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What is the definition of GERD?
at least 2 episodes of hearburn per week and/or complications
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What is the definition of NERD?
Presence of troublesome reflux sx but no damage in the esophagus at endoscopy
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What is reflux esophagitis?
inflammation of the esophagus after repeated exposure to stomach contents
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What is erosive esophagitis?
erosion of the esophagus after repeated exposure to stomach contents
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What are the causes of GERD?
- Inappropriate LES relaxation
- Impaired esophageal clearing
- Delayed gastric emptying
- Impaired esophageal mucosal defense
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What are the atypical symptoms of GERD?
- Nonallergic asthma
- Chronic cough
- Hoarseness
- Pharyngitis
- Chest pain
- Dental erosions
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What are the alarm symptoms of GERD?
- Continual pain
- Dysphagia
- Difficulty swallowing
- Unexplained wt loss
- Choking
- Bleeding
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When should an endoscopy be performed for GERD?
- When atypical or alarm sx are present
- Pt > 45yo
- Those refractory to tx
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What are some aggravating factors for GERD?
- Lying down
- Increased intra-abdominal pressure (Pg, wt)
- Reduced gastric motility
- Decreased LES tone
- Direct mucosal irritation
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What are the long-term complications of GERD?
- Esophageal erosion, ulceration, strictures, or hemorrhage
- Barrett's esophagitis
- Reduced QOL
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What medications promote GERD by lowering LES tone?
- Beta agonists
- Nicotine
- CCBs
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What medications promote GERD by delaying gastric emptying?
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What medications can cause esophageal injury directly?
- ASA
- NSAIDS
- Bisphosphonates
- Iron
- Tomatoes
- Citrus
- Alcohol
- Spicy foods
- Coffee
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What is Step-down treatment for GERD?
start at high dose PPI and gradually decrease, then switch to H2 antagonist and taper off
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What is Step-up treatment for GERD?
Lifestyle → H2 → PPI → Surgery
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What are the antacids used for GERD?
- Sodium bicarb
- Calcium carbonate
- Magnesium salts
- Aluminum salts
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What are the SE of Sodium bicarb?
- Alkalosis
- Sodium overload
- Milk-alkali syndrome (nausea)
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What are the SE of Calcium carbonate?
- Constipation
- Acid rebound
- Milk-alkali syndrome (nausea)
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What are the SE of magnesium salts?
- Diarrhea (dose-related)
- Accumulation of electrolytes in renal failure pts
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What are the SE of Aluminum salts?
Constipation
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What is the MOA of antacids in GERD?
neutralize acid and increase gastric pH → decrease activation of pepsinogen and increase LES pressure
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How long should antacids be used to treat GERD?
no more than 2wks unless a Dr is monitoring your electrolytes
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What are the H2 blockers used in GERD?
- Cimetidine
- Famotidine
- Ranitidine
- Nizatidine
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What is the MOA of H2 blockers in GERD?
Reversibly inhibit H2 receptors on the parietal cell → decreased acid secretion
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What are the SE of H2 blockers?
- CNS (HA, dizziness, fatigue, confusion - elderly at higher risk)
- Gynecomastia, galactorrhea with prolonged Cimetidine use
- Decreased platelets/WBC (rare)
- NVD
- Constipation
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What are the PPIs used in GERD?
- Omeprazole
- Lansoprazole
- Esomeprazole
- Pantoprazole
- Rabeprazole
- Dexlansoprazole
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What is the MOA of PPIs in GERD?
Irreversibly inhibit final step in gastric acid secretion
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What are the SE of PPIs?
- HA
- Dizziness
- ND
- Constipation
- Possible increased infection rate with C. diff and pneumonia
- May affect B12 and insoluble Ca absorption
- Possible risk of fracture with long-term use
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How long should H2 blockers be used for GERD?
8+ weeks
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How long should PPIs be used for GERD?
4-8 wks
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Which PPI has the most DI?
Omeprazole - don't use with Clopidogrel (use H2RA or Pantoprazole or Esomeprazole instead)
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What are the promotility agents used in GERD?
- Metoclopromide
- Bethanechol
- Cisapride
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What is the MOA of promotility agents in GERD?
Facilitate increased gastric emptying through a cholinergic mechanism
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What are the SE of Metoclopromide?
- dizziness
- fatigue
- somnolence
- drowsiness
- EPS
- Hyperprolactinemia
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What are the SE of Bethanechol?
- Diarrhea
- Blurred vision
- Abdominal cramping
- Possible increase in gastric acid production
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What are the SE of Cisapride?
Cardiac arrhythmia (QT prolongation) when used with 3A4 inhibitors
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What are the mucosal protectants used in GERD?
Sucralfate
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What is the MOA of sucralfate in GERD?
nonabsorbable aluminum salt coats the stomach
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What are the SE of sucralfate?
accumulation of aluminum in renal failure
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When should maintenance therapy for GERD by stopped?
- When there are no sx for 3mo
- Possibly try on-demand dosing
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What are the types of PUD?
- Duodenal ulcers
- Gastric ulcers
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What are the causes of ulcers?
- Duodenal: H. pylori, NSAIDs
- Gastric: H. pylori, NSAIDS, stress
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What is are the differentiating features of duodenal ulcers?
- Pain worse at night
- Relieved by eating
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What is the differentiating feature of gastric ulcers?
Pain gets worse with eating
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What are the risk factors for NSAID-induced ulcers?
- Age > 60
- Increased NSAID dose
- Longer duration of tx
- Intrinsic NSAID toxicity
- Hx of PUD
- Concurrent use of corticosteroids or anticoagulants
- Underlying CVD or rheumatologic disease
- Use of multiple NSAIDs
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What are the nonpharmacologic treatments for PUD?
- Smoking cessation
- D/C NSAIDs and ASA
- Decrease stress
- Avoid food that exacerbate sx
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What is the treatment for H. pylori PUD?
- Amoxicillin + Clarithromycin + Tinidazole or Metronidazole + PPI x 14d
- Amoxicillin + PPI for 5d, then Clarithromycin + Tinidazole or Metronidazole + PPI for 5d
- Amoxicillin + PPI for 7d, then Amoxicillin + Clarithromycin + Tinidazole or Metronidazole for 7d
- Bismuth + Tetracycline + Tinidazole or Metronidazole + PPI for 10-14d
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What is the preferred duration of therapy for H. pylori PUD?
10-14d
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How do NSAIDs cause ulcers?
Inhibition of prostaglandins and direct irritation
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How do you treat NSAID-induced ulcers?
- Remove or lower the NSAID dose
- Try a selective NSAID or COX2 inhibitor (won't heal any faster)
- Add a PPI, H2RA, or Sucralfate - heals in 6-8wks
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What are the partially selective NSAIDs?
- Etodolac
- Meloxicam
- Diclofenac
- Celecoxib
- Nabumitone
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What is the DOC for healing and prevention of PUD?
PPIs or Misoprostol
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What are the doses used for PUD?
- Omeprazole 20-40mg
- Lansoprazole 15-30mg
- Esomeprazole 20-40mg
- Pantoprazole 40mg
- Rabeprazole 20mg
- Dexlansoprazole 30-60mg
- Sucralfate 1g QID or 2g BID
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What are the SE of Misoprostol?
- Diarrhea
- Abdominal pain
- Nausea
- Flatulence
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What are the CI for Misoprostol?
Pregnancy
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What should you do if sx of PUD persist for > 8wks (duodenal) or > 12wks (gastric) despite tx?
Increase dose of PPI (may require maintenance tx with a healing dose)
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What is the tx for Zollinger-Ellison syndrome (ZES)?
- PPI (high dose)
- Octreotide
- Surgery
- Chemotherapy
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What are the causes of an Upper GI Bleed?
- PUD
- Esophagitis
- Erosive disease
- Esophageal varices
- Stress ulcers
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What are the sx of an Upper GI bleed?
- Hematemesis
- NVD
- Melena (bloody stool)
- Hypotension
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What is the tx for an Upper GI Bleed?
- Cauterize the bleed
- Remove blood thinners
- PPI (high dose bolus + continuous infusion for 72hrs)
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How are stress ulcers different from PUD?
- Multiple ulcers
- Lack of chronic inflammation
- Asymptomatic
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What are the risk factors for stress ulcers?
- Mechanical ventilation for > 48hrs (or anticipated to be)
- Coagulopathy (INR > 1.5 without Warfarin)
- GI bleeding/ulceration within last yr
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What is can be used for prevention of stress ulcers?
- Antacids
- H2RA
- PPI
- Sucralfate
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What is DOC for prevention of stress ulcers?
H2RA (cheaper, many routes available including NG feeding possible which may help by increasing use of the gut)
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When should stress ulcer prophylaxis be discontinued?
- When pt transferred out of ICU
- Extubation
- Oral intake initiated
- Consider if < 2 risk factors
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