Exam 5 Flashcards
Pathophysiology of GERD
Reduced lower esophageal sphincter pressure Direct esophageal irritation Hiatal Hernia Achalasia (lack of motility) Mucosal Resistance Delayed gastric emptying
Conditions that may worsen or cause GERD
Smoking- lowers LES pressure and has acid neutralizing effects of saliva, increases acid production
Obesity (BMI >30)
Physical activity (LES relaxation)
Alcohol- direct irritant
Zollinger- Ellison Syndrome
Very rare, most commonly seen in men aged 50-60
Gastrinomas in pancreas or duodenum secrete large amounts of gastrin , often resulting in peptic ulcers and symptoms of GERD.
Tx- surgery, chemotherapy, high-dose PPI therapy
Suspect if patient has recurrent or refractory PUD or GERD
Associated with frequent diarrhea and duodenal ulcers
GERD complications
Esophagitis (Erosive esophagitis with ulcers occurs when GERD goes untreated)
Barrett’s esophagitis- increases risk of esophageal cancer
Strictures
Anemia
Cancer
Can worsen asthma/precipitate an attack- need to check if patients with frequent asthma exacerbations have GERD (50% do)
Can cause laryngitis
Atypical chest pain
Barrett’s Esophagus
Columnar epithelium replaces squamous epithelial lining during reparative process
This increases the risk of stricture by 30-80%
Increases the risk of cancer by 30-60x
Need endoscopic surveillance
Evaluation of GERD
Take pt history and empiric treatment
- Typically aggravated by meals
- Typically aggravated by recumbent position
- If responds to PPI, the patient likely has GERD
Chest pain needs further evaluation
Typical presentation of GERD
Heartburn
Acid regurgitation
Belching
Bloating
Atypical presentation of GERD
Chest pain Laryngitis/hoarseness Asthma Insomnia Chronic cough Aspiration pneumonia Tooth decay
Alarm S/S of GERD
Needs to be evaluated: Severe dysphagia Odynophagia Weight loss Persistent vomiting Bleeding Hematemesis Anemia
Alternate diagnosis in GERD; Pt presents with chest pain, what could it be?
CAD Gallstones Gastric/esophageal cancer Peptic ulcer disease Esophageal motility disorders Pill induced esophagitis Eosinophilic esophagitis
Diagnostic testing in GERD
Not necessary if PPI resolves symptoms, but symptoms do not always predict the erosive nature of the disease
Consider testing if symptoms persist on PPI or “alarm” symptoms (Endoscopy (EGD))
Endoscopy (EDG)
Necessary to determine: Erosions Rings (Schatzki rings)- mucosal disorder causing esophageal narrowing, common symptom dysphagia Stricutres Barrett's Cancer- need additional biopsy
Treatment goals for GERD
Alleviate or eliminate symptoms
Heal esophagitis
Manage or prevent complications
Maintain remission
Nonpharm treatment of GERD
Elevate head of the bed
Weight loss
Avoid foods that may decrease lower esophageal sphincter pressure (fats, chocolate, alcohol, peppermint, spearmint)
Avoid foods that are direct irritants (spicy foods, OJ, tomato juice, coffee)
Eat small meals and avoid eating prior to sleep
Smoking cessation
Treatment of mild/intermittent heartburn
Lifestyle changes
Antacids
OTC H2RAs
OTC PPIs
Treatment of GERD
Lifestyle changes
Rx-strength H2RAs
Rx PPIs
Treatment of erosive or moderate/severe symptoms
Lifestyle changes
Rx PPIs
High Dose PPIs
Antacids
Only appropriate for intermittent or mild heartburn
Self treat for 2 weeks then see MD
Avoid aluminum and magnesium in CKD patients
Aluminum- constipation
Magnesium- Diarrhea
Tums (calcium carbonate)
DDIs- iron, antibiotics (quinolones, tcn), azoles, separate chelators by 2 hours
Histamine-2 Receptor Antagonists (H2RAs)
Nizatidine, famotidine, ranitidine, cimetidine Famotidine most common Cimetidine many DDI Ranitidine pulled off market May reduce absorption of iron and azoles
Famotidine dosing
Mild- 10-20mg/day
Moderate/Severe- 40-80mg/day BID
Renal dosing if CrCl <50mL/min (give 50% of dose)
AE of H2RAs
HA, dizziness, diarrhea, constipation, fatigue
Increased confusion in elderly (dont use it patients over 75)
Proton Pump Inhibitors
Superior to H2RAs and should be used for erosive diseases
- Reasonable to try first for typical symptoms
All PPIs are equally effective at equal doses and more effective in erosive and nonerosive diseases
OTC PPIs
Omeprazole
Lansoprazole
Esomeprazole
Omeprazole-sodium bicarb
Dont use for more than 14 days
Omeprazole
20mg QD for all indications