Gastroesophageal Reflux Disease (GERD)

etiology and pathophysiology

risk factors: presence of hiatal hernia, damage to esophageal mucosa, delayed gastric emptying, obesity, smoking, lying down after eating

foods to avoid: caffeine, citrus, peppermint, spicy foods, caffeinated drinks, chocolate, tomato

signs and symptoms

typical

regurgitation of food

atypical

excessive belching

treatment goals

decrease frequency of reflux occurence

alleviate of patient's acute symptoms

prevent long-term cell damage and disease progression

diagnostic criteria and testing

upper endoscopy

esophageal biopsy

ambulatory reflux monitoring (pH impedance test)

monitoring and follow-up

frequency of symptoms

reported severity of symptoms

healing of mucosal tissue

treatment options

non-pharmacological

pharmacological

avoid eating 2-3 hours before lying down

raise head of the bed 6-8 inches (not just pillows!)

avoid foods that may exacerbate GERD symptoms

eat smaller meals throughout the day

weight reduction

smoking cessation

wear loose-fitting clothing

dental erosion

first-line

proton pump inhibitors (PPIs)

second-line

H2 receptor antagonists (H2RAs)

omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), dexlansoprazole (Dexilent), pantoprazole (Protonix)

AEs: sedation, tachycardia, anticholinergic effects, Vit. B12 deficiency (with chronic use)

famotidine (Pepcid), cimetidine (Tagamet), ranitidine (Zantac)

antacids

provides cheap, immediate relief from reflux symptoms

NERD (non-erosive reflux disease)

pts do not have any visible esophageal injury

lower esophageal sphincter (LES) doesn't close properly, so stomach contents leak back into the esophagus, oral cavity, and/or lungs

maintain healthy dental habits to prevent tooth decay

Tums, Maalox, Rolaids, Mylanta

alarm symptoms: weight loss, difficulty swallowing, presence of epigastric mass, bleeding from mouth, choking

MOA: irreversibly block the gastric H+/K+-ATPase, inhibiting gastric acid secretion

AEs: reduced absorption of vitamins, headache, GI upset, diarrhea

an 8-week course is recommended for symptom relief and healing of erosive esophagitis

take 30-60min before meals for maximal pH control

44% of Americans experience heartburn at least once per month

sharp, burning pain in chest or throat

dry, chronic cough

acidic taste in mouth

laryngitis/hoarseness

asthma-like symptoms

image

complications of GERD

esophageal erosions

peptic stricture or obstruction

Barrett’s esophagus

adenocarcinoma

pulmonary disease

promote healing of the injured mucosa

meds that may cause GERD: anticholinergics, dopamine, NSAIDS, aspirin, iron, BZDs, CCBs, estrogen/progesterone

diagnosis can be presumed in the setting of typical symptoms of heartburn and regurgitation

neutralize secreted stomach acid

cimetidine has a ton of DDIs! (inhibits several CYP enzymes)

caution in pts with renal impairment

calcium carbonate is the most potent

onset of action: 1 hour

duration of action: 24-72 hours

duration of action: 3 hours

adjunctive therapy

further diagnostic investigation is needed before administration

for pts with known or suspected motility disorder

metoclopramide, bethanechol, cisapride (available through limited access program only)

not needed if pt has typical GERD syptoms

used for pts with alarm symptoms

needed to identify complications (Barrett’s, adenocarcinoma, etc.)

indicated before endoscopic/surgical therapy in patients with NERD

documents how long gastric pH is <4

determines severity/frequency of reflux

evaluate for C. difficile in pts receiving PPIs who have diarrhea that is not improving

MOA: competitively inhibit parietal cell H2 receptors to suppress gastric acid secretion in a linear, dose-dependent manner

administered as inactive prodrugs

substrates for CYP2C19 and CYP3A4

recommended for treatment of nocturnal acid secretion!

pts should expect to see relief in symptoms after 7 days of treatment