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IPT 1 Lectures > Dyspepsia and GORD (4.3) > Flashcards

Dyspepsia and GORD (4.3) Flashcards

1
Q

What is dyspepsia?

A

Describe a collection of symptoms that includes:

  • Pain
  • Nausea
  • Heartburn
  • Bloating
  • Stomach discomfort
  • Burping up food or liquid (regurgitation)
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2
Q

What are conditions associated with dyspepsia?

A
  • Non ulcer dyspepsia (functional dyspepsia)
  • Ulcer induced dyspepsia
  • Gastritis
  • Gastro oesophageal reflux disease
  • IBS
  • Lactose intolerance
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3
Q

What is gord? What are some protective mechanisms in place to prevent reflux and avoid damage to the esophagus?

A

Retrograde flow of food and fluid up the oesophagus

  • Occasional episodes common and normal in healthy individuals (usually after meals)
  • Condition that develops when the reflux of gastric content causes troublesome symptoms that affect a persons wellbeing

Protective mechanisms in place to prevent reflux and avoid damage at oesophagus

  • lower oesophageal sphincter (LOS)
  • external sphincter created by the contraction of the diaphragm around the sphincter
  • folds of gastric mucosa at gastro-oesophageal junction

Gord occurs as a result when normal anti-reflux mechanisms fail or there is delayed gastric emptying

>oesophageal mucosa is exposed to gastric contents for prolonged periods of time

>gastro oesophegeal mucosal injury and inflammation

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4
Q

What are some risk factors for GORD

A
  • old age
  • obesity
  • pregnancy
  • hiatus hernia
  • Medications that decrease the tone of the LOS: nitrates, calcium channel blockers, nicotine, anticholinergics
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5
Q

What are some symptoms of GORD?

A

Heartburn

>Burning retrosternal chest pain, sometimes rising upward from the stomach towards the neck and throat

> Aggravated by bending, stooping or lying down

Sour/bitter-tasting material in the mouth

>Acid regurgitation

Chronic cough

Laryngitis

Upper abdominal pain within an hour of eating

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6
Q

What are some alarm symptoms of GORD?

A
  • Unintentional weight loss
  • Haematemesis
  • Malaena
  • Anaemia
  • Dysphagia
  • Recurrent vomiting
  • Pain that wakes patient up at night
  • Chest pain radiating to chin or shoulder
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7
Q

How to diagnose GORD?

A
  • Medical history
  • Presenting symptoms –> presence of heartburn and acid regurgitation together predicts a diagnosis of GORD with greater than 90% accuracy
  • Trial and response to PPI
  • Invasive test such as endoscopy is not often necessary, only indicated when

> Diagnosis is unclear

> Symptoms progress or persist despite treatment

>Presence of alarm Sx

>Recent onset in >55 years old

>Severe/frequent Sx

  • Important to rule out cardiac ischemia
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8
Q

What are some complications of GORD?

A
  • Severe ulcerative oesophagus
  • Reflux-induced oesophageal stricture
  • Barrett’s oesophagus
  • Oesophageal cancer
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9
Q

What are some gastric secretions?

A

H+

  • Gastrin
  • PGE2
  • ACh
  • Histamine

Mucus

  • Prostaglandins

HCO3-

  • Prostaglandins
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10
Q

What is the MOA of PPI

A

PPIs work by irreversibly blocking the H+/K+ ATPase enzyme or the gastric proton pump, which is found within the parietal cells of the stomach and is the final step of acid production

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11
Q

What are some examples of proton pump inhibitors? Are they a produg? are they reversible or irreversible

A

Lansoparazole (zoton)

Omeprazole (losec or acimex)

Pantoprazole (somac)

Esomeprazole (nexium)

Rabeparazole (pariet)

Produg –> converted within parietal cells –> blood side entry

Irreversible inactivation ([H+/K+ ATPase pump])

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12
Q

What are the properties of omeprazole (PPI)?

A

Given as enteric coated granule (or IV) dissolve at relatively alkaline pH duodenum - absorption - blood - parietal cells

  • ½ life = 1 hour
  • Single daily dose (affects acid secretion for 2-3 days, plateau effect after 5 days)
  • Side effects: generally well tolerated (headache, nausea, diarrhoea, abdominal pain, fatigue, ocassional rash, thin hair

Avoid in pregnancy –> use H2 blocker instead (ok in lactation)

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13
Q

What are some drug interactions of PPIs?

A
  • CYP450 inhibition (warfarin, phenytoin, benzodiazapine, theophylline, methamphetamine)
  • Clopidogrel – antiplatelet drug
  • ketoconazole, itraconazole : pH-dependent release
  • Iron salts
  • Digoxin
  • Other drugs = increase Stomach pH
  • Omeprazole only: CYPC219 inhibition (fluconazole + voriconazole: doubles omerprazole conc)
  • Lansoprazole only: decrease Tacrolimus metab (use rabeprazole)
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14
Q

What are some risks of using PPIs

A
  • Additional risks
  • >1 year age, aged over 50y
  • Increased spine fractures (47%), forearm/wrist (26%), some studies show increased hip fractures (VIT D may help)
  • Increased C.difficile infeciton (42%)
  • Decreased serum vitamin B12
  • Increased cardiovascular problems (if given PPIs afer 1st MI event)
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15
Q

How do antacids work? What are some common ingredients found in antacids and what is their use

A

Reduce acid load of stomach (crude)

NaHCO3-: cleared quickly (Na load, alkali load, belching C02)

CaCO3: rapidly neutralise HCL (abdominal distension),

with above –> milk-alkali syndrome

Al(OH)3: effective

  • osteoporosis –> if renal insufficient
  • insoluble complexes with drugs
  • constipation

Mg(OH)2:diarrhoea

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16
Q

What are some interactions of antacids

A

Tetracyclines and quinolones –> insoluble chelate forms

  • dose 2 h apart (tetracyclines) and 6 h before or 2 h after quinolones

Phenytoin

  • dose 2h apart

Ketoconazole, itraconazole (capsule form)

  • dose antacid at least 2 h after ketoconazole or itraconazole capsules. Itraconazole absorption from oral liquid is unaffected

Tacrolimus

  • no antacids for 3 h either side of taking tacrolimus.

Reduce effect of H2 receptor antagonists and PPIs

17
Q

What are mucosal strengtheners? What are some examples

A

Adhere to mucosal craters (PUD)

> possible inhibition of H.pylori also

Sucralfate [Al(OH)3 + sulfated sucrose]

  • Polymerises in stomach

Bismuth chelate (citrate - subcitrate)

  • Excreted in breast milk (no lactation)
  • ADEC = B2. Blackens faeces and tongue
18
Q

What are PG analogues used for? give an example and some side effects

A

Protect the lining of the gastrointestinal tract from harmful stomach acid

Misoprostol

>PGE1 analogue

>Yet binds to receptor used by PGE2

>0.3 h plasma 1/2 L

Nausea, diarrhoea, abdominal cramps and flatuelence: SE

  • uterine contractions (avoid in pregnancy)
19
Q

What are some examples of H2 receptor antagonists? How do they work? Reversiblke or irreversible

A

Cimetidine > 90% BA (magicul, tagamet)

Famotidine 45% BA (pepcid)

Nizatidine >70% BA (nizac, tazac)

Rantidine 50% BA (zantac)

Reversible binding to H2 receptor

> competitive with histamine

> decrease cAMP levels in parietal cells

  • Rapid oral absorption
20
Q

What are the differences in the H2 receptor antagonists?

A

Order of plasma half life:

  • Famot (3-4h) > Ranit = Cimet (2h)> Nizat (1+h)

Duration of action: Famot (12h) > Ranit = Nizat (8h) > Cimet (6h)

  • Cim only one to have strong CYP450 inhibition
  • Both Cim and Fam can inhibit renal secretion of basic drugs
  • Cim - dose adjustment for renal impairment - CNS toxicity

All kidney excreted

21
Q

Adverse effects of H2 antagonists?

A

Generally well tolerated

  • Dizziness
  • fatigue, muscular pain
  • rash

Cimetidine:

  • Gynaecomastia - anti androgenic effect
  • possible - reduction in sperm count - reversible impotence in men. (long term, high doses only)
  • decreased platelet count
  • Confusion in elderly
22
Q

For GORD;

A) Who is the patient?

B) What are the symptoms?

C) How frequent are the symptoms

D) Action taken

E) Medications

F) Allergies

A

A)

  • Functional dyspepsia more likely in younger adult
  • Caution in patient >55 yo due to increased risk of pathological condition

B)

  • Location of pain

> pain associated with dyspepsia is located above the umbilicus

> pain behind the breastbone is associated with GORD

  • ​Nature of pain

> often describes as aching or discomfort

> unlikely to e sharp or stabbing pain

  • Time of onset of pain

> Pain shortly after eating suggest dyspepsia associated with ulceration

  • Triggers to onset of symptoms

> fatty spicy food

C)

  • Daily?
  • Recurrent?

D)

  • Any interventions in reducing pain or discomfort?

E)

Any medication that could potentially cause GORD?

> Medicines that relax LOS e.g. anticholinergics, nitrates, calcium channel blockers, phosphodiestrase-5 inhibitors, oral corticosteroids

> Medicines that may worsen oesophagitis e.g. aspirin, NSAIDs, bisphosphonates, tetracyclines, and iron salts

>Medicines that can cause GI ulceration: long term NSAIDs, low dose aspirin

F)

  • Any previous allergic reaction to medication?
23
Q

For mild intermittent GORD;

A) what does it mean to have this type of GORD

B) what to do and what medications to use

C) when to refer

A

A)
No more than one episode per week

B)

  • Diet, lifestyle modification
  • Antacid plus alginate
  • H2 receptor antagonist for 2 weeks or PPI half to an hour before food for 2 weeks

C)

  • Symptoms > (or equal) 2 times per week
  • Symptom recurs after 14 days treatment
  • taking long term NSAIDs
24
Q

For frequent and severe GORD;

A) what does it mean to have this type of GORD?

B) What to do/ what medication to use?

A

A)

Two or more doses per week

B)

  • PPI at standard dose once daily half an hour before food for 4 to 8 weeks
  • Maintenance therapy (having daily dose of PPI or dosing on alternate days, then switching to therapy only on days when symptoms occur)
  • PPI should not be used long term for the management of GORD –> reconsider the need to continue therapy regularly
25
Q

What to do for GORD if it is induced by medications

A
26
Q

Self care for GORD

A
  • Avoid food and drink that worsen GORD (fatty, spicy food, coffee, alcohol, citrus fruit)
  • Eat smaller meal and eat slowly
  • Allows swallow medication with a glass of water
  • Dont go to bed for 2 hours after eating
  • Dont exercise for 2 hours after eating
  • Avoid tight fitting clothing around the waist
  • Maintain a healthy weight
  • Bed elevation or use a wedge pillow
  • Quit smoking
  • Use relaxation techniques to manage stress

IPT 1 Lectures (24 decks)

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