GERD & PUD Flashcards
is reflux of gastric contents into the esophagus normal?
yes!
how is GERD defined as? do there need to be lesions in order to dx GERD? how do the majority of pts w/GERD present on endoscopy?
reflux leading to sxs, eso muscoal injury or both
there do not need to be lesions in order to dx GERD
majority of pts w/GERD show no abn on upper endoscopy
what 4 tests can you use to dx GERD?
EGD
esophageal manometry
24 hr pH testing
gastric emptying study
typical sxs of GERD?
heartburn
regurgitation
define functional heartburn
sxs of heartburn are present w/o evidence of reflux
9 GERD extraesophageal sxs
hoarseness cough asthma pharyngitis sinusitis pulmonary fibrosis tonsillar fibrosis recurrent otitis media sleep apnea
when can one experience transient lower esophageal sphincter relaxations and what can it lead to?
increase in intra-abdominal pressure can overpower a hypotensive LES and lead to reflux during TLESRs
it is more common to occur for reflux to occur in TLESRs which is triggered by gastric distension and serve to enable gas to vent from the stomach
how long do TLESRs last for?
for about 20 secs
last significantly longer than the typical primary peristaltic wave
what 7 situations can lead to reflux sxs?
visceral hypersensitivity delayed gastric emptying hiatal hernia decreased defenses impaired esophageal clearance bacterial overgrowth reduced LES pressure
what are the 3 types of heartburn/reflux?
acid reflux
“neutral” reflux
functional heartburn
how can PPIs lead to both GERD and DGER?
PPIs lead to weakly acidic reflux which leads to dilated intercellular spaces and persistent heartburn sxs
what 3 physical settings can lead to GERD, erosive esophagitis or NERD?
sustained esophageal contractions
esophageal visceral hypersenstivity
abnormal tissue resistance
what can GERD sxs be exacerbated by?
CRAP C: coffee, cigarettes, chocolate R: refined carbs, carbs in general, rxs A: acid foods, alcohol, allergic foods P: pop, peppermint, packing food in at bedtime, progesterone
what kind of drugs can lead to GERD?
antibiotics (tetracycline)
bisphospohates (alendronate, ibandronate, risedronate)
iron supplements
quinidine
pain relievers (ibuprofen, aspirin)
potassium supplements
anticholinergics
tricyclic antidepressants
calcium channel blockers and nitrates used for high blood pressure and heart dz
narcotics (codeine, those containing hydrocodone and acetaminophen)
progesterone
quinidine
sedatives or tranquilizers (benzodiazepines, diazepam, temazepam)
theophylline
what %age of adults with NERD do not have relief of sxs with anti-reflux medications?
over 40% do not respond to standard medical anti-reflux tx
what is significantly increased following the use of acid suppression therapies? what other dz can this dz play a potential role in developing?
non-acid reflux
widespread use of acid suppression and the development of non-acid reflux can potentially play a role for developing idiopathic pulmonary fibrosis
what are some great supplements to help relieve heartburn?
aloe vera leaf inner fillet extract glutamine glycine N-acetyl glucosamine gamma oryzanol deglycyrrhized licorice root d-limonene zinc carnosine
what is David Lamson’s protocol for heartburn? (2 fold)
- decrease irritative products of fermentation by taking pancreatic enzymes with meals and betaine HCl if indicated
- improve tone of sphincters, mucosal health and GI motility with phosphatidylcholine (420 mg BID) and if that doesn’t work add Huperzine 50 mg BID
what 4 dietary factors could you prescribe to improve gastric emptying? (16 overall)
adequate hydration eat smaller meals more often reduce intake of insoluble dietary fiber reduce foods high in fat avoid red meat reduce protein content of dinner reduce quantity of food at dinner reduce alcohol consumption improve glucose regulation avoid broccoli and cabbage gluten-free diet low carb diet aloe juice papain (super papaya enzyme plus) organotherapy (nervium vagum) improve or replace HCl and pepsin output
what are 3 ‘exercises’ one could do to tx gastroparesis?
- contract and relax the abdominal muscles w/regular rhythm immediately after meals (work up to 100 reps/meal)
- flex and extend the abdomen (sitting or standing) 20 x’s pc
- chew gum for 1st hr after meals to increase production of saliva, stimulate SM contraction and relax the pylorus
7 homeopathics that could be helpful with GERD?
phosphorous sulphur robinia arsenicum capsicum carbo veg nux vom
if you have a pt w/pyrosis and suspect serious pathology what are your next steps?
EGD and a barium study
if you have a pt w/pyrosis and want to evaluate pancreatic fxn what do you do? what if their levels are low?
stool chymotrypsin
if low dx w/pancreatic insufficiency
if you have a pt w/pyrosis what 3 possible dz causing process do you want to r/o? how would you determine each?
SIBO (breath test, serum TTG, AGA, DGP) hiatal hernia (imaging, reflex and muscle test) food sensitivities, gluten or lactose intolerance (elimination diet, IgE/IgG, EAV/Caroll)
if you have a pt w/pyrosis and want to evaluate gastric pH what are 3 ways you can do that and what are 3 possible results? what might you also evaluate at this time? how would you do this?
can do Heidelberg, string test or trial
could have hypo/achlorhydria, euchlorhydria or hyperchlorhydria
at this time you would want to evaluate GI flora including H. pylori (H. pylori breath test, stool ag testing, salivary ab testing SIBO breath test)
13 H. pylori associated dzs?
peptic ulcer atrophic gastritis gastric adenocarcinoma gastric lymphoma (Maltoma) metabolic syndrome CAD atherosclerotic stroke pancreatic adenocarcinoma iron deficiency anemia immune thrombocytopenic purpura chronic urticaria other skin dzs like rosacea hyperemesis gravidarum
7 dzs inversely associated w/H. pylori?
GERD & BE esophageal adenocarinoma asthma, eczema, rhintis fatal cardiovascular events laryngeal carcinoma Crohn's dz Obesity (?)
depending where H. pylori is growing in the stomach, what are 3 ways H. pylori overgrowth can affect stomach acid concentrations?
antral infxn: hyperchlorhydria
asx carrier: euchlorhydria
pangastritis: atrophy and hypo/achlorhydria
if a pt presents w/PUD what are you specifically going to test for? if they are (-) for that, then what should you suspect as a possible cause?
test for H. pylori
if (-) for H. pylori then ask about medication use, esp NSAIDs
what are 3 tx options besides GERD tx options, which you could use to tx PUD?
robert’s formula- 2 caps ac and hs
cabbage juice (work up to 1-2 pints/d for up to 6 weeks
counseling, stress management, etc.
what is Dr. Thad Jacob’s protocol for treating H. pylori PUD?
mastica 1000 mg tid garlic extract 300 mg tid lactoferrin 100 mg tid probiotics 5 Billion tid NAC 500-600 mg BID give all for at least 30 d
if a pt has drug resistant H. pylori PUD what can you consider adding? what is the mechanism of this added supplement?
add NAC 500-600 mg bid
helps break down biofilm essential to maintenance of H.pylori drug resistance
H. pylori triple therapy plus
OCAL for 7 days: omeprazole 20 mg bid clarithromycin 500 mg bid amoxicillin 1000 mg bid lactoferrin 900 mg hs probiotic NAC 500-600 mg bid starting one week prior to rx above OCML (if pt is allergic to penicillin) for 7 days: omeprazole 20 mg bid clarithromycin 500 mg bid metronidazole or tinidazole 500 mg bid lactoferrin 900 mg hs probiotic NAC 500-600 mg bid starting one week prior to rx
what is in the 1 d protocol?
omeprazole 40 mg
bismuth subcitrate 240 mg x 4
amoxicillin suspension 2000 mg x 4
metronidazole 500 mg x 4
what %age of pts who experienced H. pylori eradication became re-infected and had a PUD dx again and w/in what time frame?
7.6% were re-infected and became dx w/PUD
what are 11 natural alternatives for H. pylori eradication?
mastic gum water garlic glycyrrhiza lactoferrin wasabi cabbage trachypsermum copticum, xanthium basilicum, pumbago zeylanica probiotics propilis and ginger lycopene
