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GERD
| Question | Answer |
|---|---|
| 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
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