Gastroesophageal Reflux Disease (GERD) PDF

Gastroesophageal Reflux Disease GERD Learning Objectives ➢ Introduction about GERD ➢ Explain the underlying causes of gastroesophageal reflux disease (GERD). ➢ Understand the difference between typical, atypical, and alarm symptoms. ➢ Identify the desired therapeutic outcomes for patients with GER...

Gastroesophageal Reflux Disease GERD Learning Objectives ➢ Introduction about GERD ➢ Explain the underlying causes of gastroesophageal reflux disease (GERD). ➢ Understand the difference between typical, atypical, and alarm symptoms. ➢ Identify the desired therapeutic outcomes for patients with GERD. ➢ Recommend appropriate nonpharmacologic ➢ The pharmacologic interventions for patients with GERD. ➢ GERD pharmacological for infants ➢ GERD pharmacological during pregnancy The incidence of GERD complications such as erosive esophagitis and Barrett esophagus increased with age Etiology ➢Decreased LES pressure can occur via: ➢Decreased lower esophageal sphincter (LES) tone • Spontaneous relaxation These processes can be transient and are often due to physical activity, food, or medications. • Increased intraabdominal pressure • An atonic LES ➢Intra abdominal pressure ➢Spontaneous relaxation of the LES occurs during: ▪ Intra abdominal pressure may occur during: • Vomiting • Straining • Belching • Exercise • Retching • Bending over • Esophageal distention • Valsalva maneuver • Hiatal Hernia Hiatal Hernia ▪ The Valsalva maneuver is a breathing method that may slow your heart when it's beating too fast. ▪ This creates a forceful strain that can trigger your heart to react and go back into normal rhythm. ➢Foods and medications Risk Factors • Slowed esophageal clearance • Decreased salivary buffering • Impaired mucosal resistance • Delayed gastric emptying • Obesity McGraw-Hill Education, 2018 Obesity and GERD Esophageal and Mucosal Protection / GERD ➢ Obesity is a major risk factor for developing GERD symptoms and complications. ➢Swallowing enhances esophageal clearance by increasing salivary flow..?? ➢ It increased risk of Barrett esophagus, esophageal adenocarcinoma, and erosive esophagitis. ➢Salivary production decreases during sleep and in older persons..?? ➢ Obese patients have more transient LES relaxations, incompetent LES function, and impaired esophageal motility. ➢ Symptoms can be eliminated by: ➢Most patients with GERD do not produce abnormally large amounts of acid but slowed esophageal clearance of gastric contents increases contact time of refluxate with esophageal mucosa, which leads to symptoms or erosion. ❖Reduction in body mass index by at least 3.5 kg/m2 or ❖Decreased waist circumference Symptoms Symptoms ➢Typical symptoms ➢Typical symptoms • Heartburn (Pyrosis) (substernal sensation of warmth or burning rising up from the ➢Atypical symptoms abdomen that may radiate to the neck) • Hypersalivation ➢Alarm symptoms • Regurgitation • Belching • The symptoms increased with activities that worsen reflux such as bending over, or eating a high fat meal) ➢Atypical symptoms ➢Alarm symptoms • Chronic cough • Dysphagia • Laryngitis • Odynophagia • Hoarseness • Weight loss • Wheezing • Bleeding • Noncardiac chest pain (Alarm symptoms indicate GERD complications such as Barrett esophagus, • Asthma (~50% with asthma have GERD). esophageal strictures, or esophageal adenocarcinoma and require further diagnostic evaluation) (Atypical symptoms considered if typical symptoms are also present) Types of dysphagia ➢Esophageal manometry • Oropharyngeal dysphagia It is a test used to assess pressure and motor function of the esophagus which aids in the • Esophageal dysphagia evaluation of how well the muscles in the esophagus Goals of Therapy 01 02 03 04 Alleviate symptoms Decrease the frequency of recurrent disease Promote healing of mucosal injury Prevent complications Non-Pharmacological therapy ➢lifestyle modifications (a) Losing weight if overweight or obese. ➢Surgical options are effective in (b) Elevating the head of the bed with a foam wedge if symptoms are worse • Reducing GERD symptoms, with as many as 90% of when recumbent. (c) Eating smaller meals and avoiding meals 3 hours before sleeping. patient's symptom free after 10 years, and up to 60% remaining off PPIs at 17 years. (d) Avoiding foods or medications that exacerbate GERD. • Surgery is not recommended for patients who respond to (c) Smoking cessation. adequate PPI therapy. (d) Avoiding alcohol. Nissen fundoplication ➢Pharmacologic therapies for GERD increasing the pH of gastric contents by: Pharmacological Therapy involve ➢Direct gastric acid neutralization ➢Reducing acid production Antacids and Alginic Acid ➢ Antacids (Magnesium calcium carbonate ) hydroxide/ Aluminum hydroxide/ • They are useful for intermittent treatment of GERD symptoms. ➢Side effects: • Constipation or diarrhea depending on the formulation being used. ?? • Antacids are usually well tolerated • Antacids chelate with medications such as fluoroquinolones, tetracyclines, • Aluminum or magnesium containing antacids may result in electrolyte abnormalities, particularly in patients with renal impairment. iron products, and thyroid hormones; therefore, doses should be separated by several hours to avoid decreased efficacy. ➢Alginic acid creates a viscous barrier that can aid in acid neutralization and is often used in combination with antacids. Histamine 2 Receptor Antagonists (H2RAs) (Cimetidine, Famotidine, Nizatidine, Ranitidine) They decrease acid secretion by blocking histamine 2 receptors in gastric parietal cells. They can be administered prophylactically. H2RAs are more effective than antacids in controlling chronic GERD symptoms but less effective than PPIs. H2RAs are well tolerated. • PPIs block gastric acid secretion by inhibiting gastric ➢Side effects H+/K+adenosine triphosphatase in gastric parietal cells ❑Headache and nausea. ❑Gynecomastia ❑Vitamin B12 deficiency ❑Cimetidine is a weak inhibitor of the cytochrome P450, while other H2RAs have limited drug interactions. ❑Most H2RAs are eliminated through kidney and require dose adjustment in renal dysfunction. Proton Pump Inhibitors (PPIs) Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Dexlansoprazole, • Because PPIs degrade in acidic environments, they are typically formulated in delayed release capsules or tablets. • PPIs are generally well tolerated Notes about the drug absorption ➢The most common side effects are: ❑ Headache and GI effects such as diarrhea and nausea. ❑Renal complications (acute kidney injury and chronic kidney disease) ❑Bone fractures, and dementia have been reported from retrospective observational ➢ All PPIs can decrease the absorption of medications that require an acidic environment to be absorbed (eg, dabigatran, itraconazole, dipyridamole). ➢ PPIs reduced absorption of micronutrients such as calcium, magnesium, and vitamin B12 with long term use has also been reported. studies and case reports. ➢ In patients with documented hypocalcemia, it is reasonable to replete calcium with the citrate rather ❑Several concerns have been raised about consequences of long-term PPI use. than the carbonate salt due to improved absorption in a less acidic environment. Notes about the drug absorption ➢ Prokinetic Agents: used for GERD with gastroparesis ➢ For patients unable to swallow intact capsules, the capsule • Metoclopramide contents can be mixed in water or orange juice. ➢ Most patients should be instructed to take their PPI in the morning, 30 to 60 minutes before breakfast to maximize efficacy. Prokinetic Agents and Sucralfate • It is a central dopamine antagonist, accelerates gastric emptying and can increase LES pressure. • Side effects can be significant and include extrapyramidal effects and tardive dyskinesia. • Domperidone ➢ Dexlansoprazole and the combination product omeprazole– sodium bicarbonate may be taken without regard to food. • It is a peripherally acting dopamine antagonist that does not have central nervous system toxicities; however, it is not approved. ➢Sucralfate Pharmacology of • It is a non-absorbed aluminum salt of sucrose octasulfate • It dissociate to anion forms in the gastric acid then form a barrier on ulcers. - Intermitted or Mild Heartburn - Typical symptoms • It buffers acid and inhibit the pepsin actions. • It Adsorbs bile slats. - Atypical symptoms • It has limited value for treating GERD. Intermitted or Mild Heartburn • Nonprescription medications • If symptoms are unrelieved with lifestyle medications and nonprescription medications after 2 weeks, patient should seek medical attention Treatment of typical symptoms • Prescription medications • Use antacid suppressions ,four times daily use is considered as off-label use. • Patients with moderate to sever symptoms must initiated with PPIs. • If symptoms recur consider maintenance therapy Treatment of atypical symptoms, erosive esophagitis or complications • Prescription medications Infants & Children with GERD -In infants GERD may occurs several times a day with no clinical consequence. -In adults, GERD is present when symptoms become troublesome or if complications are present. Regurgitation is common in infants younger than 3 months. Most babies are happy spitters they are comfortable, gaining weight, and have no breathing problems caused by vomiting. • Start with twice daily PPI therapy (Off-Label use) • If no responding, patients should be evaluated with manometer and ambulatory reflux monitoring. Lifestyle modifications in pediatric patients with uncomplicated GERD • Troublesome symptoms that require further investigation include vomiting, apnea, poor weight gain, sleep disturbances, and refusing to eat. ➢ Symptoms usually respond to supportive therapy, including dietary adjustments such as smaller meals and more frequent feedings. ➢Causes ➢ Milk protein allergy in infants can mimic the presentation of GERD, so • Formula fed infants • Children with neurologic impairment and impaired changes in maternal diet swallowing ➢ Postural management (ie, positioning the infant in an upright position, • Obesity • Congenital abnormalities especially after meals) may be helpful but should not be used to treat GERD of the esophagus, cystic symptoms in sleeping infants. Fibrosis, or hiatal hernia are at a higher risk for developing GERD. ➢ In older children, as with adults, maintaining a healthy body weight is recommended GERD During Pregnancy ➢ Acid suppression with a PPI is the mainstay of pharmacologic therapy for pediatric GERD. ➢Lifestyle modifications such as eating smaller meals can reduce heartburn If a 2to 4week trial of lifestyle modifications is not effective, medical therapy may be indicated ➢ Monotherapy with an H2RA can be used if PPIs are unavailable or contraindicated. ➢Mild to moderate GERD symptoms can be treated with antacids that have ➢ A 4to 8week course can be attempted, followed by a taper. limited systemic absorption, such as calcium, magnesium, and aluminum. ➢ If symptoms return or if the patient is unable to discontinue the PPI (or H2RA), an endoscopy may be required. ➢ Increased use of PPIs in children has led to concerns because long-term safety is unknown. Contraindications ➢Antacids containing magnesium trisilicate specifically should be avoided due to risk of respiratory distress, cardiovascular impairment, hypotonia, and nephrolithiasis if used for long periods of time at high doses. ➢Also, compounds containing sodium bicarbonate should be avoided due to risk of metabolic alkalosis in both the mother and the fetus, as well as precipitating fluid overload. and regurgitation. ➢Severe, frequent heartburn can be started on a PPI. ➢No increase in the number of birth defects in infants exposed to PPIs in utero.