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CDM 2 Exam 3 > Lecture 7 - Heartburn & GERD > Flashcards

Lecture 7 - Heartburn & GERD Flashcards

1
Q

Peristalsis

A

Wavelike muscular contraction of the alimentary canal by which food contents are forced onwards

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2
Q

Dyspepsia

A

consistent or recurrent discomfort in the upper abdomen characterized by bloating, belching, feelings of fullness after eating or early satiety

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3
Q

GERD

A

sxs, mucosal damage or both that results from abnormal reflux of stomach contents in the esophagus

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4
Q

Heartburn

A

burning sensation in the chest, caused by acid regurgitation into the esophagus

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5
Q

Dysphagia

A

difficulty swallowing

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6
Q

Aerophagia

A

Swelling of air

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7
Q

Odynophagia

A

pain produced by swallowing

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8
Q

Stricture

A

an abnormal narrowing of a bodily passage

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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)

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10
Q

What initiates digestion

A

Salivary amylase

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11
Q

Peristalsis breakdown

A 
1/3 = voluntary (striated muscle), UES
2/3 = involuntary (smooth muscle), LES
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12
Q

Factors stimulating motility

A

Vagal stimulation
Large volume of food
Gastrin

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13
Q

Factors inhibiting motility

A 
Cholecystokinin
Secretin
SNS activity
Solids, Fats
Opiates
Dopamine
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14
Q

Gastrin

A

inc gastric blood flow

stim secretion of gastric acid & pepsinogen

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15
Q

Cholecystokinin

A

slows gastric emptying
stim secretion of pancreatic enzymes
stim contraction of gallbladder to release bile

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16
Q

Secretin

A

regulates pH of duodenum

stim produktion of bile from liver

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17
Q

Parietal and Chief cells help with….

A

aid in digestion

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18
Q

Mucous cell protects from…

A

HCL acid

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19
Q

3 main parts of small intestine

A

Duodenum - Jejunum - Ileum

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20
Q

Pathophysiology of Heartburn & Dyspepsia

A
  1. Trigger
  2. Exposure of esophagus to gastric acid
  3. sub-sternal discomfort that commonly moves upward accompanies by. burning or painful sensation
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21
Q

Etiology of Heartburn & Dyspepsia

A

Diet
Lifestyle
Medications
Medical conditions

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22
Q

Exclusions for self-care

A
  1. Heartburn > 2day/week for > 3 months
  2. Heartburn persistent while on recommended OTC, H2RAs, PPIs
  3. Nocturnal heartburn
  4. Chest pain indistinguishable from heartburn
  5. Difficulty or pain swallowing
  6. Black, tarry, stool (not on bismuth subsalicylate)
  7. Unexplained weightless
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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
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24
Q

OTC treatment options

A

Antacids
H2RAs
PPIs
Bismuth subsalicylate

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25
Q

Antacid MOA

A

neutralization of stomach acid resulting in dec activation of pepsinogen and an increase in LES pressure

fast onset, short duration, multiple times per day

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26
Q

Antacid DI

A

decrease absorption of many drugs, sep by atleast 2hrs

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27
Q

Tums info

A

AI: Calcium carbonate

SE: Belching, farting, acid rebound, constipation, chalky taste

Avoid concomitant PPI use

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28
Q

Alka-selzter info

A

AI: Sodium bicarb, ASA, citric acid

SE: increased urination/thirst

Avoid: HTN, CHF, pregnancy, renal/liver disease

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29
Q

Maalox

A

AI: Aluminum hydroxide, magnesium hydroxide, simethicone

SE: GI, abdominal pain, diarrhea (mg), consitpation (Al), nausea

Avoid: pregnancy

30
Q

antacids Special pop: elderly

A

common interaction w/ PPI, calcium carb requires acidic environment…..calcium citrate alternative

31
Q

antacids Special pop: pregnant or breastfeeding

A

Avoid sodium bicarb

Most Al, Cal or Mg containing antacids generally safe

32
Q

antacids Special pop: Children

A

< 12yrs w/ heartburn and dyspepsia = refer

33
Q

H2RAs MOA

A

reversibly blocks H2 receptors on parietal cells, inhibit histamine release resulting in dec gastric acid secretion

34
Q

H2RAs DI

A

Cimetidine: CYP450 inhib, interacts with everything

dec absorption of acid dependent drugs

35
Q

H2RAs SE

A 
HA
N/V
Diarrhea
Constipation
Dizziness
fatigue
confusion = elderly

*impotent/gynecomastia = cimetidine = rare

36
Q

H2RAs OTC

A

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
Q

H2RAs special pop: elderly

A

Dose reduction maybe necessary in impaired renal

no longer BEERs

38
Q

H2RAs special pop: Preg and breastfeeding

A

All prep category B

Famotidine/cimetidine = ok w/ breastfeeding

39
Q

H2RAs special pop: Children

A

OTC not indicated for children < 12

40
Q

PPI MOA

A

suppress gastric acid secretion by irreversibly blocking proton pumps on parietal cells resulting in long, lasting acid suppression

41
Q

PPI OTC vs Rx indication

A

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
Q

PPI DI

A

Omeprazole: inhibits CYP 2C19 (warfarin, phenytoin, diazepam, clopidogrel), escitalopram (consider change to pantoprazole)

Reduced bioavailability of acid dependent drugs

43
Q

Key counseling of PPI

A

take on empty stomach

44
Q

ADE PPI

A

HA, dizziness, somnolence, diarrhea, constipation

  • **Vitamin B12 deficiency
  • **Rebound hyper secretion in those on PPI> 2weeks, taper down, often takes 4-6weeks
45
Q

Controversial consequences of long term use of PPI

A 
increased risk of bone fractures
C.diff
CAP
Hypomagnesia
B12 deficiency
dementia*
CKD*
46
Q

Omeprazle is

A

Prilosec OTC
20mg

> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs

47
Q

Lansoprazole is….

A

Prevacid24hrs = OTC
15mg

> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs

48
Q

Esomeprazole is…

A

Nexium 24hrs = OTC
20mg

> 18 = 1 cap qAM 30-60min before 1st meal for X 14 days. Max: 1/24hrs

49
Q

Zegerid OTC is….

A

20mg omeprazole + 1100mg sodium bicarb

IR Zegerid can give qHS for nocturnal sxs

50
Q

PPI special pops

A

dont use OTC in children < 18 w/o provider discretion

Preg C = omep/esomep
Preg B = lansop

51
Q

Bismuth Subsalicylate MOA

A

exact mechanism unknown

52
Q

Bismuth Subsalicylate dosing

A

** 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
Q

Adverse effects Bismuth Subsalicylate

A

Black stool and tounge*** counsel

54
Q

OTC treatment

A
  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
Q

Frequent Heartburn OTC treatment

A
  1. Diet/Life style changes + OTC PPI qd for 14 days…

can repeat Q4 months prn, if not resolved go to PCP

56
Q

Pathophysiology of GERD

A

abnormal reflux of gastric contents form the stomach into the esophagus due to impaired gatroesophageal LES pressure or function

57
Q

Cycle of GERD

A
  1. Impaired LES function
  2. Acid reflux
  3. Esophageal mucosal acid contact time
  4. Esophagitis
  5. Decreased LES pressure
58
Q

Causes of GERD

A

Decreased LES Pressure

Impaired mucosal defense mechanisms

59
Q

Aggravating Factors GERD

A
  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
Q

Typical GERD presentation

A
  1. Worse after eating, maybe received with repeated swallowing

Sxs = Heartburn, regurgitation, hyper salivation, chest pain

61
Q

Alarming factors that should be referred to PCP?

A 
Odynophagia
Dysphagia
Weight loss
unexplained anemia
Wheezing, hoarseness, coughing
Choking/aspiration
Undiagnosed chest pain
62
Q

Diagnosis of GERD

A

PMH
Endoscopy - req referral to a gastroenterologist
Esophageal pH monitoring

63
Q

Pharmacologic options GERD

A 
Sucralfate
Metoclopramide
PPIs
H2RAs
Antacids
64
Q

Step-up GERD therapy

A
  1. TLC + least expensive/least effective -> H2RA -> PPI

Not preferred

65
Q

Step-down GERD therapy

A

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
Q

Maintenance Therapy

A

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
Q

Mild GERD Txm

A

TLC + OTC (or Rx) H2RA or PPI X 2 weeks

68
Q

Mod-severe GERD txm

A

TLC + Rx PPI X 4 -8 weeks

69
Q

Esophagitis or complications

A

TLC + Rx high dose H2RA or RX PPI BID X 4-16 weeks or anti-reflux surgery

70
Q

Counseling of PPIs

A

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

CDM 2 Exam 3 (13 decks)

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