GI - Heartburn and Indigestion Flashcards
Symptoms:
Heartburn is usually ascribed to burning discomfort and pain that can be felt in the stomach all the way up (behind the breastbone) to the oesophagus.
Indigestion (also known as dyspepsia) refers more to pain from the chest to upper
abdomen and lower abdominal symptoms. Sometimes heartburn can also be associated with an acid taste in the mouth. Heartburn and indigestion is most
commonly experienced by patients over 55 years of age and in pregnant women.
Cautions and when to refer:
• Children
• When pain radiates to the back and arms check for any underlying conditions
(e.g. symptoms can mimic a heart attack)
• Difficulty swallowing (dysphagia) may indicate obstruction of the oesophagus
• Regurgitation (can indicate oesophagitis and a peptic stricture)
• Certain drugs can cause the symptoms of heartburn including tricyclic
antidepressants, calcium channel blockers, NSAIDs and caffeine
• Persistent pain that originates from one point in the abdomen (may indicate a
duodenal or gastric ulcer)
• New or recently changed symptoms in a patient over 55 years of age
• Patients over 55 years taking any ‘over-the-counter’ indigestion or heartburn
remedy on a daily basis should inform their pharmacist or doctor
• Previous gastric ulcer or gastrointestinal surgery
• Patient has been taking symptomatic treatment of indigestion or heartburn for
4 or more weeks
• Patient has jaundice or severe liver disease
Treatment:
• Antacids neutralise the excess acid produced by the body and can be taken
during or immediately prior to symptoms developing. Preparations that are
high in sodium should be avoided by anyone on a sodium-restricted diet (e.g.
those with heart failure or kidney or liver problems).
• Alginates form a raft that sits on the surface of the stomach contents and prevents reflux. Some alginate-based products contain bicarbonate which
causes the release of carbon dioxide in the stomach meaning that the raft can
float more easily on top of the stomach contents.
• A H2 antagonist (e.g. ranitidine, famotidine) can be tried but is recommended
for short-term use only when purchased OTC (maximum 14 days’ supply).
They are not as fast-acting as antacids but their effects can last up to 9 hours.
• Proton pump inhibitors (PPIs e.g. omeprazole, pantoprazole) work by inhibiting gastric acid secretion in the stomach by blocking the hydrogen
potassium adenosine triphosphatase enzyme system. They can be used for recurrent heartburn. They may take 1-3 days to provide full therapeutic effect
(during which antacids can be used). PPIs may inhibit cytochrome P450 and
so can interact with other medicines e.g. omeprazole can delay the elimination of warfarin, phenytoin and diazepam. Interactions can also occur due to the change in gastric pH causing differences in the absorption of drugs e.g. omeprazole reducing the absorption of itraconazole or ketoconazole and possibly increasing plasma concentration of digoxin.
Side-effects:
H2 antagonists
headache, dizziness, diarrhoea and skin rashes but this is uncommon.
The most common side-effects of PPIs
headache, abdominal pain, constipation, diarrhoea, flatulence and nausea/vomiting.
Commonly used OTC preparations:
Gaviscon, Peptac, Rennies, Tums, Zantac, Pantoloc Control, Nexium Control
Counselling points:
Heartburn and indigestion can be triggered or aggravated by bending, lying down or
even slumping in a chair. Therefore warn patients to avoid these positions as much
as possible and/or take medication beforehand (about 15-30 minutes before for
antacids or 1 hour before for H2 antagonists). Some patients may find raising the
head of the bed or using pillows to lift the upper body helps to prevent acid reflux
whilst sleeping but would need to be careful not to increase pressure at the waist
- Tight clothing (particularly waistbands and belts) can trigger symptoms.
- Excess weight increases the risk of symptoms therefore advise patients to try to lose
any excess weight and inform them what their ideal weight (according to Body Mass
Index) is. - For pregnant women (usually last trimester), elderly and hypertensive patients with
heartburn – a sodium-free or low sodium antacid preparation containing an alginate. - Small meals eaten frequently are better than large meals, as reducing the amount of
food in the stomach reduces gastric distension, which helps to prevent reflux. High-
fat meals take longer to digest and therefore delay gastric emptying, which means longer acid exposure. The evening meal should be taken several hours before going
to bed. - Smoking, alcohol, caffeine and chocolate have a direct relaxing effect on the
oesophageal sphincter, therefore increasing risk of acid reflux..
In gastric ulcers the pain comes on
whenever the stomach is
empty, usually 30 minutes after eating and is generally
relieved by antacids or food, and aggravated by alcohol
and caffeine.
Duodenal ulcers
Tend to be more consistent in symptom presentation. Pain occurs 2 to 3 hours after eating, and pain that awakens a person at night is highly suggestive of duodenal ulcer.
Medicines that commonly cause dyspepsia/
abdominal discomfort
Acarbose (1%–10%) Antibiotics, e.g., macrolides and tetracyclines Anticoagulants Angiotensin-converting enzyme (ACE) inhibitors Alcohol (in excess) Bisphosphonates Calcium antagonists Iron Metformin Metronidazole Nitrates Oestrogens Orlistat (>10%) Potassium supplements SSRIs Sildenafil (1% to 10%) Steroids Theophylline
ALARM signs and symptoms
- Anaemia (signs include tiredness, pale complexion, shortness of breath) - Loss of weight - Anorexia - Recent onset of progressive symptoms - Melaena (dark stools), dysphagia (difficulty swallowing) and haematemesis (blood in vomit)
Commonly implicated foods that precipitate dyspepsia are
spicy or fatty foods, caffeine,
chocolate and alcohol.
Antacids can affect the absorption of a number of medications via chelation and adsorption. Commonly affected
medicines include
tetracyclines, quinolones, imidazoles,
phenytoin, penicillamine and bisphosphonates. In addi-
tion, the absorption of enteric-coated preparations can be
affected due to antacids increasing the stomach pH.
The majority of these interactions are easily overcome by leaving a minimum gap of 1 hour between the respective doses of each medicine.
Calcium and aluminium can cause
constipation
magnesium antacids cause
diarrhoea
