L4: GERD Flashcards
2 CLASSIFICATIONS OF GERD
- SYMPTOM-BASED GERD
- TISSUE INJURY-BASED GERD
common symptoms of symptom based gerd
- heartburn
- regurgitation
- dysphagia
less common symptoms of herd
- odynophagia
- water brash
- belching
- bloating
- hypersalivation
unintentional spitting of
undigested food from the stomach into the mouth;
has a sour taste
regurgitation
composed of stomach acid +
saliva; cause of sour taste during regurgitatio
water brash
t or f: symptom nased gerd has esophagitis as a symptoms
f
tissue injury based gerd dapat
esophagitis in tissue injury based gerd may lead to complication if not managed such as:
- barretts esophagus
- strictures
- esophageal adenocarcinoma
lining of the
esophagus thickens and becomes red. It
makes it difficult to swallow, and makes
the patient more prone to GERD
barretts esophagus
narrowing of the esophagus.
Makes it more difficult for food to pass
from the esophagus to the stomach; also
makes it difficult to swallow.
strictures
type of
esophageal cancer wherein tumors may
form in the lining of the esophagus.
*Barret’s esophagus increases the risk of
developing this.
esophageal adenocarcinoma
Erosive esophagitis is higher in
men
High progesterone levels =
relaxation of
the lower esophageal sphincter (LES)
____ pressure relaxes the LES
further.
Intra-abdominal
obesity
- intraabdominal pressure
- les pressure
- inc
- dec
reflux that does not result
in injury or GERD
Non-pathologic reflux
Muscosal protective mechanisms:
- Esophageal acid clearance
- Mucosal resistance
- Salivary buffering of acid
normally
in tonic or contracted state to prevent backflow. It
only relaxes during swallowing to allow passage
of food.
Lower esophageal sphincter (LES)
defective LES; It
relaxes or opens even without swallowing
Transient LES relaxation
it becomes
weak and cannot contract
Decreased resting tone of LES
less neutralization of
acid
decreased salivation
weak
peristaltic movement, increasing contact time of
refluxate to the esophagus..
Impaired esophageal clearance
overtime, the
protective barrier of the esophageal barrier is
destroyed
Impaired tissue resistance
from smoking and
high fat meals
Delayed Gastric Emptying –
Delayed gastric emptying → stomach fills
up → ___ intraabdominal pressure
→____ of LES
increased
relaxation
transient les relaxation causes
vomiting
esophageal distention
belching
retching
TRANSIENT INCREASE INTRA-ABDOMINAL
PRESSURE causes:
o Straining
o Bending over
o Coughing
o Eating
o Valsalva maneuver
weak sphincter muscles
atonic
Increased gastric acid also increases
activation of…..
pepsinogen into pepsin
enzyme that can break down
proteins and may cause inflammation of
the esophagus
pepsin
Can cause duodenogastric reflux
esophagitis or alkaline esophagitis
Bile acids & Pancreatic enzymes
An area of unbuffered gastric acid that
accumulates in the upper part of the
stomach after eating a meal
acid pocket
Associated with postprandial reflux
syndrome
acid pocket
Indicative of complications of GERD and require
further diagnostic evaluation
alarm symptoms
ALARM SYMPTOMS
- Dysphagia (common)
o Odynophagia
o Bleeding
Refers to when symptoms of GERD are
associated with organs aside from the
esophagus, especially the lungs
EXTRAESOPHAGEAL GERD SYNDROME
EXTRAESOPHAGEAL GERD SYNDROME symptoms
o Chronic cough
o Laryngitis
o Wheezing
o Asthma (∼50% with asthma have GERD)
Preferred for assessing for mucosal injury and
complications.
endoscopy
Camera-containing capsule swallowed by the
patient offers the newest technology for
visualizing the esophageal mucosa via
endoscopy.
pillcam eso
Indication
o Patients not responding to acid
suppression therapy when endoscopy is
normal
o Those with atypical/extrapyramidal
symptoms
o Those contemplating surgery
ambulatory refluc monitoring
Best way to monitor a patient’s abnormal
esophageal clearance, and to determine when
the patient’s reflux occurs (morning or night)
ambulatory reflux monitoring
Indication
o Those who have failed BID PPI therapy
with normal endoscopic findings
o Candidates for antireflux surgery
o To evaluate peristaltic function of the
esophagus
o To assure proper placement of pH probes
MANOMETRY/HIGH-RESOLUTION
ESOPHAGEAL PRESSURE TOPOGRAPHY
(HREPT)
Therapeutic trial for diagnosing GERD
EMPIRIC PROTON-PUMP INHIBITOR
Can detect hiatal hernia
BARIUM RADIOGRAPHY
Not routinely used to diagnose GERD
BARIUM RADIOGRAPHY
For patients with severe, chronic GERD
nissen fundoplication
Implanting a ring of titanium-encased magnet at
the esophagogastric junction
• Helps narrow the esophagus to return to tonic or
contracted state.
MAGNETIC SPHINCTER AUGMENTATION
Management of Barrett’s esophagus when
dysplasia is present
Radiofrequency ablation [Stretta®] of the LES
Beneficial in patients with chronic GERD
with abnormal pH or low grade erosive
esophagitis
Endoscopic suturing of the LES
antacids indication
mild GERD
systemic antacids
- sodium bicarbonate
- sodium citrate
nonsystemic antacids
- calcium carb
- magnesium hydroxide, aluminum hydroxide, simethicone
long term use of systemic antacid causes…
electrolyte imbalance
anti-
flatulence to decrease frequency of farting
simethicone
indication for antacid-alginic acid
mild GERD
decreases frequency of reflux
antacid-alginic acid
amtacids are taken with or without meals?
with meals
after meals and at bedtime
drug interactions of antacids
- tetracycline
- ferrous sulfate
- isoniazid and quinolone antibiotics
- sulfonylureas
Competitively inhibit H2 receptors in the
parietal cells of the stomach to suppress
secretion of gastric acid
HISTAMINE-2 RECEPTOR ANTAGONIST
indication of h2ra
mild to moderate gerd
most potent H2 blocker
famotidine
has little first-pass metabolism
nizatidine
H2 blockers in general are prone to first-pass
metabolism, and thus have ___ bioavailability
low
standard dose of nonrx h2ra
2x daily dosing
↓ GERD symptoms associated with exercise
nonrx h2ra
has gynecomastia as se
cimetidine
h2ra are contraindicated to pregnant women. why?
may cross placenta
drug interaction of h2ra
cimetidine
- theophylline
- warfarin
- phenytoin
- nifedipine
- propranolol
Faster action and longer DOA compared
to H2 blockers
PROTON-PUMP INHIBITOR
indication of PPIs
moderate to severe GERD
Indication:
o Moderate-severe GERD
o Erosive esophagitis
o w/ complications
o NERD
o Patients refractory to H2RA
PPIs
has little first-pass metabolism
nizatidine
nonrx PPI dosing
once daily dosing
se of PPI
- rebound hypersecretion
- HA
- diarrhea
- naisea
- abdominal pain
- CAP
ppi that causes bronchoconstriction and should be avoided if px has asthma or copd
lansoprazole
long term effects of ppi
o Enteric infections (Clostridium difficile)
▪ Due to reduced gastric acidicity
o Vitamin B12 deficiency
o Hypomagnesemia
o Bone fracture
drug interaction of PPI
- ketoconazole amd itraconazole
- clopidogrel
Delayed release oral suspension powder
packet
(Esomeprazole, pantoprazole,
omeprazole)
Oral disintegrating tablet
(Dexlansoprazole, lansoprazole)
IV
(lansoprazole, esomeprazole,
pantoprazole)
major metabolizer of
CYP2C19; reduces effectivity of
clopidrogel
omeprazole
can be given as
alternative for patient on clopidrogel
therapy, since it is only a minor inhibitor of
CYP2C19
rabeprazole
when should u take ppi
Take PPI in the morning 30-60 mins.
before breakfast or before the biggest
meal of the day
For patients unable to swallow the
capsules →
contents can be mixed in
apple or orange juice
(ppi) contents can be mixed
in 8.4% NaHCO3 sol.
Patients in NGT
Adjunct to acid suppression therapy for patients
with known motility defects (Delayed gastric
emptying, ↓esophageal clearance).
promotility agents
Dopamine antagonist
metoclopramide
metoclopramide SE
o EPS (Tardive dyskinesia)
o Extrapyramidal symptoms (EPS) – usually
used to describe symptoms of drugs that
cause dopamine blocking
o CNS effects (i.e. drowsiness)
Directly binds and stimulates muscarinic receptor
→ ↑ Peristalsis
betanechol
Not routinely recommended for GERD (more
common for urinary retention)
betanechol
D2 receptor antagonist
domperidone
Has no CNS side effects, unlike metoclopramide
domperidone
GABA-B Agonist
baclofen
inhibits this signaling,
preventing the relaxation of LES (it does
not have a direct effect on gastric motility)
baclofen
Delayed gastric emptying results in an
enlarged stomach (gastric distention)
baclofen
↓Transient LES relaxations → ↓esophageal acid
exposure and the number of reflux episodes
baclofen
Nonabsorbable aluminum salt of sucrose
octasulfate
sucralfate
Useful in the management of radiation
esophagitis and bile or nonacid reflux GERD.
sucralfate
Tx of nocturnal symptoms
As needed H2RA at bedtime + PPI
DOC for maintenance of patients with
moderate-to-severe GERD, erosive
disease, or other complications
PPI
Endoscopy-negative GERD
patients
“On-demand” or intermittent
maintenance therapy
t or f: For GERD, clinicians use a step-down approach
t
