GERD & PUD Flashcards
normal physiology of the EG and LES for the function of GERD and PUD
what happens when GERD occurs
EG: esophagogastric junction
- esopohagus to stomach: the EG junction is maintained by the LES: lower esophageal sphincter
- when the sphincter is contracted: prevents the backflow of gastric substances into the esophagus
LES: a muscular ring innervated by the vagus nerve that contracts and relaxes
- normally exists in a contracted and closed off state to avoid backflow
In GERD…
- there is an excessive backflow of gastric reflux ino the esophagus
- this leads to a breakdown in the mechanisms of defense within the esophagus (the acid of the stomach is too potent)
- this irriates the esophagus and leads to GERD symtpoms
other causes of GERD
- foods
- meds
- conditions
Conditions
- hiatal hernias: causes LES displacement by protruding through the diaphragm; gastric contents gets stuck & causes symptoms
- esophageal clearance: the time that the acid is mixed with the mucosa
- mucosal resistnace: breakdown of the barrier
- composition of refluxate: the pH of the acidic reflux
- gastric emptying: improper emptying leads to build up and backflow
Food
- mint
- chocolate
- fatty foods
- coffee
- carbonated beverages
- teat
- chili peppers
- garlic
- onions
Meds
- anticholenergics
- barbituates
- caffeine
- CCB
- estrogen
- alcohol
- narcotics
- nicotine
- progesterone
- theophyilline
Direct Irritants
- bisphosphanates: for osteoperosis
- chemo
- iron supps.
- NSAIDS
- KCl
- spicy foods
- organge juice nad tomato jucie
- coffee
Obestiy
Pregnancy
Stress
Tight Clothing
all have the abiity to worsen gerd symptoms
complications of GERD
why do we treat
- we treat to aleviate pt. symptoms and QOL improvement
- significant morbidity if left untreated (risk of barretts)
Complications
- Barretts
- aspiration
- perforation
- hemorrhage
- strictures
- adenocarcinoma
Non-Pharm Management of GERD
Dietary Changes
- decrease fat consuption
- increa protein
- avoid spice & citrus
- alcohol avoidance
- eat in smaller, frequent meals
- avoid eating within 3 hours of sleeping
Lifestyle Changes
- elevated HOB 6-8 inches when sleeping
- weight loss
- stop smoking
- avoid tight fitting clothing
- wait 2-3 hours to lay down after eating
what are the four classes of GERD meds
- antiacids
- Histamine 2 receptor antagonists
- PPIs
- prokinetic agents
what is the physiology of gastic acid secretion
gastric acid (H+) is secreted by teh parietal cells through the proton pump (H+/K+/ATPase pump)
this pump creates a pH of the gastric lumen to be about pH= 3 (because its pumping so much H+ in
- transfers the H+ in the parietal cells in exhcnage for a K+
the parietal cells have 3 different receptors: which when activated will increase the ability of the proton pump in the parietal cell to release H+ (gastric acid)
1. acetylcholine (M3)
2. Gastrin (CCK-B)
3. histamine (H2)
Antacids
- MOA
- when are they used
- drug interactions
MOA: work as weak bases –> they do not act directly on the proton pump but instead reduce acidity within the stomach by neutralzing the gastric acid and pepsin
when they are used
- used as needed: PRN
- quick onset of action
- short-term use: not indicated for chronic use
Drug interactions
- chelation: can bind and prevent absorbtion of other drugs in the stomach as they are just weak bases!
Antacids
- drugs and their side effects
watch all these meds in those with renal failure due to the inabiiltiy to excrete electroyltes and thuse build ups may occurr
Mg(OH2) = milk of magnesia
- side effect = diarrhea, watch in renal failure
CaCO3 = tums, maalox
- side effect = constipation
AI(OH3) = alternaGEL
- side effect = constipation
NaHCO3 = alka-seltzer
- side effect = milk-alkal syndrome (high calcium leads to alkaline)
combination meds
- CaCO3/Mg(OH2)
- AI(OH3)/Mg(OH2)
Histamine Receptor antagonists (H2RAS)
- MOA
- drug interaction
- drug names
MOA: work to competitively, reversibly bind to inhibite the histamine frm binding to the H2 receptor therefore stopping gastric acid (or reducing) its secretion
Drug Interaction
- Cimetidine: interacts at CYP therefore is the last choice of the drug class
Drug Names
- cimetidine
- famotidine (MC used)
- Nizatidine
PPIs
-MOA
Drug Interactions
MOA: work to covalently bind to the H+/K+/ATPase (proton pump) of the parietal cells -> work in a dose-response measure to inhibit the gastric acid secretion
- PPIs are prodrugs meaning thye MUST be exposed to the acidic environment in order to work properly
- theyre more effective because they bind directly ot the proton pump on the parietal cell, not like the H2RAs which bind to histamine
Drug Interactions
- clopidogrel: said that PPIs can decrease their effectiveness but for those with GERD symptoms PPIs are still indicated for use because benefit > risk
- drugs which are pH dependent: they wont work as the PPI will decrease acidity in the stomach
PPI Drug Names
end in -azole
- omeprazole
- esomeprazole
- lansoprazole
- dexlansoprazole
- pantoprazole
- rabeprazole
compare the timing, onset of action between…
- antacid
- H2RA
- PPIs
antacids: QUICK ( < 5 mins) onset, last 20-30 mines
H2RAs: best for anticipation of symptoms onset 30-45mins, lasts 4-10 hours
PPI: takes 2-3 hours last 12-24 hours (best best symptomatic relief)
Monitoring and Pt. Education
- H2RAs
- PPIs (long term use risks?)
H2RAs
- generall well tolerated
- HA, fatigue, dizzy, diarrhea constipation
- renallly dose adjusted
PPIs
- generally well tolerated
- HA, nausea, dirrhead, constiation
- long tearm use: possible osteoperosis, c. diff, CAP, vit b12, hypomag. = why you assess their need to continue med long term or not
Pt. Education
H2RAs
- take with or without food
- symptoms better in a few hours
PPIs
- take ONCE a day 15-30 minutes before you first meal : the PPI can only bind to the pumps which are ACTIVELy secreting the gastric acid
- do not chew/crush
- can pout contents of the pill intp apple sauce for those who cannoy swallow pills
- can take days to see full effect
how to appraoch treatemnt of GERD
- symptoms are frequent (without alarm) = what treatment
- who will relapse after d/c or treatment
- how do you manage specifi symptoms
GERD symptoms frequently
- start an 8 week one before meals PPI trial
- if they have resolution of symptoms = stop the PPI
- if the symptoms return after stopping, restart
- if symptoms are not resolved after 8 weeks = upper EGD - see barretts or not
Maintenance Thearpy
- large amoutn of people will relapse after d/c the PPI
- H2RA: can be used if mild symptoms; watch rebound decreased efficacy (tachyphylaxis)
- PPIs: DRUG OF CHOICE for moderate to severe esopagitis, and barretts (administer at lowest possible dose)
questions to ask to ensure pt. is adhearing to PPI treatment
note on twice daily dosing
- verify adhearance
- verifty their taking it 30-60 mins prior to first meal of teh day
- twice daily dosing: can be helpful, limited data
- GERD not PPI refractory until there is a trial of the twice daily treatment
