Term
| Gastroesophageal Reflux Disease (GERD) |
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Definition
| symptoms of mucosal damage due to the retrograde movement of acid and other substances into esophagus |
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Term
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Definition
| erosion of the squamous epithelium of the esophagus |
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Term
| Epidemiology/Etiology of GERD |
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Definition
Most common in >40 yrs old;
Western Countries;
Men = Women |
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Term
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Definition
family hx;
obesity;
smoking;
EtOH consumption;
Respiratory disease;
foods;
medications |
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Term
| Mechanism of GERD: Transient LES Relaxation |
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Definition
Esophageal distention;
Vomiting;
Belching;
Retching |
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Term
| Mechanism of GERD: Increased Intra-Abdominal Pressure |
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Definition
obesity;
pregnancy;
bending over;
straining;
lying in recumbent position;
eating large meals;
wearing tight fitting clothing |
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Term
| Mechanism of GERD: Atonic LES |
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Definition
| free reflux (scleroderma patients) |
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Term
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Definition
cells located on stomach lumen;
secrete HCl via H+/K+/ATPase (proton) pumps present on membrane;
receptors for ACh, gastrin, & histamine |
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Term
| Decreases LES pressure, leading to GERD |
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Definition
Foods: high fat content, caffeine, mint, chocolate, onions, garlic, chili peppers;
Gastric distention;
Smoking;
Ethanol;
Meds: anticholinergics, barbiturates, benzodiazepines, dihydropyridine CCBs, dopamine, estrogen, isoproterenol, narcotics, nitrates, phentolamine, progesterone, theophylline, tetracycline; |
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Term
| Offensive Factors for GERD |
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Definition
gastric acid;
pepsin;
bile acid;
pancreatic enzymes;
hypersecretory conditions |
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Term
| Defensive Factors for GERD |
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Definition
esophageal clearance;
mucosal tissue resistance;
gastric emptying;
salivary buffering;
epidermal growth factor |
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Term
| Direct Esophageal Irritants |
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Definition
orange/tomato juice;
coffee;
spicy foods;
Meds: NSAIDs, bisphosphonates, KCl, quinidine, Fe |
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Term
| Delayed Gastric Emptying Time |
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Definition
Increased overall gastric volume;
Factors: high fat meal, overeating, smoking, motility disorder; |
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Term
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Definition
May worsen by certain activities;
Waxes & wanes;
Heartburn;
Hypersalivation;
Belching;
Regurgitation; |
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Term
| Atypical Symptoms of GERD |
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Definition
May be only symptoms present;
Do not correlates w/ degree of damage, but w/ duration of reflux;
Nonallergic asthma;
Chronic cough;
Hoarseness;
Pharyngitis;
Non-cardiac chest pain;
Dental erosion;
Halitosis; |
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Term
| Complicated Symptoms of GERD |
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Definition
ALARM - results from long-term acid exposure;
Requires IMMEDIATE referral for medical evaluation;
Dysphagia;
Odynophagia;
Bleeding;
Unexplained weight loss;
Choking;
Vomiting;
Continual pain |
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Term
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Definition
MOST useful diagnostic tool;
Heartburn for > or = 2 days/wk requires medical evalution |
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Term
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Definition
visualization & biospy of esophageal mucosa;
assesses for complications |
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Term
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Definition
pt swallows camera-containing pill;
Small camera takes pics of pt's esophagus;
Less invasive than endoscopy;
Takes less than 15 min to perform;
Pill is passed through stool; |
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Term
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Definition
reflux;
symptomatic clincal condition;
OR
histological alteration |
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Term
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Definition
| GERD associated w/ organs other than the esophagus (aka extraesophageal) |
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Term
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Definition
symptoms;
but normal endoscopy |
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Term
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Definition
esophagitis;
strictures;
Barrett's esophagus;
Esophageal adenocarcinoma;
Anemia |
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Term
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Definition
| inflammation of the esophagus |
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Term
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Definition
narrowing of the esophagus;
Common in distal portion;
1-2 cm in length;
may be due to NSAIDs |
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Term
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Definition
columnar type epithelium replacing squamous epithileal lining;
Long hx of reflux;
Precancerous condition - increases risk of andenocarcinoma;
Most prevalent in white adult males in Western countries |
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Term
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Definition
Relieve & prevent Sx;
Decrease frequency & duration of gastroesophageal reflux;
Promote & maintain esophageal healing;
Prevent esophageal complications; |
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Term
| Tx of Intermittent, Mild Heartburn |
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Definition
If Sx occur <2x/wk:
Lifestyle Changes
PLUS
Pt-directed Therapy:
- Antacids: Maalox or Mylanta 30 mL PRN after meals or qHS PRN, Gaviscon 2 tabs PC & qHS, Calcium carbonate 500 mg 2-4 tabs PRN
+/-
Non-prescription H2RA (BID PRN): famotidine [Pepcid] 10 mg, ranitidine [Zantac];
OR
Non-prescription PPI (qDay): omeprazole [Prilosec] 20 mg, lansoprazole [Prevacid] 15 mg;
If Sx are not relieved after 2 wks, pt should seek medical attention; |
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Term
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Definition
Give/Take 30 mL PO PRN after meals or qHS PRN
- Tx for intermittent, mild heartburn
- w/ or w/o H2RA or PPI (non-RX) |
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Term
| Intermittent, Mild Heartburn GERD Dosing for famotidine (Pepcid) |
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Definition
famotidine (Pepcid) 10 mg PO bid PRN x 2 wks;
- Used in combo with antacids (Maalox, Mylanta) & lifestyle modifications
- re-evaluate for S/Sx after 2 wks; If Sx persist, pt should seek medical attention |
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Term
| Intermittent, Mild Heartburn GERD Dosing for ranitidine (Zantac) |
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Definition
ranitidine (Zantac) 75 mg PO BID PRN x 2 wks
- Used in combo with antacids (Maalox, Mylanta) & lifestyle modifications
- re-evaluate for S/Sx after 2 wks; If Sx persist, pt should seek medical attention |
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Term
| Intermittent, Mild Heartburn GERD Dosing for omeprazole (Prilosec) |
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Definition
omeprazole (Prilosec) 20 mg qday x 2 wks
- Used in combo with antacids (Maalox, Mylanta) & lifestyle modifications;
- re-evaluate for S/Sx after 2 wks; If Sx persist, pt should seek medical attention |
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Term
| Intermittent, Mild Heartburn GERD Dosing for lansoprazole (Prevacid) |
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Definition
lansoprazole (Prevacid) 15 mg qday x 2 wks
- Used in combo with antacids (Maalox, Mylanta) & lifestyle modifications
- re-evaluate for S/Sx after 2 wks; If Sx persist, pt should seek medical attention |
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Term
| Tx for Symptomatic Relief of GERD - mild-moderate-severe Sx with NO complications |
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Definition
Lifestyle Changes
PLUS
Rx-strength Acid Suppression:
- H2RA x 6-12 wks (famotidine [Pepcid] 20 mg BID, ranitidine [Zantac] 150 mg BID)
OR
PPI x 4-8 wks (lansoprazole [Prevacid] 15 mg qday, omeprazole [Prilosec] 20 mg qday, pantoprazole [Protonix] 40 mg qday)
**For Mild GERD Sx (3-4x/wk) --> use H2RA initially**
**For Moderate-Severe GERD Sx (>5x/wk) --> use PPI initially |
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Term
| Tx for Symptomatic Relief of GERD dosing with famotidine [Pepcid] |
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Definition
famotidine [Pepcid] 20 mg PO BID x 6-12 wks
- use with lifestyle changes;
**Start initial therapy if S/Sx are mild (3-4x/wk) |
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Term
| Tx for Symptomatic Relief of GERD dosing with ranitidine [Zantac] |
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Definition
ranitidine [Zantac] 150 mg PO BID x 6-12 wks;
- use with lifestyle changes;
**Start initial therapy if S/Sx are mild (3-4x/wk) |
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Term
| Tx for Symptomatic Relief of GERD dosing with lansoprazole [Prevacid] |
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Definition
lansoprazole 15 mg PO qday x 4-8 wks;
- use with lifestyle modifications;
**Start initially if Moderate-Severe Sx (>5x/wk) |
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Term
| Tx for Symptomatic Relief of GERD dosing with omeprazole [Prilosec] |
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Definition
omeprazole [Prilosec] 20 mg PO qday x 4-8 wks;
- use with lifestyle modifications
**Start initially if Moderate-Severe Sx (>5x/wk) |
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Term
| Tx for Symptomatic Relief of GERD dosing with pantoprazole [Protonix] |
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Definition
pantoprazole [Protonix] 40 mg PO qday x 4-8 wks;
**Start initial therapy if S/Sx are Moderate-Severe (>5x/wk) |
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Term
| Tx for Healing Erosive Esophagitis or Tx of Moderate-Severe GERD Sx WITH Complications |
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Definition
Lifestyle Changes
PLUS
PPI x 4-16 wks, given up to BID (lansoprazole [Prevacid] 30 mg qday-bid, omeprazole [Prilosec] 20 mg qday-bid, pantoprazole [Protonix] 40 mg qday-bid)
OR
High-dose H2RA x 8-12 wks (famotidine [Pepcid] 40 mg BID, ranitidine [Zantac] 150 mg QID) |
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Term
| Tx of Erosive Esophagitis or Moderate-Severe Sx WITH Complications dosing for lansoprazole [Prevacid] |
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Definition
lansoprazole [Prevacid] 30 mg qday-BID x 4-16 wks;
- use with lifestyle changes;
**Preferred b/c more cost effective |
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Term
| Tx of Erosive Esophagitis or Moderate-Severe Sx WITH Complications dosing for omeprazole [Prilosec] |
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Definition
omeprazole [Prilosec] 20 mg PO qday-BID x 4-16 wks;
- use with lifestyle changes;
**Preferred b/c more cost effective |
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Term
| Tx of Erosive Esophagitis or Moderate-Severe Sx WITH Complications dosing for pantoprazole [Protonix] |
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Definition
pantoprazole [Protonix] 40 mg qday-BID x 4-16 wks;
- use with lifestyle changes;
**Preferred b/c more cost effective |
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Term
| Tx of Erosive Esophagitis or Moderate-Severe Sx WITH Complications dosing for famotidine [Pepcid] |
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Definition
famotidine [Pepcid] 40 mg BID x 8-12 wks;
- use with lifestyle changes;
- may not be preferred because less cost effective |
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Term
| Tx of Erosive Esophagitis or Moderate-Severe Sx WITH Complications dosing for ranitidine [Zantac] |
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Definition
ranitidine [Zantac] 150 mg PO QID x 8-12 wks;
- use with lifestyle changes;
- may not be preferred because less cost effective |
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Term
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Definition
Recommend for ALL pts:
- Elevate head of bed 6-8 inches;
- Dietary Changes: avoid foods the decrease LES pressure (high fat foods, caffeine, chocolate, mint, onions, garlic, chili peppers), avoid direct mucosal irritants (orange/tomato juice, coffee, spicy foods, NSAIDs, bisphosphonates, KCl, Fe), INCLUDE protein-rich foods, eat small meals, Avoid eating w/in 3 hrs of sleeping;
- Weight Loss;
- Smoking Cessation;
- EtOH avoidance;
- Avoid tight fitting clothing;
- D/C Meds that may promote reflux (CCBs, beta-blockers, nitrates, theophylline);
- Take drugs that irritate mucosal linin with LOTS of H2O (bisphosponates, tetracyclines, quinidine, KCl, Fe, ASA, NSAIDs);
-Avoid swallowing air |
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Term
| Antacids (OTC) - magnesium salts [Milk of Magnesia], aluminum salts [Alterna Gel, Amphojel], Al/Mg combos [Maalox, Mylanta, Riopan], calcium carbonate [Tums, Rolaids], sodium bicarb [Alka-Seltzer] |
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Definition
Indication: Mild GERD;
MoA: Increases gastric pH, pH>4 --> decreases activation of pepsin & increases LES pressure;
Fast onset of Action;
Take after meals --> increases duration of action;
qHS dosing does NOT maintain acid suppression at night;
ADRs:
- Mg, Mg/Al combos: Diarrhea;
- Ca/Al: constipation;
Drug Interactions: tetracyclines, FQNs, ketoconazole, itraconazole, ferrous sulfate, digoxin, quinidine, sulfanylureas;
**Seperate doses with other meds: Take 2 hrs before or 2 hrs after (except FQNs --> Take 2 hrs before or 4 hrs after; |
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Term
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Definition
OTC product;
MoA: forms highly viscous solution, floats to top of gastric contents, acts as protective barrier, decreases frequency of reflux episodes; |
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Term
| H2 Receptor Antagonists (H2RAs) - cimetidine [Tagamet], famotidine [Pepcid], nizatidine [Axid], ranitidine [Zantac] |
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Definition
Indication: Mild-Moderate GERD Sx, erosive disease;
MoA: competitively & reversibly inhibits H2 receptors on parietal cells --> blocks gastic acid secretion;
Take doses 30-60 min before meals or at bedtime;
Longer duration of action than antacids;
ADRs:
- HA, somnolence, fatigue, dizziness, constipation, diarrhea;
- CNS effects (confusion, agitation, hallucinations): high doses, elderly, renal dysfunction;
- high doses of C: gynecomastia, impotence;
**Dose adjust in Renal Impairment**
Drug Interactions: Cyp450 |
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Term
| Proton Pump Inhibitors (PPIs) - dexlansoprazole [Dexilant, Kapidex], lansoprazole [Prevacid], omeprazole [Prilosec], pantoprazole [Protonix], rabeprazole [Aciphex], esomeprazole [Nexium] |
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Definition
Indication: Moderate-Severe GERD Sx, erosive disease;
MoA: inhibits H/K/ATPase proton pump --> inhibits gastric acid release;
Dosing:
- Daily 15-30 min BEFORE breakfast;
- If nighttime Sx, take qPM;
- BID Dosing: Take 2nd dose 10-12 hrs after first dose;
Drug Interactions: Cyp3A4, 2C9; Decreased absorption w/ azole antifungals |
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Term
| Enteric-Coated Granule PPIs |
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Definition
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Term
| Oral Packet & Delayed-Release, Orally Disintegrating Tablet (ODT) PPIs |
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Definition
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Term
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Definition
| lansoprazole, esomeprazole, pantoprazole |
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Term
| Zegerid (IR omeprazole + sodium bicarb) |
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Definition
OTC omeprazole IR tab w/ sodium bicarbonate;
Take on an empty stomach at least 1 hr before food; |
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Term
| Prokinetic Agents - cisapride [Propulsid], metoclopramide [Reglan], bethanechol [Urecholine] |
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Definition
| Indication: adjunct to acid suppression in pts w/ a motility disorder; |
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Term
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Definition
prokinetic agent;
MoA: stimulates cholinergic receptors in GI tract --> increases LES pressure --> enhanced acid clearance;
**Only available thru manufacturer using investigational limited access program**
Dose: 10 mg QID at least 30 min before meals & at bedtime;
ADRs:
- QT prolongation
- abdominal cramping
- diarrhea;
Drug Interactions: CYP3A4 |
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Term
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Definition
prokinetic agent;
MoA: central-acting D antagonist --> increases LES pressure & GI motility;
**Provides symptomatic improvement for SOME pts**
Dose: 10 mg QID at least 30 min before meals & at bedtime;
ADRs (increased risk in elderly & CKD pts):
- EPS --> interacts with psych meds (SSRIs - neuroleptic syndrome)
- anxiety
- restlessness
- drowsiness; |
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Term
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Definition
prokinetic agent;
MoA: stimulates cholinergic receptors in GI tract --> increases LES pressure --> enhanced acid clearance;
**Very limited tx value in GERD**
ADRs:
- abdominal cramping
- blurred vision |
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Term
| Goals of Maintenance GERD Therapy |
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Definition
| Improve QOL: controlling Sx, preventing complications; |
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Term
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Definition
| drug of choice for mild GERD maintenance therapy |
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Term
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Definition
| drug of choice for moderate-severe GERD maintenance therapy |
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Term
| Endoscopy-Negative Reflux Disease (ENRD) |
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Definition
| best evaluated w/ endoscopy |
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Term
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Definition
may decrease asthma symptoms & need for asthma medications
OR
no change in lung function |
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Term
| Tx of Non-Cardiac Chest Pain - Atypical Sx |
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Definition
| omeprazole 20 mg BID x 1-8 wks |
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Term
| Non-Pharm Tx of Pediatric Pts w/ GERD |
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Definition
Change diet;
Postural management;
Thickened feedings;
Small, frequent meals |
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Term
| Pharm Tx for Pediatric Pts w/ GERD |
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Definition
H2RA: ranitidine 2 mg/kg BID;
PPI: lansoprazole 15 mg qday (if <30 kg); lansoprazole 30 mg qday (if >30 kg); |
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Term
| Goal of Surgical Interventions |
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Definition
Re-establish anti-reflux barrier;
Position LES within abdomen --> under positive intraabdominal pressure;
Close any associated hiatal defect; |
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Term
| Pts Considered for Surgical Intervention |
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Definition
Fail to respond to pharm therapy;
Severe Complications (Grade 3-4 esophagitis, strictures, Barrett's esophagus);
Atypical Sx & reflux;
Lifestyle considerations; |
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Term
| Most Common Surgical Complications |
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Definition
Gas bloat syndrome;
Dysphagia;
Vagal denervation;
Splenic trauma; |
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Term
| Best Surgical Outcomes in these pts |
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Definition
Pts <50 yrs old;
Typical Sx |
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