Term
|
Definition
| a condition which develops when reflux of stomach contents causes troublesome symptoms and/or complications |
|
|
Term
decreased lower esophageal sphincter (LES) pressure due to:
spontaneous transient LES relaxation
transient increases in intra-abdominal pressure
ex) pregnancy, coughing
atonic LES - decrease in muscle tone
impaired mucosal defense mechanisms:
anatomical factors: hiatal hernia (stomach pushes up beyond the diaphragm into the esophagus, forcing LES to be dilated; corrected with surgery)
esophageal clearance: swallowing and saliva; saliva contains bicarbonate that neutralizes acid; patients with less saliva have more GERD, GERD symptoms increase at night due to less swallowing of saliva
mucosal resistance: mucus and bicarb; mucus contains bicarb, but if patient has damage to cells of the stomach the H+ within the cells are likely to be released and negate the effect of the bicarb
delayed gastric emptying: increased intra-abdominal pressure, caused by high fat foods, cigarette smoking
aggressive factors:
composition of reluxate - pH and pepsin |
|
Definition
|
|
Term
esophageal syndromes
extra-esophageal syndromes |
|
Definition
|
|
Term
symptomatic syndromes:
typical reflux
reflux chest pain
syndromes with esophageal injury:
reflux esophagitis - inflammation of the esophagus
reflux stricture - identified through EGD, makes it very difficult to swallow
Barrett's esophagus - risk factor for cancer; patient has long standing GERD, damaged squamous cells are repaired with columnar cells which are more likely to form cancer
adenocarinoma |
|
Definition
| example of esophageal syndromes of GERD |
|
|
Term
established association:
reflux cough
reflux laryngitis
reflux asthma
reflux dental erosions
proposed association:
sinusitis
pulmonary fibrosis
pharnygitis
recurrent otitis media |
|
Definition
| examples of extra-esophageal syndromes of GERD |
|
|
Term
pyrosis - heartburn
acidic taste
belching
regurgitation |
|
Definition
|
|
Term
asthma-like symptoms
chronic cough
hoarseness
pharyngitis
dental enamel loss
uncommon:
noncardiac chest pain
sinusitis/pneumonia/bronchitis/otitis media |
|
Definition
| extra-esophageal symptoms of GERD |
|
|
Term
TROUBLESOME DYSPHAGIA
WEIGHT LOSS
EPIGASTRIC MASS
vomiting
chest pain
odynophagia
bleeding
choking |
|
Definition
| alarming symptoms of GERD |
|
|
Term
esophageal erosions
Barrett's esophagus - columnar epithelium replace normal squamous epithelium
strictures/obstruction
adenocarcinoma |
|
Definition
|
|
Term
Clinical History:
classic GERD symptoms
response to acid suppressive therapy (AST) |
|
Definition
|
|
Term
alarm symptoms (weight loss, troublesome dysphagia, epigastric mass)
empiric treatment failure |
|
Definition
| indications for diagnostic testing of GERD |
|
|
Term
endoscopy:
preferred for dysphagia and treatment failure
manometry:
2nd step after treatment failure and normal endoscopy
swallow a pill and see how the esophagus is moving
used to rule out esophageal motility disorder
pH testing (% of time pH < 4 in 24 hours):
3rd step
no AST for 7 days prior |
|
Definition
| diagnostic testing of GERD (used to rule out other conditions) |
|
|
Term
alleviate symptoms
decrease frequency and duration of reflux
promote healing
prevent complications |
|
Definition
|
|
Term
recommendations should be patient specific
dietary modifications:
avoid aggravating foods/beverages
reduce fat intake and portion size
behavior modifications:
weight loss
remain upright 2-3 hours after meals
elevate head of bed
smoking cessation |
|
Definition
| lifestyle modification recommended for GERD |
|
|
Term
caffeine
nicotine
ethanol
DHP CCBs
progesterone
estrogen
narcotics |
|
Definition
| medications that decrease LES pressure |
|
|
Term
alendronate
quinidine
aspirin
iron
KCl
NSAIDs |
|
Definition
| medications that are direct gastric irritants |
|
|
Term
1st line = AST
PPIs > H2RAs > placebo
dosing schedule:
PPI once daily
PPI BID if poor response to once daily
H2RAs will be sufficient for some patients
no evidence H2RA at bedtime is beneficial when added to twice daily PPI
treatment failure = inadeequate response to BID PPI |
|
Definition
first line therapy for esophageal GERD syndrome
dosing schedule
treatment failure |
|
|
Term
rapid-acting therapy is best
antacids: efficacy sustained when combined with AST |
|
Definition
| therapy for symptomatic relief of GERD |
|
|
Term
rule out cardiac etiology
PPI BID x 4 weeks |
|
Definition
| therapy for reflux chest pain syndrome |
|
|
Term
AST once or twice daily
reasonable to start with PPI BID: 2 month trail; shown to normalize esophageal acid exposure in this population |
|
Definition
| therapy for extra-esophageal GERD syndrome with concomitant esophageal GERD syndrome |
|
|
Term
erosive esophagitis:
continuous PPI should be used
> 80% recurrence within 12 months after D/C
twice as likely to relapse with H2RAs vs. PPI
HAVE TO USE PPI WITH EROSIVE ESOPHAGITIS
non-erosive esophagitis:
less clear role of PPIs for GERD symptoms
attempt to step down therapy
maintenance PPI therapy results in less recurrence if initially responded to PPI (vs. H2RA or placebo)
on-demand therapy is reasonable
extra-esophageal GERD syndrome with esophageal GERD syndrome:
PPI once or twice daily (or H2RA)
attempt step-down therapy
extra-esophageal GERD syndrome without esophageal GERD syndrome:
discontinue AST |
|
Definition
|
|
Term
re-establishes the anti-reflux barrier
indications:
AST is efficacious, but patient is intolerant
persistent, troublesome GERD symptoms despite PPI therapy
manometry showed peristaltic function
ADRs:
dysphagia
flatulence
inability to belch
increased bowel symptoms |
|
Definition
| indications and ADRS of anti-reflux surgery |
|
|
Term
indication:
intermittent symptoms (< 2 times/week)
breakthrough therapy
ADRs:
constipation (Al, Ca)
diarrhea (Mg)
accumulation in kidney disease (may cause kidney stones)
drug interactions:
chelation
reduced absorption |
|
Definition
| indications, ADRs, and drug interactions of antacids |
|
|
Term
indications:
on-demand therapy
preventative dosing before meals or exercise
more rapid onset of action than PPIs
must renally dose:
50/50 rule - if CrCl is < 50 mL/min then decrease H2RA dose by 50%
ADRs:
accumulation (due to renal failure) can lead to mental status changes - somnolence, confusion, fatigue
hematologic effects - neutropenia, agranulocytosis, thrombocytopenia
headache
mild diarrhea
drug interactions:
decreased absorption due to increased gastric pH (azole antifungals, Ca carbonate, HIV medications)
CYP P450 inhibition - cimetidine (1A2, 2C9, 2D6, 3A4) and ranitidine (1A2, 2D6) |
|
Definition
| indications, renal dosing, ADRs, and drug interactions of H2RAs |
|
|
Term
all PPIs have similar efficacy for GERD
longer duration of action than H2RAs
administration:
prior to meals, except dexlansoprazole
esomeprazole, omeprazole, and lansoprazole capsules can be opened and put in applesauce - ganules should not be chewed
ADRs:
headache
diarrhea
constipation
drug interactions:
decreased absorption - same mechanism as H2RAs
CYP P450 inhibition - 2C9 (omeprazole), 2C19 (omeprazole, esomeprazole, lansoprazole, rabeprazole) |
|
Definition
| administration, ADRs, drug interactions of PPIs |
|
|
Term
| not recommended for GERD of any type - risk outweighs benefit |
|
Definition
| recommended use of metoclopramide |
|
|
