbituates
Beta adrenergic agonists
Benzodiazepines (especially diazepam)
CCBs
Dopamine
Estrogen
Narcotics
Nitrates
Phentolamine
Progesterone
Theophylline
Tricylic antidepressants
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14
Q

What are medications that exert a direct irritant effect?

A 
Antibiotics (especially erythromycin and tetracyclines)
Aspirin/NSAIDs
Bisphosphonates
Iron
Potassium supplements
Quinidine
Zidovudine
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15
Q

What are symptoms of dyspepsia?

A

Reflux-like symptoms
Ulcer-like symptoms
Dismotility
Unspecified (can not be classified in other areas)

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16
Q

What are reflux-like symptoms of dyspepsia?

A

Heartburn and acid regurgitation

Belching and burping

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17
Q

What are ulcer-like symptoms of dyspepsia?

A

Epigastric pain or discomfort
Pain relieved by food
Pain wakens person from sleep

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18
Q

What are dismotility symptoms of dyspepsia?

A 
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
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19
Q

What are symptoms of GERD?

A

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

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20
Q

What are symptoms classified?

A

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)

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21
Q

What are red flags of GERD and dyspepsia (referral)?

A 
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
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22
Q

When doing a differential diagnosis of GERD/dyspepsia, what other conditions should be considered?

A 
Irritable bowel syndrome (IBS)
Peptic ulcer
Gastric or pancreatic cancer
Angina
Myocardial infarction
Gallstones
Asthma
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23
Q

What are the goals of therapy for dyspepsia/GERD?

A 
Relieve symtoms
Prevent recurrence or symptoms
Heal esophageal mucosa
Improve quality of life
Prevent complications
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24
Q

What are the types of OTC products?

A 
Antacids
H2 blocker
Combo products
Foaming agents
Anti-flatuents
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25
Q

What are some antacids?

A 
Ca CO3 (Tums, Rolaids)
AlOH (Amphogel)
Mg salts (Milk of magnesia)
Mg/Al complexes (Maalox, Diovol)
Na bicarbonate (Alka-seltzer)
Na citrate (Eno)
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26
Q

What are some H2 blockers?

A

Ranitidine (Zantac 75 and 150 mg)

Famotidine (Pepcid 10 mg)

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27
Q

What are some combo products?

A

Famitodine with CaCO3 and MgOH (Pepcid Complete)
Antacid/simethicone (Maalox Plus, Diovol Plus)
Antacid/Alginate (Maalox HRF)

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28
Q

What are some foaming agents?

A

Alginic acid or alginates (Gaviscon)

Na/K bicarbonate or Al/Mg may be added to the product

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29
Q

What are some anti-flatuents?

A

Simethicone (Ovol, GasX and Phazyme)

Mixture of inert silicon polymers

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30
Q

What is the indication for antacids?

A

Relieves symptoms of dyspepsia/GERD

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31
Q

What is the indication for H2B?

A

Prevents and relieves symptoms of dyspepsia/GERD

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32
Q

What is the indication for combo products?

A

Prevents and/or relieves symptoms of dyspepsia/GERD and it may or may not relieve symptoms of bloating and gas

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33
Q

What is the indication for foaming agents?

A

Relieves symptoms of dyspepsia/GERD

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34
Q

What is the indication for anti-flatuents?

A

Relieves symptoms of bloating and gas

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35
Q

What is the MOA of antacids?

A

Neutralize existing acid
Does not affect the amount or rate of GA secretions
Increases both gastric and duodenal pH

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36
Q

What is the MOA of H2B?

A

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

37
Q

What is the MOA of foaming agents?

A

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)

38
Q

What is the MOA of anti-flatuents?

A

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

39
Q

What is ANC?

A

Acid neutralization capacity

The amount of acid buffered/dose over a specified period

40
Q

Describe the potency of antacids and dosing

A

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

41
Q

Describe the onset of action for antacids

A

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

42
Q

Describe the duration of action of antacids

A

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

43
Q

What are the side effects of Mg antacids?

A

Dose-related diarrhea (osmotic)
Electrolyte disturbances
Hypermagnesemia
Kidney stones with trisilicate salt

44
Q

What are the side effects of Al antacids?

A

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)

45
Q

What are the side effects of Ca antacids?

A

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)

46
Q

What are the side effects of Na bicarbonate antacids?

A

Ingestion after a large meal can lead to gastric distention and stomach wall perforation
Belching and flatulence
Metabolic alkalosis

47
Q

What are precautions of Mg antacids?

A

Avoid in elderly
Avoid in renal failure
Not studied extensively in pregnancy; limited absorption (risk factor B)
Does not enter breast milk significantly

48
Q

What are precautions of Al antacids?

A

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

49
Q

What are the precautions with Ca antacids?

A

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

50
Q

What are precautions of Na bicarbonate antacids?

A

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

51
Q

What are factors to consider when choosing an antacid?

A 
Practicality
Palatability
Potency of the product
Cost
Sodium, sugar and dye content
52
Q

How do antacids interact with drugs?

A

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

53
Q

What medications do antacids interact with?

A

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)

54
Q

When and how should H2B be taken for prevention?

A

Ranitidine 75-150 mg should be taken 30-60 minutes before meals
Famotidine 10 mg should be taken 10-15 minutes before meals

55
Q

How should be H2B be taken for treatment?

A

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

56
Q

What is the OOA and DOA or H2B

A

Onset: 30-60 minutes
Duration: 6-8 hours
Degree and DOA are dose dependent

57
Q

How should alginates be taken for treatment?

A

2-4 tablets or 10-20 ml as needed after meals and at night

58
Q

What is the OOA and DOA of alginates?

A

Onset: within minutes
DOA: 4 hours

59
Q

How should simethicone be taken for treatment?

A

80-160 mg QID PRN

Max: 500 mg/day

60
Q

What is the OOA and DOA of simeticone?

A

Onset: 15 minutes
DOA: few hours

61
Q

What are the side effects of H2B?

A

Famotidine: headache, drowsiness, dizziness
Ranitidine: N/V, diarrhea and headache

62
Q

What are the side effects of alginates?

A

N/V, flatulence and belching

63
Q

What are the side effects of simethicone?

A

Not absorbed from GI tract; no known side effects

64
Q

What are special instructions for H2B?

A

Bioavailability is not affected by food

65
Q

What are special instructions for alginates?

A

Must chew tablets and drink a glass of water right after taking
Only works if patient is upright
Take after meals

66
Q

What are special instructions for simethicone?

A

Take after meals and at bedtime

67
Q

What are drug interactions for H2B?

A

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

68
Q

What are drug interactions for alginates?

A

Simethicone

69
Q

What are drug interactions for simethicone?

A

Do not use with alginates (causes bubbles to coalesce)

70
Q

What are precautions for H2B?

A

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

71
Q

What are precautions for alginates?

A

Use in adults only
Not systemically absorbed
Considered compatible with pregnancy and lactation

72
Q

What are precautions for simethicone?

A

Used in infants and adults
Do not use if suspected intestinal perforation or obstruction
Compatible with pregnancy
Probably compatible with breastfeeding

73
Q

What is the MOA of bismuth subsalicylate (aka Peptobismol)?

A

Once called an antacid but is not used for this indication

Suppresses H. pylori

74
Q

What is they indication for bismuth subsalicylate?

A

Treatment of overindulgence of food and alcohol, common and Traveler’s diarrhea
Eradication of H. pylori in combination with other agents

75
Q

What are the directions for bismuth subsalicylate?

A

Adults and children over 12 years

Regular strength product: 2 tablets or 30 ml QID with meals and at bedtime

76
Q

What are the side effects of bismuth subsalicylate?

A

Darkening of the tongue
Grayish-black stools
Bismuth toxicity with chronic use
Tinnitus (ringing in the ears)

77
Q

What are precautions for bismuth subsalicylate?

A

Young children
Bleeding disorders
Salicylate sensitivity
Patients taking medications that may interact with salicylate
Do not use during pregnancy or breastfeeding

78
Q

What is omeprazole?

A

Class of drugs known as proton pump inhibitors (PPI)

79
Q

What is the MOA omeprazole?

A

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

80
Q

What is the indication for omeprazole?

A

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

81
Q

What is the dosage for omeprazole?

A

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

82
Q

What are the omeprazole drug interactions?

A

CYP 2C19

May decrease the absorption of pH-dependant drugs

83
Q

What are the side effects of short term omeprazole use?

A

Diarrhea
Constipation
Headache

84
Q

What are the side effects of long term omeprazole use?

A

Increased risk of osteoporosis, bone fracture, C. difficile infections and possibly hypomagnesaemia and vitamin B12 deficiency

85
Q

What is the treatment approach for dyspepsia and GERD?

A

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

86
Q

What can be used if a patient is pregnant or breastfeeding?

A

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

87
Q

What is a non-drug advice?

A

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)

88
Q

What are monitoring parameter for GERD and dyspepsia?

A

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

89
Q

What are red flags?

A

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

Clinical 1 (25 decks)

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