Lecture 14 Flashcards
Indigestion
A persistent or recurrent pain of discomfort in the upper abdomen due to a disorder of the digestive function.
Is often a sign of underlying conditions like GORD, ulcers.
Gastro oesophageal reflux disease (GORD)/heartburn
A digestion disorder involving the lower oesophageal sphincter (LOS) causing the reflux of gastric contents particularly acid into the oesophagus.
Chronic heartburn is GORD.
What do the oesophagus and throat not have ?
They both do not have a protective lining like the stomach, to protect itself from acid.
So when acid is pushed back up the oesophagus/throat, this can cause burning, pain and disruption to the lining of the throat and the oesophagus.
Non-drug advice of indigestion
Small meals often, eating with mouth closed, drink after meals, lose weight, reduce alcohol consumption, stop smoking, avoid trigger foods like spicy, fatty foods, avoid stressful situations.
How to treat indigestion - who is it for ?
Anyone can be affected by indigestion.
If 50+ person affected for the first time - REFER.
How to treat indigestion - what are the symptoms ?
Must confirm what the symptoms are exactly.
Epigastic discomfort with or without: a feeling of fullness after eating, heartburn, abdominal distension - bloating, flatulence - burping and passing wind, acidic taste (more of an indicator of acid reflux), nausea and vomiting.
Danger symptoms
Persistent abdominal pain. Anorexia. Unexpected weight loss. Blood in vomit - looks like coffee grounds, or stools - black tarry appearance. Severe pain in the upper or lower abdomen. Vomiting with or without blood. Difficulty swallowing. All of these - REFER.
How to treat indigestion - how long have the symptoms persisted ?
More than five days - REFER.
Recurrent symptoms over a period of time - REFER.
Differential diagnosis - ulcer, gallstones, gastric cancer, angina, heart attack (MI).
How to treat indigestion - action already taken ?
It is important to know what the patient has already tried and whether it has worked before which will affect what will be choice of treatment/advice.
How to treat indigestion - medication being taken (OTC + Rx) ?
If the patient is taking other medication, this could either:
Explain the symptoms experienced - NSAIDs, iron, erythromycin, steroids, oestrogen, oral contraceptives.
Affect choice of product to treat symptoms - tetracyclines, ketoconazol, chlorpromazine, enteric coated formulations.
OTC treatments for indigestion
Antacids, deflatulents, histamine H2 receptors, proton pump inhibitors.
Antacids
Work by physically neutralising stomach acid.
There are a variety of formulations or tablets - patients choice.
Best used 1 hour after meals as the gastric emptying is slowed down.
Good for occasional use.
Some antacids have very high levels of sodium salts so must be careful with patients who have cardiovascular disease and blood pressure medications so that the sodium system is not overloaded.
Aluminium salts
Can be slightly constipating.
Magnesium salts
Can cause diarrhoea or looseness of stool.
Calcium salts
Are fast acting and long duration, i.e. calcium, carbonate products.
Deflatulents
Break up and release trapped wind.
e.g. dimethicone, simeticone, peppermint oil.
Histamine H2 receptors
Reduce the amount of acid produced in the stomach.
e.g. famotidine, zantac.
They work at both the basal and stimulated gastric acid secretion where they are inhibited which reduces the acid content and to a smaller extent the pepsin content and volume of gastric juice.
Rapid onset of action and long duration of action, up to 12 hours.
Proton pump inhibitors (PPIs)
A specific inhibitor of the acid pump in the parietal cell is bonded to by the PPI which inhibits the enzyme HKATPase which is the final stage of HCl production.
e.g. esomeprazole - Guardium or Nexium, omeprazole, pantoprazole.
Takes 1/2 hours to work and has a long duration of action (24 hours).
Where is the entrance to the stomach ?
It is located just below the diaphragm that separates the thorax from the abdomen.
Where is the LOS located ?
It is located at the entrance of the stomach.
What happens if the sphincter is not working properly ?
When the stomach is churning and mixing the food, the acid can be moved back up the oesophagus.
Why is the stomach not affected by the production of acid ?
This is because the stomach has a protective lining to protect itself from the acid.
Are the symptoms of GORD and indigestion similar ?
Yes.
How to treat GORD - who is it for ?
Anyone can be affected by indigestion.
If 50+ person affected for the first time - REFER.
How to treat GORD - what are the symptoms ?
Must confirm exactly what the symptoms are.
Burning pain in the chest between the stomach and the throat with or without: pain, flatulence.
Danger symptoms
Difficulty swallowing, i.e. dysphagia.
Severe pain radiating to the back and arms.
Pain aggravated by exercise.
All of these - REFER.
How to treat GORD - how long have the symptoms persisted ?
More than 1 week - REFER.
Recurrent symptoms - REFER.
Severe radiating pain - REFER
Differential diagnosis - tumour, heart disease (atypical angina, heart attack MI)
How to treat GORD - action already taken ?
It is important to know what the patient has already tried and whether it has worked before which will affect what will be choice of treatment/advice.
How to treat GORD - medication being taken (OTC + Rx) ?
If the patient is taking other medication, this could either:
Explain the symptoms experienced - same as indigestion, anticholinergics e.g. hyoscine, tricycles, calcium channel blockers, nitrate, theophylline, caffeine which all relax the sphincter muscle which leads to regurgitation.
Affect the choice of product to treat symptoms.
Non-drug advice for GORD
The same as indigestion. Avoid bending. Raise the head of the bed. Dietary. Healthy promotion.
OTC treatments available for GORD
Same as indigestion to neutralise/reduce acid production, rafting agents.
Rafting agents
Work by floating on top of the stomach contents i.e. alginates.
Work as a physical barrier to prevent the acid from being used back up.
e.g. gaviscon, peptic, acedex - contain acedex but also rafting agents protecting the lining of the oesophagus in case reflux does occur.
