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In GERD the resting tone of the ? tends to be less than normal permitting transient relaxation 1-2 hours after eating lower esophageal sphincter (LES)
factors that decrease LES tone estrogen, progesterone, glucagon, secretin, cholecystokinin, tobacco, alcohol, peppermint, chocolate, high fat/carbs food
drugs that increase LES tone urecholine, reglan, pentobarbital, histamine, antacids
drugs that decrease LES tone anticholinergics, theophylline, Demerol, calcium channel blockers
other causes of GERD (than LES) delayed gastric emptying, gastric or duodenal ulcers that can cause pyloric stenosis, pyloric strictures, hiatal hernia
s/s of GERD burning pain that radiates upward, regurgitation, dysphagia
s/s suggestive of cancer or alarm dysphagia, painful swallowing, noncardiac CP, hematemesis, weight loss, choking
diagnosis: GERD the AGA recommends diagnostic testing if pt does not respond to PPIs bid or if alarm sx are present
drugs that improve LES tone reglan, bethanechol; not considered for monotherapy antacids
drugs to reduce the amount of acid H2 blockers and PPIs
increase esophageal healing by about 50% H2 blockers
increase esophageal healing by about 80% and decrease acid secretion by almost 100% PPIs
goals of treatment for GERD (4) 1. reduce or eliminate the symptoms 2. heal any esophageal lesions 3. manage or prevent complications such as stricture, Barrett's esophagus, esophageal carcinoma 4. prevent relapse
Step-up approach: 1. lifestyle and antacids 2. H2 blockers 4-8 weeks 3. PPIs 4-8 weeks 4. Gastroenterologist
Step-down approach: 1. lifestyle and PPIs daily for 8 weeks 2a. if no relief, PPIs bid for 4-8 weeks 2b. if relief, step back to H2s 3. if no relief after 8 weeks PPIs, refer to gastroenterologist
Antireflux maneuvers: HOB elevated, avoid laying, bending, or exercising within 3 hours of meal, appropriate body weight
Endoscopy needed if no symptom relief after ? months or sx that suggest complications 3
Occurrence of GER in infants up to 100% of 3 month olds; 4% of 6 month olds; 20% of 12 month olds 90-95% outgrown by 12-18 months
most infants outgrow GER so aggressive management is reserved for those experiencing: poor weight gain, feeding refusal, arcing, crying during feeding, persistent irritability, pain apnea, cyanosis
Diagnosis of GER in infants; H&P, caloric intake, CBC,BMP, BUN, upper GI not recommended
most sensitive and accurate way to dx GER in infants and young children: esophageal pH monitoring or combined multiple intraluminal impedance (MII)
infants with suspected GER tx: referral to pediatric gastroenterologist empirical tx with drugs is not approptiate
older children with GERD sx: lower CP, dysphagia, hematemesis, iron deficiency anemia, wheezing, aspiration, recurrent pheumonia, chronic cough, stridor
older children and adolescents tx GERD: may be empirically treated for 4 weeks with PPI(Prilosec, Nexium, or Prevacid) may use H2s in children do not recommend prokinetics (Reglan) in children
older children dx of GERD: if atypical or extra-esophageal sx, do not respond to initial therapy, recurrent/progressive sx refer to gastroenterologist if vomiting, difficult or painful swallowing, may require endoscopy
older adults with H. pylori decreases acid secretion d/t the production of bacterial products and cytokines thus enhancing the acid inhibition of H2s and PPIs, then after eradication of H.pylori the acid reducing efficacy of the drugs is diminished
there is significant variation in older adults r/t drug clearance r/t two genotypes slow metabolizers(more predominant in white and Asian) and extensive metabolizers
Drugs affected by slow metabolizers in older adults: most affected: omeprazole least affected: rabeprazole (Aciphex) moderately affected: Nexium Therefore Aciphex and Nexium may do better in older adults.
H2s in older adults: Pepcid generally safe, caution with renal Axid: asymptomatic VT, hepatic damage Zantac and Tagamet: confusion, toxicity,lots of drug interactions with Tagamet
Prokinetics in older adults: Reglan risk for CNS toxicity. Contraindicated in CHF, RF, hypokalemia
Concerns of long-term PPI use: development of pre-cancerous cells d/t hypochlorhydria with enterochromaffin cell-like hyperplasia changes, increase risk of hip fxs if on PPIs longer than 2 years, Vitamin B12 deficiency
Created by: heatherbrown2020