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condition that develops when reflux of the stomach contents causes macroscopic damage to the esophagus
GERD (gastoesophageal reflux disease)
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risk factors for GERD (7)
- 1) family history
- 2) obesity
- 3) smoking
- 4) EtOH
- 5) respiratory diseases
- 6) diet & meds
- 7) reflux chest pain syndrome
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deterioration of squamous tissue into columnar (intestine-like) in the esophagus; can lead to adenocarcinoma of esophagus
Barrett's esophagus
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dynophagia
painful swallowing
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2 types of esophageal syndromes in GERD
- 1) symptomatic syndromes
- 2) syndroms w/ esophageal injury
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complications of GERD (5)
- 1) erosive esophagitis
- 2) stricture
- 3) Barrett's esophagus
- 4) adenocarcinoma
- 5) reduction in QOL
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Los Angeles classification
grades A (mild) - D (severe)
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Savary Miller classification
grades I (mild) - IV (severe)
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What therapy is directed at (5)
- 1) decrease acidity of refluxate
- 2) decrease amount refluxed
- 3) improve gastric emptying
- 4) increase LES pressure
- 5) protect esophageal mucosa
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GERD exacerbating drugs (10)
- 1) NSAIDs
- 2) opioids
- 3) adrenergic agonists
- 4) calcium channel blockers
- 5) progesterone
- 6) alcohol, caffeine, nicotine
- 7) tetracyclines
- 8) potassium chloride
- 9) iron salts
- 10) bisphosphonates
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rx medications for moderate-severe or complicated GERD (4)
- 1) acid suppression
- 2) promotility agents
- 3) mucosal protectants
- 4) combination tx
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the mainstay of GERD therapy
acid suppression
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drug class of famotidine, ranitidine, nizatidine, cimetidine
H2RA's (H2 blockers)
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H2RA place in therapy
patients w/ mild-moderate non-complicated GERD
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drug class of esomeprazole, omeprazole, lansoprazole, rabeprazole, pantoprazole, dexlansoprazole
proton pump inhibitors
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appropriate initial PPI dose for most patients
once daily
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timing of PPI dose
15-30min prior to eating
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drug class of metoclopramide
promotility agent
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MOA of metoclopramide
DA2 receptor antagonist
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duration of GERD treatment
reassess initially w/in 2-4 weeks
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diration of erosive disease treatment
continuous for 16 weeks (to forever)
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treatment for GERD w/ delayed upper GI emptying
metoclopramide
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treatment of new diagnosis of GERD w/ erosive esophagitis
PPI for 16 weeks - forever
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PPI adverse effects (3)
- 1) infections (community acquired pneumonia, C. diff)
- 2) fractures
- 3) hypomagnesemia
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how to manage PPIs and CDAD
start PPIs after finishing antibiotics course
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relationship between PPIs and hip fracture risk
PPIs cause decreased calcium absorption
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causes of peptic ulcer disease (PUD) (3)
- 1) H. pylori
- 2) NSAIDs
- 3) SRMD (stress related mucosal damage)
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complications of PUD (3)
- 1) bleeding
- 2) perforation
- 3) gastric outlet obstruction
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Triple therapy for H. pylori treatment
- Triple Therapy (1st line treatment)
- - 2 antibiotics (clarithromycin + amoxicillin) BID
- - PPI BID
10-14 days
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duration of H. pylori treatment
10-14 days
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if a patient is allergic to penicillin, what do you do for H. pylori treatment?
using triple therapy as a 1st line treatment, substitute amoxicillin with metronidazole
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Quadruple therapy for first line H. pylori treatment
- PPI BID
PLUS...
- QID:
- - Bismuth subsalicylate or subcitrate
- - Metronidazole
- - Tetracycline
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mechanism of NSAID-induced GI injury
COX inhibition -> PG inhib., decr. mucus formation, decr. bicarbonate formation -> impairment of mucosal healing
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PUD high risk factors (2)
- 1) hx of previous complicated ulcer
- 2) multiple (>2) moderate risk factors
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PUD moderate risk factors (4)
- 1) >65yo
- 2) high dose NSAID tx
- 3) previous hx of uncomplicated ulcer
- 4) concurrent use of ASA, corticosteroids, or anticoagulants
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Misoprostol
- synthetic PGE1 analog
- used as PG replacement for PUD prophylaxis
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PUD prophylactic therapies (2)
- 1) PG replacement (Misoprostol)
- 2) PPI + NSAID
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duration of PPI tx for healing NSAID-induced ulcers
8-12 weeks
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does enteric coating protect against GI bleeding?
NO
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