GERD Flashcards
Gastro-oesophageal reflux disease (GORD) is usually a chronic condition where there is reflux of gastric contents (particularly ____________, ____________, and _____________) back into the oesophagus, causing symptoms of heartburn and acid regurgitation
acid
bile
pepsin
Common symptoms of GERD include… (2)
Less common symptoms include… (6)
- Heartburn
- Acid regurgitation
—————————— - Chest pain
- Hoarseness
- Cough
- Wheezing
- Asthma
- Dental erosions
GERD can be classified as _______________ or ________________ based on endoscopy findings
Erosive esophagitis
Non-erosive
Non-erosive GERD is characterized by:
the presence of symptoms but normal endoscopy
Erosive esophagitis is characterized by:
Symptoms of GERD accompanied by esophageal inflammation and mucosal erosion seen at endoscopy
What are the risk factors for GERD? (10)
- Consumption of trigger foods and fatty foods
- Pregnancy
- Hiatus hernia
- Family history of GERD
- Increased intra-gastric pressure from straining or coughing
- Stress
- Anxiety
- Obesity
- Drug side-effects
- Smoking and alcohol
What are the complications of GERD? (7)
- Esophagitis
- Ulceration
- Hemorrhage
- Stricture formation
- Anemia due to chronic blood loss
- Aspiration pneumonia
- Barrett’s esophagus
What lifestyle information should be given to patients with GERD to improve symptoms? (9)
- Healthy eating
- Weight loss if obese
- Avoiding trigger foods
- Eating smaller meals
- Eating the evening meal 3-4 hours before bed
- Raising the head of the bed
- Smoking cessation
- Reducing alcohol consumption
- Reduction of stress and anxiety
Which patients with symptoms of upper abdominal pain, reflux, or dyspepsia require urgent endoscopic investigation? (3)
Patients with…
- Dysphagia
- Significant acute GI bleeding
- Age over 55 years with unexplained weight loss
Endoscopy can be considered to diagnose _________________ if the patient has GORD. Patient preference and individual risk factors should be taken into account
Barrett’s oesophagus
Which drugs may exacerbate the symptoms of GERD? (11)
- Alpha blockers
- Beta blockers
- Anticholinergics
- Benzos
- Bisphosphonates
- Corticosteroids
- NSAIDs
- Nitrates
- Theophyllines
- TCAs
- CCBs
- The lowest effective dose should be used and if appropriate, stopped
Is long term continuous use of antacids advisable for patients with GERD?
No
Patients with uninvestigated symptoms which suggest GORD should be managed as ______________
uninvestigated Dyspepsia
In patients with an endoscopy confirmed diagnosis of GORD, a _______________, should be offered for 4 or 8 weeks
proton pump inhibitor (PPI)
In patients with an endoscopy confirmed diagnosis of GORD, a proton pump inhibitor (PPI), should be offered for ______________
4 or 8 weeks
In patients with endoscopy-confirmed GERD, if there is no response to a PPI, then offer a(n) ___________________
histamine2-receptor antagonist (H2-receptor antagonist
What is the pharmacological management of severe esophagitis?
PPI for 8 weeks, taking into consideration patient preference and factors such as underlying health conditions and possible interactions with other drugs
How should patients with refractory GERD by followed-up? (4)
- New alarm symptoms should be assessed and alternate diagnoses considered
- Prescribe a further course of PPI for 1 month OR
- Double initial dose for 1 month OR
- Add a H2-receptor antagonist at bedtime for nocturnal symptoms or for short term use
*patient’s adherence to initial management should also be checked and lifestyle advice reinforced
What is the management of patients with GERD in whom symptoms recur after initial treatment?
PPI should be give at the lowest dose that can achieve symptom control and self management on an “as-needed” basis should be discussed
How should patients with severe esophagitis be managed if initial management with PPIs fails? (2)
- Higher dose of the same PPI
- Switch to another PPI
Taking into account patient preference, tolerability, underlying health conditions, and possible drug interactions
For how long should patients with severe esophagitis remain on PPI therapy?
Long-term
For how long should patients who have had dilation of an esophageal stricture remain on PPI therapy?
Long-term
Heartburn and acid reflux are symptoms of ______________ in pregnancy commonly caused by GORD
Dyspepsia
Heartburn and acid reflux are symptoms of dyspepsia in pregnancy commonly caused by ____________
GERD
What is the first line management of GERD in pregnancy?
Dietary and lifestyle advice
If dietary and lifestyle modification fail to control symptoms of GERD in pregnancy, what should be offered?
An antacid or alginate
If antacids and/or alginates fail to control symptoms of GERD in pregnancy, what should be offered?
Omeprazole OR ranitidine (unlicensed)
What is the mechanism of action of PPIs?
Inhibit gastric acid secretion by blocking the H+/K+ pump (‘proton pump’) of the gastric parietal cells
PPIs are associated with a very low risk of ____________________
Subacute cutaneous lupus erythematosus (SCLE); can occur weeks, months, or even years after drug exposure
What is the management of patients treated with PPIs that develop skin lesions accompanied by arthralgia? (4)
- Advise to avoid exposing skin to sunlight
- Consider SCLE as a possible diagnosis
- Consider discontinuing PPI treatment unless it is imperative; a patient who develops SCLE with a particular PPI may be at risk of the same reaction with another
- Topical or systemic steroids may be necessary for the treatment of SCLE only if there are NO signs of remission after a few weeks or months of PPI withdrawal (though most cases resolve on their own)
PPIs may increase the risk of _______________ and ________________. Additionally, they may mask the symptoms of _______________
Osteoporosis and fractures, particularly in the elderly
GI infection including C.diff
Gastric cancer
Particular care is required when prescribing PPIs in those presenting with ‘alarm features’, in such cases ______________ should be ruled out before treatment
gastric malignancy
Patients who are taking PPIs and are at risk of ____________________ should maintain an adequate intake of calcium and vitamin D, and if necessary, receive other preventative therapy
osteoporosis
What are the common or very common side effects of PPIs? (6)
- Abdominal pain, constipation, diarrhea, nausea, vomiting
- Dizziness
- Dry mouth
- Headache
- Insomnia
- Skin reactions
In patients taking PPIs, development of skin reactions accompanied by _____________ should alert you to SCLE
Arthralgia
Are PPIs safe to use during pregnancy and breastfeeding?
Yes, not known to be harmful
Are PPIs safe to prescribe in patients with hepatic and/or renal impairment?
Prescribe no more than 20 mg daily in patients with hepatic impairment
What are the monitoring requirements for patients taking PPIs?
Measurement of serum-magnesium concentrations before and during prolonged treatment ESPECIALLY when used with other drugs that cause hypomagnesemia OR with digoxin
Measurement of serum- _______________ concentrations should be considered before and during prolonged treatment with a proton pump inhibitor, especially when used with other drugs that cause _______________ or with ______________.
magnesium
hypomagnesaemia
digoxin
PPIs can be dispersed in non-carbonated water or slightly acidic liquids but should NOT be taken with _____________ or ____________
Milk
Carbonated water
