GERD Flashcards
GERD Defined
Symptoms of complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity or lungs
Lower Esophageal Sphincter
Only thing that keeps the acid in the stomach
Intra-abdominal pressure can close the pathway
GERD Pathophysiology
Caustic Agents of GERD (Acid or Pepsin)
Loss of lower esophageal pressure (most common cause)
Increased gastric pressure (obesity, pregnancy, etc)
Nocturnal Reflux Symptoms
Reduced salivation Potential absence of arousal Potential absence of arousal response to heartburn Ineffective peristalsis Absence of gravitational forces
Classic Symptoms Heartburns
Exacerbated in supin eo r bending position
Burning sensation right on the sternum
Most common postprandially
>2X week to qualify for GERD
**Alarm Symptoms of GERD
Weight loss Choking Odynophagia (painful swallowing) Chest pain Bleeding Dysphagia (difficulty swallowing)
Disease Profile of GERD
80% of the time it is just symptoms but 20% of the time the patient will have erosive esophagitis
Complications of GERD
Bleeding Perforation Ulcer Stricture Barrett's Esophagus Adenocarcinoma
Primary Therapeutic Objectives
Relieve symptoms
Heal esophageal mucosa
Prevent complications
Secondary Therapeutic Objectives
Decrease reflux episodes Neutralize reflux Protect mucosa Restore LES tone Increase esophageal clearance
Lifestyle Modifications
Weight loss BMI greater than 25
Elevate head of bed
Avoidance of late evening meals
“No kisses (chocolate) before bed”
Things that decreased LES pressure:
Fatty meal, chocolate, coffee/cola/tea
Medications (anticholinergics, bisphosphonates, TCA)
Things that are direct irritants to the esophageal mucosa:
Spicy foods, orange/tomato juice
Aspirin
NSAIDs
Iron
Pharmacologic Agents
-Antacids/Alginic Acids (Gaviscon)
-OTC H2RAs (don’t use in Grade C or D)
Both treat mild GERD
-Prokinetic agents
***Who should NOT be treated with OTC therapy?
Heartburn occurring more frequently than 1-2 X per month
Alarm symptoms
Requiring continuous OTC therapy more than 2 weeks
Metoclopramide Use and Effectiveness
Similar to H2RA
Healing is dependent on severity of GERD
No more effective than H2RAs and less effective than PPIs
More toxic
SHOULD NOT BE USED MONOTHERAPY OR ADJUNCTIVE THERAPY
Other Prokinetic Agents (not metoclopramide)
Erythromycin (usually fails)
Bethanechol (too many ADEs)
Prescription H2RAs Use in GERD?
NOT severe
Relieve symptoms in 80% and heal mucosa in 60-75% of mild GERD
- Develop tolerance to acid suppression over time
H2RAs + Severe GERD
Use with PPI to the point at which the PPI starts working (2-3 days)
PPIs + GERD
Moderate to Severe symptomatic GERD
PPIs are more effective than H2RAs and they are all equivalent to each other
PPI Dosings
Omeprazole 20 mg QD Lansoprazole 30 mg QD Rabeprazole 20 mg QD Pantoprazole 40 mg QD Esomeprazole 20 mg QD Duration: 4-8 weeks
At what point should all grades be healed?
8 weeks
Maintenance Therapy in GERD
70-90% relapse within the first 12 months
- Don’t need a supper high dose for maintenance therapy
Who will need long-term medical therapy for GERD?
Grade C or D and not complicated by GI disturbances related to NSAIDs
Initial presence of GERD requiring strong acid suppression for healing
Occurrence of residual symptoms after healing
Prolonged intitial therapy to relieve symptoms or heal GERD
Long duration of symptoms before intitial therapy
