Lecture 7 - Heartburn & GERD Flashcards
1
Q
Peristalsis
A
Wavelike muscular contraction of the alimentary canal by which food contents are forced onwards
2
Q
Dyspepsia
A
consistent or recurrent discomfort in the upper abdomen characterized by bloating, belching, feelings of fullness after eating or early satiety
3
Q
GERD
A
sxs, mucosal damage or both that results from abnormal reflux of stomach contents in the esophagus
4
Q
Heartburn
A
burning sensation in the chest, caused by acid regurgitation into the esophagus
5
Q
Dysphagia
A
difficulty swallowing
6
Q
Aerophagia
A
Swelling of air
7
Q
Odynophagia
A
pain produced by swallowing
8
Q
Stricture
A
an abnormal narrowing of a bodily passage
9
Q
Melena
A
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)
10
Q
What initiates digestion
A
Salivary amylase
11
Q
Peristalsis breakdown
A
1/3 = voluntary (striated muscle), UES 2/3 = involuntary (smooth muscle), LES
12
Q
Factors stimulating motility
A
Vagal stimulation
Large volume of food
Gastrin
13
Q
Factors inhibiting motility
A
Cholecystokinin Secretin SNS activity Solids, Fats Opiates Dopamine
14
Q
Gastrin
A
inc gastric blood flow
stim secretion of gastric acid & pepsinogen
15
Q
Cholecystokinin
A
slows gastric emptying
stim secretion of pancreatic enzymes
stim contraction of gallbladder to release bile
16
Q
Secretin
A
regulates pH of duodenum
stim produktion of bile from liver
17
Q
Parietal and Chief cells help with….
A
aid in digestion
18
Q
Mucous cell protects from…
A
HCL acid
19
Q
3 main parts of small intestine
A
Duodenum - Jejunum - Ileum
20
Q
Pathophysiology of Heartburn & Dyspepsia
A
- Trigger
- Exposure of esophagus to gastric acid
- sub-sternal discomfort that commonly moves upward accompanies by. burning or painful sensation
21
Q
Etiology of Heartburn & Dyspepsia
A
Diet
Lifestyle
Medications
Medical conditions
22
Q
Exclusions for self-care
A
- 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
23
Q
Non-pharm treatment options
A
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
24
Q
OTC treatment options
A
Antacids
H2RAs
PPIs
Bismuth subsalicylate
25
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
26
Antacid DI
decrease absorption of many drugs, sep by atleast 2hrs
27
Tums info
AI: Calcium carbonate
SE: Belching, farting, acid rebound, constipation, chalky taste
Avoid concomitant PPI use
28
Alka-selzter info
AI: Sodium bicarb, ASA, citric acid
SE: increased urination/thirst
Avoid: HTN, CHF, pregnancy, renal/liver disease
29
Maalox
AI: Aluminum hydroxide, magnesium hydroxide, simethicone
SE: GI, abdominal pain, diarrhea (mg), consitpation (Al), nausea
Avoid: pregnancy
30
antacids Special pop: elderly
common interaction w/ PPI, calcium carb requires acidic environment.....calcium citrate alternative
31
antacids Special pop: pregnant or breastfeeding
Avoid sodium bicarb
Most Al, Cal or Mg containing antacids generally safe
32
antacids Special pop: Children
< 12yrs w/ heartburn and dyspepsia = refer
33
H2RAs MOA
reversibly blocks H2 receptors on parietal cells, inhibit histamine release resulting in dec gastric acid secretion
34
H2RAs DI
Cimetidine: CYP450 inhib, interacts with everything
dec absorption of acid dependent drugs
35
H2RAs SE
```
HA
N/V
Diarrhea
Constipation
Dizziness
fatigue
confusion = elderly
```
***impotent/gynecomastia = cimetidine = rare**
36
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
37
H2RAs special pop: elderly
Dose reduction maybe necessary in impaired renal
| no longer BEERs
38
H2RAs special pop: Preg and breastfeeding
All prep category B
| Famotidine/cimetidine = ok w/ breastfeeding
39
H2RAs special pop: Children
OTC not indicated for children < 12
40
PPI MOA
suppress gastric acid secretion by irreversibly blocking proton pumps on parietal cells resulting in long, lasting acid suppression
41
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
42
PPI DI
Omeprazole: inhibits CYP 2C19 (warfarin, phenytoin, diazepam, clopidogrel), escitalopram (consider change to pantoprazole)
Reduced bioavailability of acid dependent drugs
43
Key counseling of PPI
take on empty stomach
44
ADE PPI
HA, dizziness, somnolence, diarrhea, constipation
* **Vitamin B12 deficiency
* **Rebound hyper secretion in those on PPI> 2weeks, taper down, often takes 4-6weeks
45
Controversial consequences of long term use of PPI
```
increased risk of bone fractures
C.diff
CAP
Hypomagnesia
B12 deficiency
dementia*
CKD*
```
46
Omeprazle is
Prilosec OTC
20mg
> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs
47
Lansoprazole is....
Prevacid24hrs = OTC
15mg
> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs
48
Esomeprazole is...
Nexium 24hrs = OTC
20mg
> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs
49
Zegerid OTC is....
20mg omeprazole + 1100mg sodium bicarb
IR Zegerid can give qHS for nocturnal sxs
50
PPI special pops
dont use OTC in children < 18 w/o provider discretion
Preg C = omep/esomep
Preg B = lansop
51
Bismuth Subsalicylate MOA
exact mechanism unknown
52
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
53
Adverse effects Bismuth Subsalicylate
Black stool and tounge*** counsel
54
OTC treatment
1. Lifestyle/diet changes
2. 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
55
Frequent Heartburn OTC treatment
1. Diet/Life style changes + OTC PPI qd for 14 days...
can repeat Q4 months prn, if not resolved go to PCP
56
Pathophysiology of GERD
abnormal reflux of gastric contents form the stomach into the esophagus due to impaired gatroesophageal LES pressure or function
57
Cycle of GERD
1. Impaired LES function
2. Acid reflux
3. Esophageal mucosal acid contact time
4. Esophagitis
5. Decreased LES pressure
58
Causes of GERD
Decreased LES Pressure
| Impaired mucosal defense mechanisms
59
Aggravating Factors GERD
1. composition and volume of refluxate
2. duration of exposure
3. large meals
4. laying down after eating
5. tobacco
6. bending over
7. food
8. medication
60
Typical GERD presentation
1. Worse after eating, maybe received with repeated swallowing
Sxs = Heartburn, regurgitation, hyper salivation, chest pain
61
Alarming factors that should be referred to PCP?
```
Odynophagia
Dysphagia
Weight loss
unexplained anemia
Wheezing, hoarseness, coughing
Choking/aspiration
Undiagnosed chest pain
```
62
Diagnosis of GERD
PMH
Endoscopy - req referral to a gastroenterologist
Esophageal pH monitoring
63
Pharmacologic options GERD
```
Sucralfate
Metoclopramide
PPIs
H2RAs
Antacids
```
64
Step-up GERD therapy
1. TLC + least expensive/least effective -> H2RA -> PPI
Not preferred
65
Step-down GERD therapy
Preferred
1. TLC + Start w/ PPI to achieve control then step down to maintain remission PPI -> H2RA -> antacid
Relapse occurs: step up to previously effective therapy
66
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
67
Mild GERD Txm
TLC + OTC (or Rx) H2RA or PPI X 2 weeks
68
Mod-severe GERD txm
TLC + Rx PPI X 4 -8 weeks
69
Esophagitis or complications
TLC + Rx high dose H2RA or RX PPI BID X 4-16 weeks or anti-reflux surgery
70
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
