GERD Flashcards
GERD definition
heart burn
“symptoms or complications resulting from the reflux of gastric contents into the esophagus, oral cavity, or lung”
epidemiology of GERD
prevalence of 14-20% (1/5)
men = women (except during pregnancy)
obese = increased risk
pathophysiology of GERD
abnormal reflux of gastric contents
lower esophageal sphincter (LES) must be relaxed and there must be a pressure difference
defective LES pressure - spontaneous LES relaxations not associated with swallowing (vomiting, belching, retching), increased intraabdominal pressure, atonic LES
other factors: pregnancy (hormonal effects, LES tone, increased abdominal pressure, usually resolves after delivery), foods, medications
anatomic factors - hiatal hernia
delayed gastric emptying - increased gastric volume may increase intragastric pressure, emptying may be slowed by high fat meals, smoking, diabetic gastroparesis
esophageal clearance - how long acid stays in contact with mucosa, primary - swallowing, saliva production, secondary - disention, gravity
mucosal resistance - esophagus has limited protective mechanisms
reluxate composition - pH and volume
Drugs that can decrease LES pressure
AChs, barbiturates, caffeine, DHP CCBs, dopamine, estrogen, ethanol, nicotine, nitrates, progesterone, tetracycline, theophylline
drugs that are direct irritants to esophageal mucosa
alendronate, aspirin, NSAIDs, iron, quinidine, potassium chloride
typical clinical presentation
heartburn, acid brash (hypersalivation), regurgitation/belching - not concerning
chest pain - always concerning
may be aggravated by activities - recumbent position, bending over, high-fat meal
atypical clinical presentation
aka extraesophageal symptoms
have an association with GERD
should only be considered if a typical symptom is present as well
Sxs: chronic cough, hoarseness, non-allergic asthma, dental enamel erosion
ALARMing clinical presentation
may be indicative of GERD complications
requires further diagnostic evaluation
Sxs**:
dysphagia, odynophagia, bleeding, unexplained weight loss, continual pain
esopagitis
GERD complication
inflammation as a result of repeated insult and irritation
may cause erosions over time
Sxs: painful swallowing, difficulty swallowing, chest pain, food impaction
can be as a result of other mechanisms: eosinophilic, drug-induced, infections
stricture
GERD complication
narrowing of the esophagus
common in distal esophagus
usually 1-2 cm in length
can cause obstruction and difficulty swallowing
occurs in up to 23% of untreated GERD patients
Barrett’s esophagus
GERD complication
replacement of squamous epithelial lining of the esophagus by columnar-type epithelium
inc incidence of stricture
inc risk of developing esophageal cancer
adenocarcinoma
GERD complication
usually occurs in the distal esophagus
involves cells of the mucus-secreting glands
most commonly seen in white men
clinical history of GERD
most useful tool for diagnosis
avoids use of invasive procedures
typical mild symptoms: clinical history + response to treatment = diagnosis
PPI trial of 8 weeks is the best diagnostic tool
consider other tests in those who do not respond to therapy OR who have alarming symptoms
Diagnosis of GERD
endoscopy - visualization and biopsy of the mucosa, reserved for PPI refractory GERD, routine endoscopies are not recommended, useful for complications of GERD
capsular endoscopy - uses a small, swallowed capsule for imaging
“other” diagnostic methods
reserved for PPI refractory GERD
manometry - measures pressures and muscle contraction during swallowing, useful prior to antireflux surgery
ambulatory reflux monitoring - measures esophageal acid exposure via pH probe, useful prior to antireflux surgery
do not recommend: barium radiograph
GERD treatment desired outcomes
alleviate or eliminate symptoms, decreased the frequency and duration, promote healing of the injured mucosa, prevent the development of complications
targets of GERD therapy
decrease acidity of refluxate (increase pH), decrease gastric volume to be refluxed, improve gastric emptying, increase LES pressure/tone, enhance esophageal acid clearance, protect esophageal mucosa
nonpharmacologic treatment of GERD
Weight loss, Increase exercise, Elevate head of bed, Consume smaller meals and no food within 3 hours of sleeping, ***Avoid foods/medications that exacerbate GERD, Smoking cessation, Avoid alcohol, Take medications in an upright position w/plenty of liquid
lifesytle changes help to:
decrease symptoms, decrease doctor visits, decrease use of drugs
overview of antacids
short-term relief, Efficacy and safety not well studied, Chronic use not recommended, Require direct delivery to site of action (must be taken PO)
work by binding and neutralizing protons that will be released into the stomach
May be used concomitantly with other acid suppressing therapies, Increases LES pressure via neutralization of
gastric fluid, Used FIRST LINE for intermittent symptoms* (LESS THAN twice weekly*), NOT appropriate for healing established esophageal lesions
antacid agents
Aluminum, Calcium carbonate, Magnesium, Alginic acid, Combination
Doses range from PRN to hourly
Similar efficacy at equipotent doses