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60 Cards in this Set
- Front
- Back
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natural defense mechanisms of the esophagus
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barriers to limit reflux (LES)
clearance via peristalsis in response to swallowing saliva contains bicarbonate which buffers the esophagus |
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natural defense mechanisms of the stomach
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epithelial cells
mucosal blood flow prostaglandins |
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definition of heartburn (pyrosis)
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burning that arises from the substernal area (lower chest) and moves upward towards the neck or throat
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4 types of heartburn
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postprandial
nocturnal simple frequent |
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postprandial heartburn
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usually occurs within 2 hours after eating or when bending over or lying down
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nocturnal heartburn
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occurs during sleep and often awakes the individual
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simple heartburn
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mild, infrequent, episodic and often associated with diet or lifestyle
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frequent heartburn
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occurs 2 or more days a week
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pathophysiology of heartburn
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Arises from sensory nerve endings in the esophageal epithelium most likely stimulated by spicy foods or by the reflux of gastric acid contents into the esophagus
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risk factors for heartburn
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coffee, tea, chocolate, citrus
regular use of aspirin or NSAIDs life stress tobacco smoking, alcohol weight lifting, cycling, sit-ups obesity, pregnancy iron supplements, theophylline, TCAs, nitrates, progesterone, NSAIDs, aspirin |
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definition of dyspepsia
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consistent or recurrent discomfort located primarily in the upper abdomen (epigastrum)
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characteristics of dyspepsia
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bloating, belching, postprandial fullness, nausea and early satiety
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2 types of dyspepsia
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acute, infrequent: associated with food, alcohol, smoking or stress
chronic: associated with PUD, GERD, H. pylori, lack of identifiable cause |
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risk factors for dyspepsia
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food
alcohol caffeine certain meds PUD GERD gastric cancer |
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peptic ulcer disease (PUD)
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gastric or duodenal ulcer caused mostly by H. pylori infection and/or NSAIDs
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symptoms of PUD
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Gnawing or burning epigastric pain, occurring during day and frequently at night; may be accompanied by heartburn and dyspepsia
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definition of Gastro-esophageal Reflux Disease (GERD)
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reflux of gastric contents into the esophagus, causing symptoms and/or esophageal damage that are sufficient to interfere with quality of life
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common symptoms of GERD
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heartburn: usually frequent and persistent (3 or more months)
dyspepsia regurgitation: acid taste in mouth |
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alarm symptoms of GERD
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dysphagia: difficulty swallowing
odynophagia: painful swallowing chest pain upper GI bleeding unexplainable weight loss continuous NVD |
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atypical symptoms of GERD
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noncardiac chest pain
hoarseness cough asthma laryngitis dental erosions sleep apnea |
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pathogenesis of GERD
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reduction of lower esophageal sphincter (LES) tone
increased acid secretion delayed gastric emptying impairment of gastroesophageal pressure gradient |
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causes of reduction of LES tone from GERD
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smoking
food: alcohol, caffeine, chocolate, fatty foods, spearmint, peppermint medications: anticholinergics, beta-agonists, estrogen/progesterone, morphine, mitrates, TCAs |
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causes of increase acid secretion from GERD
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smoking
foods: alcohol, citrus, coffee, garlic, onions, soda, spicy foods, tomatoes hypersecretory conditions: ulcers, Zollinger-Ellison |
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causes of delayed gastric emptying from GERD
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smoking
fatty meals/ overeating anticholinergics motility disorders |
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causes of impairment of gastroesophageal pressure gradient from GERD
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supine position
obesity tight clothing |
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complications of long term untreated GERD
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bleeding: acute and chronic
developement of strictures Barrett's esophagus gastric and esophageal cancer pulmonary effects: bronchitis, pneumonia |
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Barrett's esophagus
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precancerous condition
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stricture
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gradual narrowing of the esophagus, which can lead to swallowing difficulties
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non-pharmacologic treatment for GERD PUD and heartburn
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elevate head of bed (6 inches)
dinner at least 3 hours before bed avoid lying down after meals avoid foods that lower LES pressure limit NSAID use reduce portion size stop smoking weight loss smaller meals food diary |
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Antacids
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Gaviscon®, TUMS ®, Mylanta ®, Maalox ®, Rolaids ®
MOA: direct neutralization of acid, inhibits the conversion of pepsinogen to pepsin, may also increase LES pressure Indication: mild infrequent heartburn, sour stomach, and acid indegestion 4 types: aluminum salts, sodium bicarbonate, magnesium salts, calcium carbonate |
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antacid dosing
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Begin with 40-80 mEq acid neutralizing capacity (ANC) as needed then titrate to after meals and before bed
max: 600 mEq/day |
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duration of antacids
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last for 20-30 mins
Al-hydroxide and Ca-carbonate > Na-bicarbonate and MgOH |
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sodium bicarbonate antacids
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Alka-Seltzer
short term relief of overeating or indigestion only completely absorbs into systemic circulation avoid if pt has chronic renal failure, CHF, HTN, cirrhosis, edema, sodium restricted diets can cause milk-alkali syndrome if taken with calcium |
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calcium-based antacids
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Rolaids, Tums (calcium carbonate)
MOA: slow dissolution, but potent and prolonged neutralization ADR: hypercalcemia, milk-alkali syndrome, constipation good for elderly and pregnant only 500-600mg of calcium can be absorbed at one time |
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aluminum-based antacids
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Mylanta, Maalox
slowest dissolution, lowest ANC Caution: chronic renal failure (CRF) Side effects: constipation, intestinal obstruciton, hypophosphatemia |
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magnesium-based antacids
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Mylanta, Dulcolax milk of magnesia
Caution: CRF common side effects: diarrhea (dose related) severe side effects: cardiac arrhythmias, respiratory depression, hypotension, N/V, muscle paralysis |
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alginic acid
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gaviscon
MOA: forms a barrier that floats on the top of the stomach, so when reflux occurs sodium alginate rather than acid is refluxed (does not neutralize acid) Indications: GERD but not PUD do not take before bed or lying down |
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Bismuth subsalicylate
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Maalox, Kaopectate, Pepto-Bismol
MOA: Possibly coat mucosal lining Indication: heartburn, upset stomach, indigestion, nausea and diarrhea dosing: 2 chewable tabs or 2 tblsp after meals and at bedtime for no more than 14 days Side Effect: Darkened stool, tongue Avoid in patients with CRF, allergy to aspirin, pregnancy and children |
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Histamine-2 receptor antagonist (H2RA)
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Pepcid (famotidine), Zantac (ranitidine), Tagamet (cimetidine), Axid AR (nizatidine)
MOA: decrease gastric acid secretion by inhibiting histamine from binding to parietal cells Indications: mild-to-moderate, infrequent, episodic heartburn and for the prevention of heartburn associated with acid indigestion and sour stomach Onset: 30-45 mins duration: 4-10 Dose reduction needed in elderly and renal insufficiency |
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H2RA dosing
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Pepcid (famotidine): 10–20mg/day
Tagamet (cimetidine): 200–400mg/day Zantac (ranitidine): 75–150mg/day Axid AR (nizatidine): 75–150mg/day Take 30 min to 1 hour prior to an event (exercise) or meal Not approved for children under 12 |
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side effects of H2RA
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Side Effects: headache, N/V, constipation/diarrhea (C/D), drowsiness
ranitidine: dark tongue/stool cimetidine: hair loss, impotence or gynecomastia in men |
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drug interactions with H2RAs
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Cimetidine:
Binds to CYP 3A4, 2D6, 1A2, 2C9 inhibitor Major: warfarin, theophylline, phenytoin Minor: TCAs, benzodiazepines, beta-blockers, ca-channel blockers Ranitidine: cautionary warfarin, phenytoin Nizatidine/famotidine: negligible choose one of these if patient is on a lot of medications |
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proton pump inhibitors
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Prilosec OTC (omeprazole), Prevacaid 24H (lansoprazole)
MOA: direct acid secretion suppression via proton pump inhibition Indication: frequent heartburn, not GERD or PUD dose: 1 tab/capsule po daily before meal for 14 days side effects: diarrhea, constipation, abdominal pain, headache Onset: 2-3 hours – but complete relief may take 1 to 4 days drug interactions: warfarin, cyclosporine, benzodiazepines, phenytoin For adults 18 years and older |
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Geriatrics with intestinal gas
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usually refer unless side effects are related to overeating or spicy foods
H2RA (not cimetidine) or PPI preferred stay away from Na-bicarb likely to have side effects with antacids |
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pediatrics with intestinal gas
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refer if < 12 yrs old
avoid BSS and H2RA antacids commonly used but safety is unknown |
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pregnancy with intestinal gas
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antacids preferred other than Na-bicarb
calcium most preferred 1300mg/day max of 2500mg/day avoid PPIs refer before H2RAs |
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lactation with intestinal gas
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magnesium hydroxide, aluminum hydroxide, ranitidine and famotidine preferred
do not recommend PPI |
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exclusions for self-treatment of heartburn
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frequent heartburn > 3 months
heartburn that continues after 2 months of OTC treatment worsening symptoms nocturnal heartburn difficulty or painful swallowing vomitting blood unexplained weight loss continuous NVD chest pain with sweating, pain related to shoulder arm neck or jaw, shortness of breath |
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pathophysiology of intestinal gas
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intestinal bacteria generates gas from food that is eaten but not digested absorbed
gases are primarily nitrogen, hydrogen, carbon dioxide, oxygen and methane |
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etiology (causes) of intestinal gas
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chronic disease: lactose intolerance, irritable bowel syndrome
indigestible carbs fatty foods carbonated beverages/sweeteners antibiotics meds |
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drugs that may lead to intestinal gas
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antibiotics
α-glucosidase inhibitors GI lipase inhibitors calcium channel blocker (CCB) effervescent solution drugs (Alka-Seltzer®) |
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signs and symptoms of intestinal gas
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common: excessive belching, abdominal discomfort or cramping, bloating, flatulence
uncommon: nausea, audible bowel sounds, dyspepsia |
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nonpharmacological therapy for intestinal gas
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avoidance of foods and beverages that cause gas
exercise good oral hygiene eat slowly |
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pharmacologic treatment of intestinal gas
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anti-flatulent meds
digestive enzymes |
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simethicone
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Gas-X, Maalox, Mylicon drops, Gelusil
MOA: Acts in the stomach and intestine to reduce surface tension of gas bubbles embedded in the mucus of the GI tract allowing them to escape via flatulence or belching Indication: FDA approved for antiflatulence usually given for unknown causes or food associated gas dose: 1 tab after meals or at night as needed max: 500mg/24hrs not systemically absorbed so no drug interactions can be given to children and infants |
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activated charcoal
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not indicated or approved for relief and treatment of gas
may increase effectiveness when combined with antiflatuence agent reported to be beneficial for elimination of malodorous, sulfur-based gases DO NOT RECOMMEND |
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α-Galactosidase Replacement
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Beano, Gaz Away
MOA: hydrolyzes carbohydrates before they can be metabolized by bacteria in the colon Indication: FDA approved for antiflatulence, mainly used with food with oligosaccharides- beans and high fiber food dose: with first bite drops or tabs caution with diabetics may increase BG |
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Lactase Replacement Products
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lactaid, dairy ease
MOA: Lactase enzyme break down lactose to glucose and galactose, which are absorbed Indication: lactose intolerance dose: differs by product start with lowest dose and increase as needed with first bite of dairy |
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Probiotics
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may treat GI complaints including intestinal gas and bloating
max duration of 14 days avoid with pancreatitis Align capsules, activia yogurt |
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exclusions for self-treatment of intestinal gas
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symptoms persist for several months or occur more than occasionally
unbearable symptoms change in location of abdominal pain increase in frequency or severity Presence of an accompanying symptoms such as diarrhea, constipation, GI bleeding, fatigue, unintentional weight loss, or frequent nocturnal symptoms |
