NMT 150 GERD Week 11 AY2022-2023 PDF

Putting it Together - Week 11 NMT 150 - GERD Dr. Ellen Wong, ND - Toronto Campus  Learning Objectives Continue discussion of management of chronic...

Putting it Together - Week 11 NMT 150 - GERD Dr. Ellen Wong, ND - Toronto Campus  Learning Objectives Continue discussion of management of chronic conditions Practice discussing gut-brain connection to patients Practice using electronic resources to support design of management plan Practice creating a treatment plan that: Is comprehensive with evidence-informed rationale Meets requirements of informed consent Incorporates dietary, lifestyle and natural health products (with rationale for selection) based on patient’s needs and lifestyle Picture: decorative, woman's hands typing on laptop Picture: decorative, concept sketch of stomach, person with stethoscope in background Diagnostic Considerations Diagnostic Considerations GERD is mainly a symptom based diagnosis Most commonly due to inappropriate lower esophageal sphincter relaxation lack of compelling evidence that GERD is caused by H.pylori Commonly "test by treatment" of PPI Patients may have already tried OTC antacids Gastroscopy (and further investigations): absolute indications - heartburn with red-fags (bleeding, weight loss, dysphagia, vomiting, FHx of GI cancer) persistent symptoms after PPI trial for 4-8 weeks BID high-risk for Barrett's Esophagus - male, >50yoa, white, tobacco use, obese, long history of symptoms Picture: decorative, paper napkin with written "your gut feeling" Therapeutic Order Considerations Small Group Role Play Organize into groups of 4-5 Within your group, get into pairs (or group of 3) Scenario 1 - 15 minutes Scenario 2 - 15 minutes Picture: decorative, various vegetables, fruit, nuts, seeds, and chocolate Management Considerations  Picture: decorative, glass of alcohol with cigarette in ashtray Risk Factors >50yoa Smoking Frequent NSAID or aspirin use Obesity Low socioeconomic status Alcohol PMID: 28232473 Sleep deprivation can worsen symptoms (PMID: 31701607 - very small study) Picture: decorative, group of students in discussion Small Group Discussion Points of discussion: Dietary recommendation Lifestyle recommendation NHP recommendation "Are PPIs dangerous? I heard that it decreases my absorption of nutrients? Which ones? Should I take a supplement? Groups of 4-5 30 minutes Picture: decorative, examples of fried, fatty foods, chocolate and pastries Dietary Management Common Food Triggers EtOH Caffeine (including tea) Tobacco Fatty or fried foods Chocolate Mint Spicy foods / spices Citrus Tomato (ketchup) Low FODMAP diet similar (PMID: 34051134) Of note: removal of food triggers treats symptoms, not underlying cause Picture: decorative, dog lying on back on yellow sofa Lifestyle Management If living with obesity: weight loss If nocturnal symptoms: elevate head of bed Small meals Reduce / avoid late night meals / eating Avoid lying down soon after eating Picture: decorative, drawing of human outline with macaroni outlining connection between brain and stomach Lifestyle Management - Con't Gut-Brain Connection Regulation Communication between the CNS and ENS Links cognitive and emotional centers of brain to the digestive system Previously: CNS affects ENS; now - ENS affects CNS too Stress management - mindfulness, meditation CBT Hypnotherapy Picture: decorative, wooden ladle with various supplements NHP Management Melatonin (PMID: 20082715) very small study 3 mg qd before bed; 8 weeks Artichoke leaf (PMID: 14653829) GERD with functional dyspepsia Associated biliary concerns 640 mg tid; 6 weeks specific formulations DGL (Deglycyrrhizinated Licorice) lots of rat studies may be useful if GERD in addition to H.pylori (PMID: 27614124) and peptic ulcer disease (several very old studies) Picture: decorative, hand holding pill Let's Chat About PPIs TL;DR: nutrient deficiencies may occur if: long-term use of PPI; baseline / borderline deficiency (either because of diet or underlying health concern) Mostly observational studies B12: higher doses of PPI (>1 pill/day) for >2yrs Vitamin C: if also positive H. pylori Picture: decorative, hand holding pill Let's Chat About PPIs Calcium + Fracture risk: 2010 - FDA added "warning"; removed in 2011 risk may increase if higher dose of PPI or >1yr (or both) studies: renal failure patients on dialysis or severe hypochlorhydria Iron: decrease in hemoglobin, hematocrit and MCV PPI > 1 yr no recommendation for iron supplementation Picture: decorative, hand holding pill Let's Chat About PPIs Magnesium: PPI > 1 yr Severe hypomagnesemia - usually other underlying health conditions Other medications can decrease Mg as well subclinical insufficiency