Esophageal Reflux Management Quiz

Gastrointestinal (GI) Pharmacology

• GI pharmacology involves the actions of drugs affecting GI system function.
• These drugs normalize impaired function in the GI tract.
• The GI tract is the pathway of the digestive system, from the mouth to the anus (oral cavity, pharynx, esophagus, stomach, small intestine, large intestine, and anal canal).

GI Picture

• A diagram shows the parts of the digestive system including the mouth, esophagus, stomach, small intestine (duodenum, jejunum, ileum), large intestine (colon), rectum, anus, liver, gallbladder, and pancreas.
• The diagram visually represents the location of these organs within the body.
• The cececum and ileocecal valve are labeled.

Gastroesophageal Reflux Disease (GERD)

• GERD is the flow back or return of stomach contents into the esophagus, causing symptoms or mucosal damage.
• Gastroesophageal reflux is when stomach contents return to the esophagus.
• A classic symptom is frequent and persistent heartburn.

Normal Physiology Functions (Esophagus)

• The esophagus transports food from the mouth to the stomach through peristaltic contractions.
• The lower esophageal sphincter (LES) relaxes during swallowing to allow food into the stomach and then contracts to prevent reflux.

Pathogenesis of GERD

• Three lines of defense must be impaired for GERD to develop.
• These defenses can be compromised due to:
• LES barrier impairment
• Relaxation of LES
• Low resting LES pressure
• Increased gastric pressure
• Decreased clearance of refluxed materials
• Decreased esophageal mucosal resistance

Contributing Factors

• Factors that decrease LES pressure, irritate the gastric mucosa, or stimulate acid secretions:
• Chocolate, alcohol, fatty meals, coffee, cola, tea, garlic, onions, smoking
• Tomato-based products, coffee, spicy foods, citrus juices, NSAIDs, aspirin, iron, potassium chloride, alendronate
• Soda, beer, smoking

Lines of Defense

• Refuxed materials are cleared from the esophagus through:
• Primary peristalsis triggered by swallowing (increasing salivary flow)
• Secondary peristalsis from esophageal distension
• Gravitational effects
• Esophageal mucosal resistance (including mucus production and bicarbonate movement from blood to mucosa)

Factors Affecting Esophageal Damage

• Esophageal damage depends on:
• The composition of refluxed material (acid vs. alkaline)
• The volume of refluxed material
• The length of contact time of reflux material
• The natural sensitivity of the esophageal mucosa
• The rate of gastric emptying

Typical Symptoms

• Common symptoms appear when pH is less than 4:
• Heartburn, belching, regurgitation, hypersalivation
• These symptoms may be exacerbated by eating or reclining.

Atypical Symptoms

• Atypical symptoms of GERD can include:
• Chronic cough, hoarseness, chest pain (mimicking angina)
• These symptoms may be the only indication of GERD.

Complications

• Potential complications of GERD include:
• Esophagitis
• Esophageal strictures and ulcers
• Hemorrhage
• Perforation
• Aspiration
• Precipitation of an asthma attack

Warning Signs

• Conditions that merit endoscopic evaluation include:
• Dysphagia
• Odynophagia
• Bleeding
• Unplained weight loss
• Choking
• Chest pain

Diagnosis

• GERD diagnosis involves a review of clinical symptoms and history.
• Presenting symptoms and associated risk factors are considered.
• Empiric therapy and evaluation of improvement are common diagnostic pathways.
• Endoscopy is used if warning signs are present.

When to Refer for Further Care

• Conditions requiring referral for additional care include:
• Chest pain
• Heartburn while taking proton pump inhibitors (PPIs)
• Heartburn that persists after 2 weeks of treatment
• Nocturnal heartburn symptoms
• Frequent heartburn lasting 3 or more months
• GI bleeding or other warning signs
• Concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs)
• Pregnancy or breastfeeding
• Children under 12 years old

Therapy Goals

• Therapy aims to:
• Alleviate or eliminate symptoms
• Reduce the frequency and duration of esophageal reflux
• Promote healing in injured mucosa
• Prevent complications

Therapy

• Treatment strategies address:
• Increasing lower esophageal sphincter (LES) pressure
• Enhancing esophageal acid clearance
• Improving gastric emptying
• Protecting esophageal mucosa
• Decreasing the acidity of reflux
• Decreasing gastric volume available for reflux

Treatment Phases

• GERD treatment is categorized into three phases:
• Phase 1: Lifestyle changes (2 weeks) include lifestyle modifications and patient-directed therapy with over-the-counter (OTC) medications.
• Phase 2: Pharmacologic intervention, with standard/high-dose antisecretory therapy
• Phase 3: Surgical intervention for patients who don't respond to pharmacologic therapy, or have severe complications

Treatment Selection

• Mild intermittent heartburn is treated with lifestyle changes and antacids.
• Symptomatic relief for mild to moderate GERD uses lifestyle changes and proton-pump inhibitors (PPIs) for 4-8 weeks.
• For healing erosive esophagitis or moderate to severe GERD, lifestyle changes plus PPIs for 8-16 weeks.
• PPIs are preferred for their rapid symptom relief and healing rate.
• Prokinetic agents may also be considered in selected patients.

Examples of Prokinetic Agents

• Metoclopramide
• Domperidone

Lifestyle Modifications

• Elevating the head of the bed, decreasing fat intake, quitting smoking, avoiding recumbency after meals, achieving weight loss, limiting alcohol intake, loose-fitting clothing, and avoidance of aggravating foods are lifestyle strategies.

Drug Therapy - Antacids

• Antacids: reduce gastric acid, frequently containing magnesium salts, aluminium salts, or calcium carbonate and sodium bicarbonate.
• They increase LES pressure and do not promote esophageal healing.

Drug Therapy - PPIs

• Proton pump inhibitors (PPIs) are used to treat moderate-to-severe GERD.
• Omeprazole, esomeprazole, lansoprazole, pantoprazole, and rabeprazole are examples.

Drug Therapy - Prokinetiacs

• Prokinetic agents enhance smooth muscle motility from the esophagus to the proximal small bowel, accelerating gastric emptying and intestinal transit.
• Metoclopramide is an example.

Special Populations (Pregnancy)

• GERD is common in pregnancy due to decreased LES pressure and increased abdominal pressure.
• Antacids are generally safe but avoid chronic high doses.

Counseling Questions

• Key questions to consider before recommending a treatment include:
• Duration and frequency of symptoms
• Quality and timing of symptoms
• Alcohol and tobacco use
• Dietary choices
• Medications already tried
• Presence of other diseases or medications

Case Study

• A 45-year-old male postal worker, with occasional heartburn after meals, and limited success with Tums, seeks further treatment options.
• The case study involves questions about additional questions to ask the patient, reasons to refer him to a physician, the patient's GERD type, and recommended treatment options.

Test your knowledge on the goals, treatments, and lifestyle modifications for managing esophageal reflux and gastroesophageal reflux disease (GERD). This quiz covers both pharmacological and non-pharmacological approaches, including the role of the lower esophageal sphincter. Perfect for students and healthcare professionals alike.