Dyspepsia nd GERD Flashcards
What is the definition of dyspepsia?
- Epigastric pain or discomfort originating from upper GI tract
What is dyspepsia?
- An umbrella term to describe many possible symptoms and causes
What is functional dyspepsia?
Where no abnormalities are found
What is GERD?
- Reflux of gastric contents into the esophagus
- Described as heartburn
What is peptic ulcer disease?
- An ulcer formed in the gastric or duodenal mucosa
- May have symptoms similar to dyspepsia / GERD
What is the diagnostic flow of dyspepsia?
What is generally the functional dyspepsia?
What is the causes of dyspepsia (Most common)
Normal finding, functional dyspepsia (70%)
What is the next cause of dyspepsia?
GERD
What are the risk factors for dysepepsia?
Risk factors for dyspepsia
* No strong association with sex, age, socioeconomic status
* Dietary indiscretion
* Medications
* H. pylori infection
* Anxiety
* Irritable bowel syndrome
Alcohol use
Smoking accreddited for making it worse
What is the drug induced dyspepsia drugs we should know?
Bisphosphonates
Iron
NSAIDs
Potassium
What are the symptoms of dyspepsia
How long does the symptoms of dyspepsia usually last?
> 1 month duration of symptoms
Often follows relapsing-remitting course
What are the main alarm symptoms we should be concerned with?
VBAD
Vomiting, bleeding, abdominal mass, dysphagia
What is generally the main diagnosis of GERD?
Reflux or regurgitation as main symptoms.
What other things do we follow as a systemic approach in patients with dyspepsia?
2) Upper GI location?
3) New onset symptoms (other than reflux/heartburn) >50 (++>60) or red flag
symptoms?
4) NSAID use?
5) Reflux or regurgitation as main symptom?
6) H.pylori present?
What is the dietary contributors to GERD?
Over-eating
What is the classification of mild GERD?
What is the presentation of moderate to severe gerd?
What are the further classification of GERD?
Non-erosive reflux disease
Erosive esophagitis
What are potential complications of GERD?
- Esophagitis
- Esophageal stricture
- Esophageal erosions
- Barrett’s esophagus
- Esophageal cancer
What are the Red flags for physician referral?
- VBAD symptoms
- Choking
- Constant pain
How is GERD typically diagnosed?
made based on symptoms after ruling out other causes
Trial course of pharmacological therapy
Who are the candidates for upper endoscopy?
Upper endoscopy not typically required. Candidates:
* New onset symptoms (other than reflux/heartburn) >50 (>60) or red flag
symptoms?
* Any alarm features
* Refractory GERD
* At risk for Barrett’s esophagus
What are the risk factors of barrett’s esophagus?
At risk for Barrett’s esophagus
* Male, chronic (>5 years) or frequent (>1/week) GERD AND 2 or more of the following:
- > 50 years of age
- Caucasian
- Central obesity
- Current or past history of smoking
- Family history of Barrett’s esophagus
What are some of hte other diagnostic tests of GERD?
Barium swallow
Esophageal manometry
Ambulatory esophageal pH monitoring
What are the treatment goals of GERD?
- Relieve symptoms
- Promote healing of injured mucosa
- Prevent and treat complications
- Prevent recurrence
- Avoid issues with long-term use of pharmacotherapy
What are the three main non-pharmacological treatments we should consider?
- Lose and maintain ideal weight
- Stop smoking
- Elevate head of bed
What are the 4 main prn and on demand treatments of gerd available (Categories)
- Alginates
- Antacids
- Histamine 2 Receptor Antagonists (H2RAs)
- Proton-pump inhibitors (PPIs)
What are the alinates?
Gaviscon formulation
Better than placebo worse than other agents
What are the antacids we should know?
- Aluminum hydroxide
- Magnesium hydroxide
- Magnesium trisilicate
- Calcium carbonate
- Sodium bicarbonate
- Combination of above
What are CI with antacids?
- Avoid in severe renal impairment
- Unless dialysis – calcium carbonate for phosphate binding
What is the MOA of antacids?
- Neutralizes stomach acid
- Inhibits pepsin generation
- Binds to bile acids
What is the duration of action of Antacids?
- Rapid acting
- Short duration of action
What is the general dosing of Antacds?
What is the typical dose of elemental per tablet?
What are the common side effects of aluminium?
Constipation
What are the common side effects of magnesium?
Laxative effect
What are the common side effects of calcium?
Well tolerated
What are the serious side effects of Aluminum, Mg, Ca
- Aluminum – bone demineralization, neurotoxicity, hypophosphatemia
- Magnesium – hypermagnesemia
- Calcium – hypercalcemia, alkalosis
What are the DI of antacids?t to chelation
What are the DI of antacids to impaired absorption?
What is the efficacy of antacids?
- Limited evidence
- Slight reduction in symptom severity and frequency
- Better than placebo, inferior to other agents
- Possible role of add-on therapy in severe cases
What are the 4 H2RAs?
Cimetidine
* Famotidine
* Ranitidine
* Nizatidine
Which H2RA has the most side effect? Why?
Cimetidine, can cross BBB and cause sedation
What is the special indication for famotidine?
GERD maintenance of remission
What are the MOA of H2RAs?
CI of H2RAs?
None
What is the onset nad duration of H2RAs?
When should H2RAs be given?
30 – 60 min prior to meal
Common side effects of H2RAs?
- Extremely well tolerated
- Headache, vomiting, diarrhea, drowsiness
Common side effect of cimetidine?
- Exception: Cimetidine poorly tolerated
- Higher rates of above
- Gynecomastia
What are the DI of H2RAs?
- All: decrease absorption of drugs requiring acidity
Cimetidine weakly to moderately inhibits enzymes
What is an issue with H2RAs?
- Significant tachyphylaxis demonstrated
Are H2RAs better then PPI?
No
What are the 6 PPIs?
- Rabeprazole
- Omeprazole
- Esomeprazole
- Pantoprazole sodium and magnesium
- Lansoprazole
- Dexlansoprazole
What is the indication of PPIs?
- Treatment of GERD symptoms
- Symptomatic relief and healing of erosive esophagitis
- Symptomatic relief and healing of duodenal and gastric ulcers
- Prevention of NSAID-induced ulcers
- Use in H. Pylori eradication regimens
- Treatment of Zollinger-Ellison syndrome
Contraindications of PPIs?
No
What is Zollinger-Ellison-syndrome?
Hyper secretion of acid
What is the onset and duration of action of PPIs?
What is the MOA of PPIs?
What is the dosage administration of PPIs?
What is the duration of therapy with respect to GERD?
4-8 weeks at standard or double dose
What are the indications for double dose ppis?
- If standard dose not effective after adequate trial (~4-8 weeks)
- Initial presentation of erosive esophagitis
- Ulcers or GI bleed indications
- H. Pylori eradication
What are the common side effects of PPIs/
What are the serious side effects of PPIs?
Clostridium difficile infection
Microscopic colitis
Hypomagnesemia
Fracture
Fundic gland polyps
B12 Deficiency
Pneumonia
Gastric cancer (Long term usage)
Mortality increase (Concurrent medical conditions)
What are the serious side effects not as trusted?
Observation studies only indicating
- All concerns based off low quality evidence with significant confounding
- Understand there are potential risks
- Understand PPIs tend to be overused
- Periodically reassess dose and need for on-going therapy
- Do not withhold PPIs when benefit demonstrated
What is an important DDI with PPIs?
Decrease in clopidogrel
Which PPIs do not have enzyme effects?
Dexlansoprazole, pantoprazole, rabeprazole
What is the efficacy of PPIs comparred to H2RAs when comparing intital gerd vs maintenance?
What are the 2 prokinetic agents?
Domperidone and Metoclopramide
What is the MOA of prokinetic agents/
- Dopamine antagonists stimulate gastric motility
Contraindications of metoclopramide?
Contraindications - metoclopramide
* GI obstruction, perforation or hemorrhage
* Seizure disorder
* Extra-pyramidal symptoms
* Parkinsons
Contraindications of Domperidone?
- Contraindications – domperidone
- GI obstruction, perforation or hemorrhage
- Long QT interval
- Electrolyte disorders
- Use with potent 3A4 inhibitors
Common side effects of domperidone?
- Dry mouth
- Mild headache
What are the serious side effects of domperidone?
- QT prolongation
- Gynecomastia
What are the two approaches to treatment with GERD?
What is the summary of efficacy for GERD management?
What are the monitoring parameters for Safety with respect to antacids?
Gauge for overuse, renal function
What are the monitoring parameters for Safety with respect to H2RAs?
Tachyphylaxis
What are the monitoring parameters for Safety with respect to PPIs?
Hypomagnesemia
BMD if numerous other risk factors
Increase in C.Diff infections
What is considered refractory GERD (3)
What is the cause of Refractory GERD?
medicaiton timing and adherence
Differences in PPI metabolism (2C19, 3A4)
Weakly acidic or alkaline reflux
Reflux hypersensitivity
Alternative diagnoses
How might we deprescribe?
Who should be considered for chronic PPI usage? (4)
Barrett’s esophagus
Chronic NSAID users with bleeding risk
Severe esophagitis
Documented history of bleeding GI ulcer
When should GERD treatment in infants be considered?
Poor weight gain
Blood in sstool or vomitus
Intense irritability temporally related to food intake
What are t he warning signs in pediatrics for more serious pathology?
Forceful Vomiting
Abdominal tenderness or distension
Fever
Systemic signs
What are the safety concerns of acid suppression in pediatrics?
Acid rebound
Diarrhea
Pneumonia
What should be avoided to use in pregnancy?
Sodium bicarbonate and magnesium trisilicate
What is the preferred PPI in pregnancy?
Pantoprazole
What is drug induced esophagitis?
