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Gastroesophageal Reflux Disease (GERD) (etiology and pathophysiology (risk…
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
meds that may cause GERD: anticholinergics, dopamine, NSAIDS, aspirin, iron, BZDs, CCBs, estrogen/progesterone
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
44% of Americans experience heartburn at least once per month
signs and symptoms
typical
regurgitation of food
sharp, burning pain in chest or throat
acidic taste in mouth
atypical
excessive belching
dental erosion
dry, chronic cough
laryngitis/hoarseness
asthma-like symptoms
treatment goals
decrease frequency of reflux occurence
alleviate of patient's acute symptoms
prevent long-term cell damage and disease progression
promote healing of the injured mucosa
diagnostic criteria and testing
upper endoscopy
not needed if pt has typical GERD syptoms
used for pts with alarm symptoms
esophageal biopsy
needed to identify complications (Barrett’s, adenocarcinoma, etc.)
ambulatory reflux monitoring (pH impedance test)
indicated before endoscopic/surgical therapy in patients with NERD
documents how long gastric pH is <4
determines severity/frequency of reflux
diagnosis can be presumed in the setting of typical symptoms of heartburn and regurgitation
monitoring and follow-up
frequency of symptoms
reported severity of symptoms
healing of mucosal tissue
alarm symptoms
: weight loss, difficulty swallowing, presence of epigastric mass, bleeding from mouth, choking
pts should expect to see relief in symptoms after 7 days of treatment
treatment options
non-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
maintain healthy dental habits to prevent tooth decay
pharmacological
first-line
proton pump inhibitors (PPIs)
omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), dexlansoprazole (Dexilent), pantoprazole (Protonix)
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
duration of action: 24-72 hours
evaluate for
C. difficile
in pts receiving PPIs who have diarrhea that is not improving
administered as inactive prodrugs
substrates for CYP2C19 and CYP3A4
antacids
provides cheap, immediate relief from reflux symptoms
Tums, Maalox, Rolaids, Mylanta
neutralize secreted stomach acid
caution in pts with renal impairment
calcium carbonate
is the most potent
duration of action: 3 hours
second-line
H2 receptor antagonists (H2RAs)
AEs: sedation, tachycardia, anticholinergic effects, Vit. B12 deficiency (with chronic use)
famotidine (Pepcid), cimetidine (Tagamet), ranitidine (Zantac)
cimetidine
has a ton of DDIs! (inhibits several CYP enzymes)
onset of action: 1 hour
MOA: competitively inhibit parietal cell H2 receptors to suppress gastric acid secretion in a linear, dose-dependent manner
recommended for treatment of nocturnal acid secretion!
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)
complications of GERD
esophageal erosions
peptic stricture or obstruction
Barrett’s esophagus
adenocarcinoma
pulmonary disease
