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z - Gastrointestinal > Gastro-Oesophageal Reflux Disease > Flashcards

Gastro-Oesophageal Reflux Disease Flashcards

1
Q

What is GORD?

A

A long-term condition where the stomach contents come back up into the oesophagus, resulting in symptoms or complications

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2
Q

What is GORD caused by?

A

The failure of the lower oesophageal sphincter

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3
Q

What prevents reflux in healthy individuals?

A

The Angle of His, which is the angle at which the oesophagus enters the stomach, creates a valve that prevents duodenal bile, enzymes, and stomach acid from travelling back into the oesophagus

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4
Q

What does duodenal bile, enzymes, and stomach acid cause when they come into contact with the oesophagus?

A

Burning and inflammation

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5
Q

What are the risk factors for the development of GORD?

A
  • Lower oesophageal sphincter hypotension
  • Hiatus hernia
  • Oesophageal dysmotility
  • Obesity
  • Gastric acid hypersecretion
  • Delayed gastric emptying
  • Smoking
  • Alcohol
  • Pregnancy
  • Drugs, including tricyclics, anticholinergics, and nitrates
  • Helicobacter Pylori
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6
Q

What are the symptoms of GORD?

A
  • Heartburn
  • Belching
  • Acid brash
  • Waterbrash
  • Odynophagia
  • Noctural asthma
  • Chronic cough
  • Laryngitis
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7
Q

What is acid brash?

A

Acid or bile regurgitation

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8
Q

What is waterbrash?

A

Increased salivation

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9
Q

How may GORD be investigated?

A
  • Endoscopy
  • 24 hour oesophageal pH monitoring, with or without manometry
  • H. Pylori testing
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10
Q

When is endoscopy used to investigate GORD?

A

If dysphagia, or if over 55 years old with alarming symptoms

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11
Q

When is 24 hour oesophageal pH monitoring used to investigate GORD?

A

When endoscopy is normal

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12
Q

What are the management options in GORD?

A
  • Lifestyle
  • Drugs
  • Surgery
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13
Q

What is involved in the lifestyle management of GORD

A
  • Weight loss
  • Smoking cessation
  • Small, regular meals
  • Reduce certain foods and drinks
  • Avoid eating <3hours before bed
  • Raise bed head
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14
Q

What foods and drinks should be reduced in GORD?

A
  • Alcohol
  • Citrus fruits
  • Tomatoes
  • Onions
  • Fizzy drinks
  • Spicy foods
  • Things containing caffeine
  • Chocolate
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15
Q

What drugs are used in the management of GORD?

A
  • Antacids
  • PPIs
  • Histamine blockers
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16
Q

What are the types of antacids used in GORD?

A
  • Simple antacids
  • Compound antacids
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17
Q

Give an example of a simple antacid

A

Aluminium hydroxide

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18
Q

What course of PPI should patients with GORD be given initially?

A

Offer people with GORD a full-dose PPI for 4-8 weeks

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19
Q

What should be done if symptoms reoccur after initial treatment with PPI in GORD?

A

Offer PPI at lowest possible dose to control symptoms

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20
Q

When should a histamine blocker be added in the management of GORD?

A

For refractory symptoms

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21
Q

What drugs should be avoided in GORD?

A
  • Drugs affecting oesophageal motility
  • Drugs that damage mucosa
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22
Q

Give 3 examples of drugs that affect oesophageal motility

A
  • Nitrates
  • Anticholinergics
  • Calcium channel blockers
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23
Q

Give 3 examples of drugs that can damage the oesophageal mucosa

A
  • NSAIDs
  • Potassium salts
  • Bisphosphonates
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24
Q

What are antacids?

A

Weak bases that react with gastric acid to form water and a salt to diminish gastric acidity

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25
Q

What effects do antacids have on pepsin activity?

A

They reduce it

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26
Q

Why do antacids reduce pepsin activity?

A

Because pepsin is inactive at a pH greater than 4

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27
Q

What is aluminium hydroxide used for?

A
  • Symptomatic relief of GORD and peptic ulcer disease
  • May promote healing of duodenal ulcers
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28
Q

What are the adverse effects of aluminium hydroxide?

A
  • Tends to cause constipation
  • Can sometimes cause hyperphosphataemai
29
Q

What can happen to aluminium hydroxide in renal impairment?

A

Absorption of the cations from antacids, in this case Mg2+, can cause accumulation in renal impairment.

This is not normally a problem in patients with normal renal function

30
Q

When can the sodium content of antacids be an important consideration?

A

In patients with hypertension or congestive heart failure

31
Q

How do compound alginates work in GORD?

A

They form a raft floating on the surface of the stomach contents, and therefore reduce reflux and protect the oesophageal mucosa

32
Q

Where are compound alginates used?

A

In dyspepsia and GORD

33
Q

What are the side effects of compound alginates?

A
  • Stomach distention
  • Nausea
34
Q

What effect might taking compound alginates at the same time as other medications have?

A

May impair the medications absorption, or damage its enteric coating

35
Q

What secretes gastric acid?

A

The parietal cells of the gastric mucosa

36
Q

What stimulates gastric acid secretion from parietal cells?

A
  • Acetylcholine
  • Histamine
  • Gastrin
37
Q

How do acetylcholine, histamine, and gastrin stimulate the secretion of gastric acid?

A

They bind to receptors and stimulate the proton pump to secrete hydrogen ions in exchange for potassium ions in the lumen of the stomach

38
Q

What is ranitidine?

A

A copmetitive antagonist of histamine receptors

39
Q

What effect does ranitidine have?

A

it inhibits histamine receptors to partially inhibit gastric acid secretion

40
Q

What is ranitidine particularly effective against?

A

Noctural acid secretion

41
Q

How effective are histamine antagonists at inhibiting acid secretion?

A

They can inhibit greater than 90% of basal, food-stimulated, and noctural secretion of gastric acid after a single dose

42
Q

Is the action of histamine receptor antagonists fully reversible?

A

Yes

43
Q

Why has the use of histamine receptor antagonists decreased?

A

With the advent of PPIs

44
Q

What kind of drug is ranitidine?

A

A long-acting histamine receptor antagonist

45
Q

What are the side effects of ranitidine?

A

Minimal side effects, but if present may include;

  • Headache
  • Dizziness
  • Diarrhoea
  • Muscular pain
46
Q

What effect might histamine receptor antagonists have on drugs?

A

Drugs which depend on acidic medium for gastric absorption, such as ketoconazole, may not be efficiently absorbed if taken with a histamine receptor antagonist

47
Q

Give 3 examples of PPIs?

A
  • Omeprazole
  • Lansoprazole
  • Esomeprazole
48
Q

How do PPIs work?

A

They bind to the H/K/ATPase enzyme system (proton pump) of the parietal cell which acts to suppress the secretion of the hydrogen ions into the gastric lumen

49
Q

How effective are PPIs?

A

At standard doses, they inhibit basal and stimulated gastric acid secretion by more than 90%

50
Q

In what respects are PPIs superior over histamine receptors?

A

For suppressing acid production and healing peptic ulcers

51
Q

What are the indications for the use of PPIs?

A
  • Stress ulcer treatment and prophylaxis
  • Treating erosive oesophagitis and active duodenal ulcers
  • Long-term treatment of pathologic hypersecretory conditions
  • GORD
    Gastroprotection with use of drugs such as NSAIDs and aspirin
52
Q

Give an example of a pathologic hypersecretory condition

A

Zollinger-Ellison syndrome

53
Q

When should PPIs be taken for maximum effect?

A

30 to 60 minutes before breakfast or the largest meal of the day

54
Q

When should a histamine antagonist be taken if used alongside a PPI?

A

Well after the PPI

55
Q

Why should a histamine receptor be taken well after a PPI if both are needed?

A

Because histamine antagonists reduce the activity of the proton pump, and PPIs require active pumps to be effective

56
Q

Which PPIs are effective orally?

A

All

57
Q

How are PPI metabolites excreted?

A

In urine and faeces

58
Q

Are PPIs generally well tolerated?

A

Yes

59
Q

What are the adverse effects of PPI?

A
  • Nausea
  • Diarrhoea
  • Headache
  • Increased risk of bone fractures
60
Q

Why does omeprazole interact with some drugs?

A

Because of competitive inhibition of CYP450 enzymes

61
Q

What drugs may omeprazole effect?

A

It has been shown to inhibit the metabolism of warfarin, phenytoin, diazepam, and cyclosporin

62
Q

What effect have PPIs been shown to have on clopidogrel?

A

All PPIs have been shown to decrease the effectiveness of clopidogrel

63
Q

What are the options for the surgical management of GORD?

A
  • Laparoscopic Nissen fundoplication
  • Laparoscopic insertion of a magnetic bead band
  • Radiofrequency-induced hypertrophy
64
Q

What is the aim in the surgical management of GORD?

A

To increase resting lower oesophageal sphincter pressure

65
Q

When should surgery be considered in the management of GORD?

A

If severe GORD where drugs are not working

66
Q

What symptoms of GORD are less likely to improve with surgery?

A

Atypical symptoms, such as cough and laryngitis

67
Q

What are the complications of GORD?

A
  • Oesophagitis
  • Ulcers
  • Benign strictures
  • Iron-deficiency
  • Barrett’s oesophagus
68
Q

What is Barrett’s oesophagus?

A

Where the distal oesophageal epithelium undergoes metaplasia from squamous to columnar

69
Q

What % of people with Barrett’s oesophagus progress to oesophageal cancer?

A

0.1-0.4%/year

z - Gastrointestinal (6 decks)

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