Lecture 7 - Heartburn & GERD Flashcards
Peristalsis
Wavelike muscular contraction of the alimentary canal by which food contents are forced onwards
Dyspepsia
consistent or recurrent discomfort in the upper abdomen characterized by bloating, belching, feelings of fullness after eating or early satiety
GERD
sxs, mucosal damage or both that results from abnormal reflux of stomach contents in the esophagus
Heartburn
burning sensation in the chest, caused by acid regurgitation into the esophagus
Dysphagia
difficulty swallowing
Aerophagia
Swelling of air
Odynophagia
pain produced by swallowing
Stricture
an abnormal narrowing of a bodily passage
Melena
passage of dark, tarry, bloody stools, usually resulting from a bleed in the upper part of the alimentary tract (esp the esophagus, stomach and duodenum)
What initiates digestion
Salivary amylase
Peristalsis breakdown
1/3 = voluntary (striated muscle), UES 2/3 = involuntary (smooth muscle), LES
Factors stimulating motility
Vagal stimulation
Large volume of food
Gastrin
Factors inhibiting motility
Cholecystokinin Secretin SNS activity Solids, Fats Opiates Dopamine
Gastrin
inc gastric blood flow
stim secretion of gastric acid & pepsinogen
Cholecystokinin
slows gastric emptying
stim secretion of pancreatic enzymes
stim contraction of gallbladder to release bile
Secretin
regulates pH of duodenum
stim produktion of bile from liver
Parietal and Chief cells help with….
aid in digestion
Mucous cell protects from…
HCL acid
3 main parts of small intestine
Duodenum - Jejunum - Ileum
Pathophysiology of Heartburn & Dyspepsia
- Trigger
- Exposure of esophagus to gastric acid
- sub-sternal discomfort that commonly moves upward accompanies by. burning or painful sensation
Etiology of Heartburn & Dyspepsia
Diet
Lifestyle
Medications
Medical conditions
Exclusions for self-care
- Heartburn > 2day/week for > 3 months
- Heartburn persistent while on recommended OTC, H2RAs, PPIs
- Nocturnal heartburn
- Chest pain indistinguishable from heartburn
- Difficulty or pain swallowing
- Black, tarry, stool (not on bismuth subsalicylate)
- Unexplained weightless
Non-pharm treatment options
Diet Weight loss Avoid meds that lower LES Elevate head of bed Avoid eating within 2-3hr bedtime Limit EtOH intake Wear loose fitting clothing
OTC treatment options
Antacids
H2RAs
PPIs
Bismuth subsalicylate
Antacid MOA
neutralization of stomach acid resulting in dec activation of pepsinogen and an increase in LES pressure
fast onset, short duration, multiple times per day
Antacid DI
decrease absorption of many drugs, sep by atleast 2hrs
Tums info
AI: Calcium carbonate
SE: Belching, farting, acid rebound, constipation, chalky taste
Avoid concomitant PPI use
Alka-selzter info
AI: Sodium bicarb, ASA, citric acid
SE: increased urination/thirst
Avoid: HTN, CHF, pregnancy, renal/liver disease
Maalox
AI: Aluminum hydroxide, magnesium hydroxide, simethicone
SE: GI, abdominal pain, diarrhea (mg), consitpation (Al), nausea
Avoid: pregnancy
antacids Special pop: elderly
common interaction w/ PPI, calcium carb requires acidic environment…..calcium citrate alternative
antacids Special pop: pregnant or breastfeeding
Avoid sodium bicarb
Most Al, Cal or Mg containing antacids generally safe
antacids Special pop: Children
< 12yrs w/ heartburn and dyspepsia = refer
H2RAs MOA
reversibly blocks H2 receptors on parietal cells, inhibit histamine release resulting in dec gastric acid secretion
H2RAs DI
Cimetidine: CYP450 inhib, interacts with everything
dec absorption of acid dependent drugs
H2RAs SE
HA N/V Diarrhea Constipation Dizziness fatigue confusion = elderly
*impotent/gynecomastia = cimetidine = rare
H2RAs OTC
Cimetidine (Tagamet)
Famotidine (Pepcid)
Nizatidine (Axid)
Tolerance may occur if take daily vs prn
Take upon sxs or 30-60min prior to eating to prevent
H2RAs special pop: elderly
Dose reduction maybe necessary in impaired renal
no longer BEERs
H2RAs special pop: Preg and breastfeeding
All prep category B
Famotidine/cimetidine = ok w/ breastfeeding
H2RAs special pop: Children
OTC not indicated for children < 12
PPI MOA
suppress gastric acid secretion by irreversibly blocking proton pumps on parietal cells resulting in long, lasting acid suppression
PPI OTC vs Rx indication
OTC: frequent HB > 2days/week or mild GERD
RX: mod/severe GERD, erosive esophagitis, and GERD-related complications
Not intended for immediate HB relief
PPI DI
Omeprazole: inhibits CYP 2C19 (warfarin, phenytoin, diazepam, clopidogrel), escitalopram (consider change to pantoprazole)
Reduced bioavailability of acid dependent drugs
Key counseling of PPI
take on empty stomach
ADE PPI
HA, dizziness, somnolence, diarrhea, constipation
- **Vitamin B12 deficiency
- **Rebound hyper secretion in those on PPI> 2weeks, taper down, often takes 4-6weeks
Controversial consequences of long term use of PPI
increased risk of bone fractures C.diff CAP Hypomagnesia B12 deficiency dementia* CKD*
Omeprazle is
Prilosec OTC
20mg
> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs
Lansoprazole is….
Prevacid24hrs = OTC
15mg
> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs
Esomeprazole is…
Nexium 24hrs = OTC
20mg
> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs
Zegerid OTC is….
20mg omeprazole + 1100mg sodium bicarb
IR Zegerid can give qHS for nocturnal sxs
PPI special pops
dont use OTC in children < 18 w/o provider discretion
Preg C = omep/esomep
Preg B = lansop
Bismuth Subsalicylate MOA
exact mechanism unknown
Bismuth Subsalicylate dosing
** dont use for more than 2 days **
Regular: 8 doses/day, 524mg po Q30m-1h prn
Extra strength: 4 doses/day 1050mg po q1h prn
Adverse effects Bismuth Subsalicylate
Black stool and tounge*** counsel
OTC treatment
- Lifestyle/diet changes
- Antacid or OTC low dose H2RA
or
Antacid/ OTC H2RAs
If works = continue TLC, repeat up to 2 weeks if symptoms reoccur
If doesn’t work = try different agent, OTC PPI or go to PCP
Frequent Heartburn OTC treatment
- Diet/Life style changes + OTC PPI qd for 14 days…
can repeat Q4 months prn, if not resolved go to PCP
Pathophysiology of GERD
abnormal reflux of gastric contents form the stomach into the esophagus due to impaired gatroesophageal LES pressure or function
Cycle of GERD
- Impaired LES function
- Acid reflux
- Esophageal mucosal acid contact time
- Esophagitis
- Decreased LES pressure
Causes of GERD
Decreased LES Pressure
Impaired mucosal defense mechanisms
Aggravating Factors GERD
- composition and volume of refluxate
- duration of exposure
- large meals
- laying down after eating
- tobacco
- bending over
- food
- medication
Typical GERD presentation
- Worse after eating, maybe received with repeated swallowing
Sxs = Heartburn, regurgitation, hyper salivation, chest pain
Alarming factors that should be referred to PCP?
Odynophagia Dysphagia Weight loss unexplained anemia Wheezing, hoarseness, coughing Choking/aspiration Undiagnosed chest pain
Diagnosis of GERD
PMH
Endoscopy - req referral to a gastroenterologist
Esophageal pH monitoring
Pharmacologic options GERD
Sucralfate Metoclopramide PPIs H2RAs Antacids
Step-up GERD therapy
- TLC + least expensive/least effective -> H2RA -> PPI
Not preferred
Step-down GERD therapy
Preferred
- TLC + Start w/ PPI to achieve control then step down to maintain remission PPI -> H2RA -> antacid
Relapse occurs: step up to previously effective therapy
Maintenance Therapy
on demand = preferred
Take agent until Sxs are controlled, then stop
Recurrence of sxs = resume therapy until sx free X 24hrs, then top
Intermittent = take agent until sxs are controlled, then stop
Recurrence of sxs = resume agent for 2-4wk then stop
Mild GERD Txm
TLC + OTC (or Rx) H2RA or PPI X 2 weeks
Mod-severe GERD txm
TLC + Rx PPI X 4 -8 weeks
Esophagitis or complications
TLC + Rx high dose H2RA or RX PPI BID X 4-16 weeks or anti-reflux surgery
Counseling of PPIs
take before meals
Exception: Dexlansoprazole can be taken w/o regard to meals
DR tablets and capsules should not be crushed or chewed
pts w/ swallowing difficulties may open DR capsules and sprinkle contents on applesauce
