Heartburn and Dyspepsia Flashcards
Definitions - Symptoms
• Heartburn (“pyrosis”)
- Burning sensation of stomach or lower chest that rises up toward the neck and occasionally to the back
- Described as indigestion, acid regurgitation, sour stomach, or bitter belching
• Dyspepsia
- Symptoms originate from gastroduodenal region
- Bothersome postprandial fullness, early satiation, epigastric pain, and epigastric burning
• +/- anorexia, belching, NV, upper abdominal bloating
Disorders
• Gastroesophageal reflux disease (GERD)
- Sx: heartburn (common), dysphagia, odynophagia, globus sensation, hypersalivation, and regurgitation
• +/- esophageal damage resulting from reflux of acidic gastric contents into esophagus
- Peptic ulcer disease (PUD)
• Ulcers in the stomach/duodenum
• Dyspepsia can be a symptom
Dietary Risk Factors
- Alcohol
- Caffeinated beverages
- Carbonated beverages
- Chocolate
- Citrus fruits or juices
- Coffee
- Fatty foods
- Garlic or onions
- Mint (spearmint/peppermint)
- Spicy foods
- Sugars
- Tomatoes/tomato juice
Other Risk Factors
- Lifestyle • Emotions (anxiety, fear, worry) • Exercise (isometric, running) • Obesity • Smoking tobacco • Stress • Supine body position • Tight-fitting clothing
- Diseases
• Insulin resistance (pre-diabetes, diabetes, PCOS)
• Motility disorders (gastroparesis)
• PUD
• Scleroderma, Sjogren disease, Zollinger-Ellison syndrome - Pregnancy
- Genetics
Medications That May Cause Heartburn
Main • Aspirin/NSAIDs • Bisphosphonates • Iron • Potassium
Also • Alpha blockers • Benzodiazepines • Beta agonists • Calcium channel blockers • Opioid analgesics • Oral contraceptives • Doxycyline
Pathophysiology/Etiology of Dyspepsia
- PUD
- GERD
- Celiac disease
- Gastric or esophageal cancer
- Motility disorders
- Medications: NSAIDs, iron, antibiotics, opioids, digoxin, estrogens, theophylline
- Visceral hypersensitivity
Clinical Presentation: Heartburn
- Alone or as a symptom of GERD (2x/week is indicative) or PUD
- Within 1 hr of especially large meal or offending foods/beverages
- Lying down or bending over may exacerbate
- ≥2 times/week suggests GERD
- Regurgitation and water brash may also occur
- Generally classified as mild or moderate
- Mild - somewhat bothersome, doesn’t interfere with normal activities
- Moderate - bothersome sx that interfere with normal activities
Clinical Presentation: Dyspepsia
- Postprandial fullness
- Early satiation
- Epigastric pain
- Epigastric burning
- Less specific: • Bloating • Nausea • Belching • Vomiting
Alarm Symptoms
- Dysphagia
- Odynophagia
- Upper GI bleeding (hematemesis, melena, occult bleeding, anemia)
- Unexplained weight loss
Heartburn: Exclusions for Self-Treatment
- Frequent >3 months
- While on OTC H2RAs or PPIs
- Continuing after 2 weeks of OTC H2RA or PPI
- When taking RX H2RA or PPI
- Severe heartburn or dyspepsia
- Nocturnal heartburn
- Difficulty or pain swallowing solid foods
- Vomiting blood/black material or passing black tarry stools
- Chronic hoarseness, wheezing, coughing, or choking
- Unexplained weight loss
- Continuous N/V/D
- Chest pain + sweating, pain radiating to shoulder, arm, neck, or jaw, shortness of breath
- Children <2 y.o. [for antacids], <12 y.o. [for H2RAs], and <18 y.o. [for PPIs]
- Adults >45 y.o. with new-onset dyspepsia
Non-pharmacologic Therapy
- Diary to track dietary, lifestyle, and med triggers; then avoid those triggers
- Weight loss if overweight
- Elevate head of the bed 6-8 inches or use foam wedge (GERD pillow)
- Avoid tobacco products
- Dietary interventions
- Eat smaller meals
- Refrain from eating within 2-3 hours of lying down and sleep on left side
- Limit/discontinue alcohol or caffeine
- Plant-based Mediterranean diet and alkaline water (pH ≥8)
Pharmacologic Therapy
- Antacids
- Histamine type 2 receptor antagonists (H2RAs)
- Proton pump inhibitors (PPIs)
- Bismuth subsalicylate
Antacids: MoA
- Neutralize gastric acid; act as buffering agents in GI tract (pH >5, stop pepsinogen -> pepsin, increase LES pressure)
- FOR: Temporary and rapid relief of mild, infrequent heartburn
- Contain one of the following salts (all interchangeable):
• Magnesium (hydroxide, carbonate, or trisilicate)
• Aluminum (hydroxide or phosphate)
• Calcium carbonate
• Sodium bicarbonate
Antacids: Avoid If…
• Avoid antacid-aspirin combination products due to risk of serious bleed, especially in following patients:
- ≥60 years old
- History of stomach ulcers or bleeding problems
- Using anticoagulants, systemic steroids, or NSAIDs
- Consume ≥3 alcoholic beverages daily
Antacids: AEs,
- Mg2+ → diarrhea (avoid if CrCl <30 mL/min d/t toxicity)
- Al → constipation, hypophosphatemia (avoid if CrCl <30 mL/min)
- Ca2+ → belching and flatulence, constipation
• NaHCO3 → belching and flatulence
- Avoid in renal failure, HF, cirrhosis, pregnancy, and sodium-restricted diets
• If taking calcium supplement
- Avoid Ca2+ and NaHCO3 antacids
- Avoid Ca2+ antacid in renal failure
