GERD (Exam 2) Flashcards
Reflux esophagitis
Repeat exposure to refluxed material for long periods of time
Reflux esophagitis may progress into
erosion of squamous epithelium (erosive esophagitis)
Causes of GERD
Defective LES pressure
Mucosal defense mechanism problems
Hiatal hernia
Mucosal defense mechanism problems
Prolonged clearing time from esophagus
Delayed gastric emptying
Reduced mucosal resistance
Foods that decrease LES pressure
fatty meals
garlic, onions, chili peppers
carminatives
chocolate
coffee, cola, tea
Medications that decrease LES pressure
ethanol + nicotine
anticholinergics
barbiturates
nitrates
DHP CCB
progesterone
dopamine
tetracycline
estrogen
theophylline
Direct food irritants to esophageal mucosa
spicy foods
tomato + orange juice
coffee
Direct medication irritants to esophageal mucosa
alendronate
iron
aspirin
quinidine
NSAIDs
potassium chloride
Which comorbidities are not necessarily risk factors but can mimic GERD-like symptoms
Respiratory diseases
Chest pain
Severity of symptoms correlates with
duration of reflux
Typical symptoms of GERD
HEARTBURN
water brash
belching
regurgitation
Heartburn may be aggravated by
recumbent position
bending over
fatty meal
Atypical symptoms of GERD
Nonallergic asthma
chronic cough
hoarseness
pharyngitis
chest pain
dental erosions
Alarm symptoms of GERD
Continual pain
Choking
Dysphagia
Odynophagia
Complications of GERD
Barrett’s esophagus
Esophageal strictures
Esophageal adenocarcinoma
GERD Stage 1 (Mild) Symptoms
Heartburn + regurgitation occurring less than once a week
GERD Stage 1 (Mild) Treatment
Lifestyle modifications
OTC antacids PRN
GERD Stage 2 (Moderate) Symptoms
Heartburn + regurgitation occurring a few times a week
GERD Stage 2 (Moderate) Treatment
Lifestyle modifications
OTC H2RA or PPI
PPI preferred if > 2x week
GERD Stage 3 (Severe) Symptoms
Heartburn + regurgitation
difficulty swallowing
cough, change in voice
chest pain
GERD Stage 3 (Severe) Treatment
Lifestyle modifications
QD - BID prescription H2RA or PPI
PPI or PCAB > H2RA
GERD specialist
GERD Stage 4 (Complications) Symptoms
Heartburn + regurgitation
difficulty swallowing
cough, change in voice
chest pain
strictures, barrett’s esophagus, cancer
GERD Stage 4 (Complications) Treatment
Lifestyle modifications
QD prescription H2RA or PPI
PCAB > PPI in erosive
GERD specialist
Which stages of GERD have relapsing disease?
Severe/Complicated
Relapsing disease requires ______ therapy
long-term maintenance
Potassium-competitive acid blocker (PCAB)
Vanoprazan
PCAB MOA
reversibly bind to K+ ions and block H+/K+ ATPase –> inhibits acid secretion
Typical symptoms treatment
Initial empiric trial of acid-suppression therapy
Diagnosis of patient responds to therapy
Tests for GERD diagnosis
24 hr ambulatory pH monitoring
Endoscopy
Barium/Iodine contrast
PillCam ESO
24 hr ambulatory pH monitoring useful in ____ and ____ patients
typical symptoms not improving
atypical symptoms
Endoscopy
preferred for assessing mucosa, identifying barrett’s, and complications
Alarm symptoms
Barium/Iodine contrast radiography
Lacks sensitivity and specificity
PillCam ESO
Camera-containing barium contrast
No radiation exposure
GERD therapy is directed at
decreasing acidity + gastric volume
improving gastric emptying
increasing LES pressure
enhancing acid clearance
protecting mucosa
Esophageal clearance medications
Bethanechol
Cisapride
Esophageal mucosal resistance medications
Alginic acid
Sucralfate
Gastric emptying medications
Metoclopramide
Cisapride
LES pressure medications
Bethanechol
Metoclopramide
Cisapride
Gastric acid medications
Antacids
H2RAs
PPIs
PCAB
Lifestyle modifications with GERD
Elevate head of bed
Diet changes
Weight reduction
Smoking cessation
Avoid alcohol
Avoid tight-fitting clothes
Phase I Treatments
Lifestyle modifications
PLUS
OTC antacids
AND/OR
Low dose OTC PPIs or H2RAs
Phase II Treatments
Lifestyle modifications
PLUS
Standard dose H2RAs for 6-12 weeks
OR
PPIs for 4-8 weeks
OR
PCAB for 4 or 8 weeks
Phase III Treatments
Interventional Surgeries
Antacids
Maalox or Mylanta
Calcium carbonate
Gaviscon
H2RAs
Cimetidine
Famotidine
Nizatidine
PPIs
Omeprazole
Lansoprazole
Esomeprazole
Pantoprazole
Rabeprazole
Deslansoprazole
Antacid MOA
Protective barrier for esophagus against reflux by forming highly viscous solution
Mucosal Protectants
Sucralfate (Carafate)
Mucosal Protectants is limited to management of GERD in ______.
pregnancy
If no response to Phase I after ______, start phase II
two weeks
PCAB for nonerosive esophagitis
Vanoprazan for 4 weeks
PCAB for erosive esophagitis
Vanoprazan for 8 weeks
Efficacy of H2RA in Phase II GERD
symptomatic improvement in 60% of patients
endoscopic healing of 50%
Initial therapy for severe/complicated symptoms
PPIs»_space;» H2RAs
83% improvement and 78% healing
_____ is an alternative for treating sever or frequent reflux-like symptoms
PCAB vanoprazan
When is vanaprazan therapy preferred?
Erosive esophagitis
Promotility agents
Cisapride (Propulsid)
Bethenchol (Urecholine)
Metoclopramide (Reglan)
Cisapride (Propulsid)
increases LES pressure, esophageal clearance, and gastric emptying
Cisapride (Propulsid) side effects
life-threatening cardiac arrhythmias
Cisapride (Propulsid) is contraindicated in
mechanical obstruction
anticholinergic agents
(can get through limited access program)
Bethenchol (Urecholine)
increases LES pressure and esophageal clearance
selectively stimulates muscarinic receptors –> increases ACh
Bethenchol (Urecholine) is contraindicated in
mechanical obstruction
anticholinergic agents
Which promotility agent has an off label indication for GERD
Bethenchol (Urecholine)
Metoclopramide (Reglan)
dopamine antagonist
increases LES tone and accelerates gastric emptying
Metoclopramide (Reglan) side effects
tachycardia
EPS syndrome
Metoclopramide (Reglan) is contraindicated in
parkinson’s disease
mechanical obstruction
dopamine + anticholinergic agents
Maintenance therapy is with the ____ effective dose for _____ patients.
lowest
relapse
Preferred maintenance drugs
PPIs or PCAB»_space; H2RAs
Surgical intervention of GERD
reestablish anti reflux barrier to position LES within abdomen
