GERD Flashcards
What are the 2 classifications of GERD?
NERD
ERD
What is the presence of GERD symptoms without erosions on endoscopic exam?
NERD (non-erosive reflux disease)
What is the presence of GERD symptoms with erosions present
ERD (erosive reflux disease)
What is GERD?
chronic symptoms or mucosal damage due to abnormal reflux of gastric contents into the esophagus
What is the most frequently reported symptom of GERD?
heartburn
Which patient populations are most likely to get GERD?
- > 40 y/o
- ~50% of pregnant women
- infants
What are risk factors for GERD?
- genetics
- obesity
- alcohol use beyond moderation
- smoking
- excess caffeine
What are the key factors in development of GERD?
- decrease in lower esophagal sphincter pressure/ tone
- decreased clearance of gastric contents from esophagus
- decrease mucosal resistance
- decreased gastric emptying
- pH < 4 of gastric fluid
- anatomic features (hiatal hernia)
Why does a hiatal hernia increase GERD incidence?
large opening for gastric contents to move through
What are typical symptoms of GERD?
- heart burn >/= 2 times/ week on regular basis
- regurgitation
- belching
- hypersalivation
What are extraesophageal (atypical) symptoms?
- chronic cough
- asthma like symptoms
- laryngitis/ hoarseness
- recurrent sore throat
What are complicated symptoms that need refered on?
- Dysphagia (trouble swallowing)
- Odynophagia (painful swallowing)
- bleeding
- weight loss
What are aggravating factors?
- laying down (recumbency)
- increased intraabdominal pressure
- decreased gastric motility
- decreased LES tone
- foods and medications that decrease LES tone
- direct mucosal irritation
What medications decrease LES tone?
Anticholinergics
Benzos
Caffeine
Dihydropyridine CCBs
Estrogen
Alcohol
Nicotine
What medications are direct irritants to the esophagus?
Oral bisphosphonates
ASA
Iron
NSAIDs
Potassium
What are complications of GERD?
Erosions
Ulcerations
Strictures
Barrett’s esophagus
Adenocarcinoma
Why must those with Barrett’s esophagus be monitored every few years for adenocarcinoma?
40- fold increased risk of developing adenocarcinoma
How is GERD diagnosed?
presence of symptoms
What is an endoscopy required for?
identifying complications of GERD
What are the agents used to treat GERD?
- PPIs
- H2RA
- antacid/ alginic acid
Why are PPIs preferred for treatment?
significantly faster esophageal healing
When should PPIs be administered?
30-60 minutes before meals
What are things to look out for when using PPIs?
- C. difficile- associated diarrhea
- osteoporosis related fractures
- hypomagnesemia
Which 2 PPIs should not be administered with Clopidogrel due to CYP2C9 inhibition?
Omeprazole
Esomeprazole
What are adverse effects with PPIs?
Headache
N/D
Which H2RA is associated with gynocomastia?
Cimetidine
What are adverse effects with H2RAs?
Headache
Constipation
Diarrhea
What is the treatment of intermittents, mild heart burn?
Lifestyle modification + Antacid (Maalox, Mylanta)
+/- OTC H2RAs or OTC PPI
What is the treatment of GERD?
Lifestyle modification + PPI QD-BID x 8 weeks
+/- maintenance therapy if symptoms return
What is utilized for GERD maintenance therapy?
PPI @ lowest effective dose
H2RA (if no erosive esophagitis or Barret’s)
What is the treatment of erosive esophagitis/ severe sx/ complications?
Lifestyle modifications + Rx PPI QD-BID x 8 weeks
What are lifestyle modifications?
- weight loss
- elevate head 6-8 inches
- smaller, more frequent meals
- do not eat 3 hours prior to sleep
- avoid aggravating foods
- avoid alcohol/ tobacco
What is used for maintenance therapy for those with NERD/ uncomplicated GERD?
intermittent PPI or H2RA
What is used for maintenance therapy for complicated GERD?
long-term PPI maintenance treatment at lowest effective dose
What are risks with long term PPI therapy?
- increase fracture risk
- increase infection risk (C.diff URTi)
- hypomagnesemia
- vitamin B12 deficiency
What can be added to PPI therapy to decrease breakthrough symptoms overnight?
H2RA
How do you taper a PPI in a patient with rebound acid secretion?
Taper over 4-6 weeks:
1. lower dose
2. extend interval QOD–> q 3rd day
3. use H2RAs and antacids on “off days”
Switch to H2RA with prn antacids then D/C
