- GERD (Gastroesophageal reflux disease)
What is GERD?
GERD = Gastroesophageal reflux disease
Definition: symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus
What are characteristics of GERD?
Prevalent in patients of all ages
Many patients do not seek treatment
No gold standard in diagnostic criteria
- A chronic condition
- - Once you get it = usually life-long
- Common in pregnancy
- - Increased hormone production
- - Growing fetus causes pressure
What are the three categories of GERD?
- Erosive esophagitis
- Non-erosive reflux disease (NERD)
- Barrett’s esophagus
What is a difference between GERD and NERD?
- More men have GERD
- More women have NERD
What makes Barrett's esophagus different from GERD?
In Barrett's esophagus, the epithelial cells change into specialized columnar cells, which increases the risk of cancer by about 30%.
Barrett's esophagus can develop with long-term GERD.
What is esophagitis?
Gastric content can inflame and damage the lining of the esophagus (esophagitis).
You may have a lot of symptoms, but not a lot of esophageal inflammation, and visa versa.
What does regurgitated liquid usually contain?
usually contains acid
(and even some bile
) that are produced by the stomach.
Our medications usually target the pepsin and the acid, but not so much the bile.
- Pepsin is active in an acidic environment, so acid suppressing therapies can decrease GERD.
What are the goals of treatment for GERD?
- Alleviate symptoms
- Decrease the frequency of recurrent disease
- Promote healing of mucosal injury
- Prevent complications
What are some possible treatment options for GERD?
- Lifestyle changes
- Pharmacologic intervention
- Endoscopic therapies
What are some examples of lifestyle changes for the treatment of GERD?
- change diet
- - no spicy foods
- - decrease citric or acidic products
- - decrease fatty foods
- - don’t eat within three hours of bedtime
- - smaller more frequent meals
: foam wedges to give 30 degree angle
What is perhaps the most important factor in preventing acid reflux?
Lower Esophageal Sphincter (LES)
What is the LES?
The Lower Esophageal Sphincter (LES) is a specialized ring of muscle that surrounds the lower-most end of the esophagus where it joins the stomach.
Is the LES usually open or closed?
Actively closed most of the time
Contracts and closes off the passage from the esophagus into the stomach
Closing of the passage prevents reflux
- When food or saliva is swallowed, the LES relaxes for a few seconds to allow the food or saliva to
- pass from the esophagus into the stomach, and then it closes again.
- Open LES
- Closed LES
What may decrease LES pressure?
- Fatty/Fried foods
- Chili peppers
What does the LES have to do with GERD?
- Laxity of the LES
- Easier opening of the LES allows for a greater backward flow of acid into the esophagus
Does the severity of symptoms typically correlate with the disease?
The severity of symptoms DOES NOT correlate to the severity of the disease.
What are typical symptoms of GERD?
- *Heartburn (painful) hallmark symptom**
- Regurgitation (food particles in mouth)
What are atypical symptoms of GERD?
- Chest pain
- Dental erosions
- Metallic taste in mouth
What are the two different ways GERD can affect asthma?
50% of patients with asthma
actually have GERD
- Two different ways GERD can affect asthma:
- 1) affect vagus nerve
- 2) aspiration of reflux into the lung
can worsen asthma
What is the mechanism of action for antacids and what does that tell us about when to use antacids?
Reacts with hydrochloric acid to form water and respective salt, thereby neutralizing acid.
Increases gastric pH.
Does not decrease acid production.
USE antacids when you already have heartburn.
What other medications (besides antacids) treat mild to moderate GERD?
Histamine (H2) Antagonists
Mainly used for heart-burn (not inflammation or damage)
- Does NOT heal the inflammation
What is the mechanism of action for H2 antagonists and what does that tell us about when to take them?
Bind H2 receptors on parietal cell preventing histamine-induced activation
Best if taken 30 minutes before a meal
How well do H2 antagonists work?
12 weeks of therapy = symptomatic improvement in 60% of patients
What are the H2 Antagonists?
Which medications treat moderate to severe GERD?
Proton Pump Inhibitors
Shuts off acid productionfor longer periods of time
Protects esophagus so it can HEAL
- May also strengthen the LES
What is the proton pump inhibitor mechanism of action and what does that tell us about when to take them?
Blocks the secretion of acid into the stomach by the acid-secreting parietal cells
Take 1 hour before meals
What is an important patient education counseling point for proton pump inhibitors?
Avoid alcohol due to GI irritation
What are the Proton Pump Inhibitors?
What is an ulcer?
Ulcers: break in the lining of the esophagus that occurs in an area of inflammation
How do ulcers form?
Acid reflux into the esophagus damages the cells that line the esophagus.
The body responds with inflammation (esophagitis)
If the damage is severe, an ulcer forms.
May erode into the esophageal blood vessels and give rise to bleeding into the esophagus
commonly causes ulcers
Bacteria that infects the mucus lining of stomach and upper intestines
Commonly cause ulcers, gastritis
2/3 of the world are infected
Most are Asymptomatic
What is a commonly used class of medications that could cause ulcers?
NSAIDS also can cause ulcers: decrease prostaglandins, which increase risk of ulcers.
What are the two primary therapy options for treating H-Pylori?
What types of stimuli will cause nausea and vomiting?
(substance that causes vomiting) stimuli
to chemoreceptor trigger zone (CTZ)
through blood or CSF
causing motion sickness
Direct irritation of GI tract
sending stimuli to vomiting center in brain
with psychiatric disorders
What do pro-motility drugs do?
Increase the pressure in the lower esophageal sphincter (LES) and strengthen the contractions (peristalsis) of the esophagus
Speeds up the emptying of the stomach
Does NOT heal inflammation
When should a patient take a pro-motility agent?
Take 30 minutes before a meals and at bedtime
L.P. a 45 yo male, visits your community
pharmacy today complaining of burning in his chest after eating. He is awaken by the pain at night and wants to know what you can do to fix his problem. What do you recommend for L.P.?
- First ask about his diet and recommend any needed changes.
- Recommend any other needed lifestyle recommendations.
- Recommend an antacid for 2 weeks.
- If pain does not subside after 2 weeks, ask which medications he is on.
- For severe nocturnal heartburn, recommend an H2 at night and a PPI during the day.