GI Pharmacology and GERD Overview

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is the classic symptom of gastroesophageal reflux disease (GERD)?

Nausea

Frequent and persistent heartburn (correct)

Difficulty swallowing

Stomach cramps

What is the primary function of the lower esophageal sphincter (LES)?

To stimulate acid secretion

To aid in peristalsis

To transport nutrients to the bloodstream

To allow food to enter the stomach and prevent reflux (correct)

Which factor is not a contributor to decreased LES pressure?

Antacids (correct)

Chocolate

Alcohol

Garlic

Which of the following actions promotes the clearance of refluxed materials from the esophagus?

Gravitational effects Signup and view all the answers

Which material composition is considered to be most harmful in the context of esophageal damage?

Acid refluxed material Signup and view all the answers

Which of the following is an example of decreased mucosal resistance in the esophagus?

Decreased mucus production Signup and view all the answers

Which of the following beverages is known to stimulate acid secretion and could contribute to GERD?

Soda Signup and view all the answers

What are the three lines of defense required to be impaired for GERD to develop?

LES barrier impairment, clearance of refluxed materials, and mucosal resistance Signup and view all the answers

Which substance is NOT known to irritate the gastric mucosa?

Milk products Signup and view all the answers

What physiological action is primarily responsible for transporting food down the esophagus?

Peristaltic contractions Signup and view all the answers

What is one of the therapy goals for managing esophageal reflux?

Promote healing if the mucosa is injured Signup and view all the answers

What lifestyle modification can help in managing GERD symptoms?

Elevate the head of the bed 6-8 inches Signup and view all the answers

Which of these is a common symptom of esophageal reflux?

Heartburn Signup and view all the answers

In which phase of treatment are lifestyle changes implemented?

Phase I Signup and view all the answers

What is a common treatment for mild intermittent heartburn?

Lifestyle changes plus antacids Signup and view all the answers

Which agent is not a prokinetic agent mentioned in the treatment options?

Omeprazole Signup and view all the answers

What should be avoided for at least 3 hours after eating to help manage GERD symptoms?

Recumbency Signup and view all the answers

Which treatment is preferred for healing erosive esophagitis?

Proton pump inhibitors (PPIs) Signup and view all the answers

What should be decreased to help manage GERD symptoms?

Fat intake Signup and view all the answers

What is the main aim of pharmacologic interventions in GERD treatment?

To provide symptomatic relief and prevent complications Signup and view all the answers

What is the primary function of antacids in therapy?

Neutralize gastric acid Signup and view all the answers

Which of the following is a common product containing alginic acid?

Gaviscon Signup and view all the answers

What is the standard dosing for Esomeprazole?

20 to 40 mg daily Signup and view all the answers

What is a key characteristic of Proton Pump Inhibitors (PPIs)?

Effective in treating moderate to severe GERD Signup and view all the answers

What timing is recommended for taking PPIs?

30 to 60 minutes prior to meals Signup and view all the answers

What effect do prokinetic agents have on gastric motility?

They accelerate gastric emptying Signup and view all the answers

Which of the following is an appropriate use for Metoclopramide?

If motility dysfunction is documented Signup and view all the answers

During pregnancy, which therapy is commonly experienced by women?

GERD symptoms due to decreased LES pressure Signup and view all the answers

Which of the following is NOT an active ingredient in common antacids?

Proton pump inhibitors Signup and view all the answers

What is the role of alginic acid in antacids like Gaviscon?

To form a viscous barrier on top of gastric contents Signup and view all the answers

Study Notes

Gastro-Intestinal (GI) Pharmacology

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

GI Picture

Diagrams depicting the following components of the digestive system:
- Mouth
- Esophagus
- Stomach
- Small intestine (Duodenum, Jejunum, Ileum)
- Large intestine
- Colon
- Rectum
- Anus
- Liver
- Gallbladder
- Pancreas
- Ileocecal valve

Gastroesophageal Reflux Disease (GERD)

GERD is defined as the abnormal reflux of gastric contents into the esophagus.

Overview of GERD

Symptoms of GERD can include:
- Reflux
- Heartburn (frequent and persistent)

Normal Physiology Functions

Esophagus: Transports food from the mouth to the stomach.
Lower Esophageal Sphincter (LES): Relaxes when swallowing to allow food to enter the stomach. LES contracts to prevent reflux.

Pathogenesis

3 Lines of defense need to be impaired for GERD to develop:
- LES barrier impairment
- Relaxation of LES
- Low resting LES pressure
- Increased gastric pressure
- Decreased clearance of refluxed materials from esophagus
- Decreased esophageal mucosal resistance

Contributing Factors

Contributing factors to GERD include:
- Decrease LES Pressure: Chocolate, alcohol, fatty meals, coffee, cola, tea, garlic, onions, and smoking.
- Directly irritate gastric mucosa: Tomato-based products, coffee, spicy foods, citrus juices, NSAIDs, aspirin, iron, potassium chloride, and alendronate.
- Stimulate acid secretions: Soda, beer, and smoking.

Lines of Defense

Clearance of refluxed materials from esophagus: Primary peristalsis increases salivary flow, secondary peristalsis from esophageal distension, and gravitational effects.
Esophageal mucosal resistance: Mucus production in the esophagus, and bicarbonate movement from blood to the mucosa.

Factors Determining Extent of Esophageal Damage

The severity of esophageal damage depends on several factors:
- Amount of esophageal damage
- Composition of refluxed material (acid or alkaline)
- Volume of refluxed material
- Length of contact time of reflux material
- Natural sensitivity of esophageal mucosa
- Rate of gastric emptying

Typical Symptoms

Typical symptoms of GERD present when pH < 4
- Heartburn
- Belching
- Regurgitation
- Hypersalivation
Symptoms can be aggravated by meals and reclining position.

Atypical Symptoms

Atypical symptoms can include:
- Chronic cough
- Hoarseness
- Chest pain (mimics angina)
- May be only symptoms – “omeprazole test"

Complications

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

Warning Signs

If present, consider an endoscopy for the following:
- Dysphagia
- Odynophagia
- Bleeding
- Unexplained weight loss
- Choking
- Chest pain

Diagnosis

The diagnosis of GERD involves:
- Clinical symptoms and history
- Presenting symptoms and associated risk factors
- Give empiric therapy and look for improvement
- Endoscopy if warning signs present

When to Refer for Further Care

Refer for further care in the following conditions:
- Chest pain
- Heartburn while taking PPIs or continuous heartburn after 2 weeks of treatment.
- Nocturnal heartburn
- Frequent heartburn (>3 months)
- GI bleeding
- Concurrent use of NSAIDs
- Pregnancy or nursing
- Children <12

Therapy Goals

Therapy for GERD aims to:
- Alleviate or eliminate symptoms
- Diminish the frequency and duration of esophageal reflux
- Promote healing (if mucosa is injured)
- Prevent complications

Therapy

Therapy is directed at:
- Increasing LES pressure
- Enhancing esophageal acid clearance
- Improving gastric emptying
- Protecting esophageal mucosa
- Decreasing acidity of reflux
- Decreasing gastric volume available to be refluxed

Treatment

Treatment for GERD consists of three phases:
- Phase I: Lifestyle changes (2 weeks) and potentially OTC medications.
- Phase II: Pharmacologic intervention (standard/high-dose antisecretory therapy).
- Phase III: Surgical intervention for patients who don't respond to Phase I and II therapies or have severe complications.
- LES positioned within the abdomen with positive pressure may also be an issue.

Treatment Selection

Mild intermittent heartburn (Phase I): Lifestyle changes plus antacids
Symptomatic relief of mild to moderate GERD (Phase II): Lifestyle changes plus standard doses of proton pump inhibitors (PPIs) for 4-8 weeks
Healing of erosive esophagitis or moderate to severe GERD (Phase II): Lifestyle modifications plus PPIs for 8-16 weeks. PPIs are often preferred due to rapid symptom relief and higher healing rate. A prokinetic agent may also be added in selected cases

Examples of Prokinetic Agents

Metoclopramide
Domperidone

Lifestyle Modifications

Lifestyle modifications for GERD management include:
- Elevating the head of the bed (6-8 inches)
- Decreasing fat intake
- Smoking cessation
- Avoiding recumbency after meals (at least 3 hours post-prandial)
- Weight loss
- Limiting alcohol intake
- Wearing loose-fitting clothing
- Avoiding aggravating foods

Drug Therapy - Antacids

Antacids: Antacids increase LES pressure, do not promote esophageal healing, neutralize gastric acid, and cause alkalinization. Alginic acid forms a viscous solution that floats on top of gastric contents. Dose as needed– typical action is 1–3 hours.
- Products: Magnesium salts, aluminum salts, calcium carbonate, and sodium bicarbonate
  - Examples listed: Maalox/Mylanta, Maalox TC/Mylanta II, Gaviscon, Tums, Nugel.

Drug Therapy - PPIs

Proton Pump Inhibitors (PPIs): Used for moderate to severe GERD. All agents effective, choose based on cost.
Timing: Best taken 30-60 minutes prior to meals
- Products:
  - Esomeprazole
  - Lansoprazole
  - Omeprazole
  - Pantoprazole
  - Rabeprazole
Higher doses may be used for patients with partial response, breakthrough symptoms, or severe esophageal dysmotility. Always give second dose 30-60 min before evening meal.

Drug Therapy - Prokinetics

Prokinetic Agents: Enhance motility of smooth muscle from esophagus to proximal small bowel; accelerates gastric emptying and transit of intestinal contents.
- Results: Improved gastric emptying; enhanced tone of the lower esophageal sphincter (LES); and stimulates esophageal peristalsis

Prokinetic Agents-Products

Metoclopramide: Only if motility dysfunction documented; administer at least 30 minutes prior to meals; dose 10-15mg before meals and at bedtime

Special Populations

Pregnancy: GERD is common due to decreased LES pressure and increased abdominal pressure. Antacids are generally considered safe; however, avoid chronic high doses.

Counseling Questions

Before recommending a therapy ask:
- Duration and frequency of symptoms
- Quality and timing of symptoms
- Use of alcohol and tobacco
- Dietary choices
- Medications already tried to treat symptoms
- Other disease states present and medications being used

Case Study

AA, a 45-year-old male postal worker experiences 3-4 heartburn episodes per month, primarily after meals. He has tried Tums with limited success. He wants a more effective treatment.
Questions to ask:
- What questions should you ask AA first?
- What would cause you to refer AA to a physician?
- What type of GERD does AA have (mild, moderate, or severe)?
- What treatment should you recommend?

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz covers key concepts in Gastro-Intestinal pharmacology, with a special focus on Gastroesophageal Reflux Disease (GERD). It includes the functions of various components of the digestive system and the actions of drugs that normalize GI tract functions. Test your understanding of these vital topics in GI health.