Heartburn
Reflux of gastric contents, particularly acid, into the esophagus
Patient assessment with GERD 1-signs and symptoms The hallmark of typical symptom of GERD is heartburn (restrosternal),acid regurgitation, cough, hoarseness,
Pharyngitis, chest pain, dental erosion.
2-Precipitating or aggravating factors. A-Bending or lying down (e.g. at night). B-Overweight. C-After large meal. D-Pregnancy. E-It can be aggravated or even caused by belching.
3-Severity and location of pain: Patient who have severe pain should be referred as well as pain that radiate to the back and arm
4-Difficulty in swallowing (dysphagia ) and regurgitation----referral :
5-Age: children with symptoms of heartburn should be referred.
6-Medication
DOXYCYCLINE
DIAGNOSIS The most useful tool in diagnosis of GERD is the clinical history, including both presenting symptoms and associated risk factors. Endoscopy with biopsy if needed in patients with alarm signs/symptoms(dysphagia, weight loss).
Summary of Symptoms and circumstances for referral 1-Failure to respond to antacids 2-Pain radiating to arms 3-Difficulty in swallowing 4-Regurgitation 5-Long duration 6-Increasing severity 7-Children
Treatment timescale If symptoms have not improved within 7 days, the patient should see the doctor.
Non-pharmacological advices 1-Eat small and frequent meals 2-The evening meal is best taken several hours before going to bed 3-Use extra pillow to elevate the head of the bed).
4-Do not wears tight fitting clothing 5-Avoid smoking, and foods that exacerbate symptoms of GERD. 6-Weight reduction should be advised
Antacids (AL salts, Mg salts, Cacarbonate, Na-bicarbonate, ): The majority of marketed antacids are combination products,quick onset (Na or Ca salts) and long duration of action (AL salts, Mg salts, and Casalts). Practical points Best time for taking Antacids: 1-2hr after meal Interactions: e.g., ciprofloxacin and tetracyclines. Use of antacids during pregnancy: Side effects of antacids:
2-Dosage form
Alginates( Gaviscon ) Alginate-containing Antacids : Form a sponge like matrix that float on the top of the stomach contents, thus protecting esophagus against reflux of gastric content. It not a potent acidneutralizing agent.
Histamine 2 receptor antagonists (H2RA)
C-Histamine 2 receptor antagonists (H2RA): 1-The patients: in adults and children over 16 years. Also as OTC doses of H2RA is limited to no more than two doses times a day, and not used as OTC in pregnancy. 2- (take 1 tablet when symptoms occur)( another tablet may be repeated after more than 1hour), but when food is known to ppt symptoms----- taken an hour before food. 3-maximum 2 weeks for OTC.
Side effects of H2RA: Headache,somnolence, dizziness, diarrhea, constipation. Cimetidine may inhibit the metabolism of theophylline, warfarin, phenytoin, nefidepine and propranolol. Also cimetidine associated with antiandrogenic so gynacomastia, impotence when used in high dose.
D-Proton pump inhibitors (PPIs): 1- PPIs available OTC are Omeprazole (10 mg e/c tablet) and rabeprazole (10 mg e/c tablet) (In UK) and omeprazole (20 mg capsule), Lansoprazole (15 mg capsule) and esomeprazole (20 mg capsule) in USA.
2- in adults over 18 years. 3-It may take 1 to 4 days to achieve full symptom relief. (may need to take a concomitant antacid). 4-Treatment with OTC PPIs is limited to a maximum of 4 weeks (2 weeks in USA).
Single dose each day before breakfast
All PPIs are most effective if taken about 30 min before a meal as they inhibit only actively secreting proton pumps. Meals are the main stimulus to proton pump activity. The optimal dosing time is 30 60 min before the first meal of the day (PPIs are most effective after a prolonged fast)
Adverse effect of PPI Headache,dizziness, somnolence, diarrhea, constipation, nausea, vit b12 deficiency also decrease absorption of iron, Ca, mg with long use. Inhibit absorption of ketocanozole and itraconazole. Omperazole can increase the concentration of ciclosporin
Omeprazole inhibit the metabolism of clopidogrel, therefore, the effect of clopidogrel will be: ( Decreased) so either give rabiprazole or rantidine
PPI formulated as enteric coated tab or delay release cap. bec it degrade in acidic media. In p.t with nasogastric tube should give PPI as dispersed tab mixed with Na-bicar. Zegerid is a combination product of omperazole + sod. Bicarb. In immediate release cap.
Promotility agent : useful combination with acid supression only in p.t with motility defect e.g., LES incompetence, decreased esophageal clearance and delayed gastric emptying. Metoclopramide(dopamine antagonsit,increase LES pressure and increase gastric emptying rate )and domperidone( increase gastric emptying rate.)
Domperidone previously was used as an OTC for the treatment of postprandial stomach symptoms of excessive fullness. It increases the rate of gastric emptying.
Sucralfate not useful in GERD.
Indigestion (dyspepsia) Heartburn should not be confused with dyspepsia. The discomfort of dyspepsia is variably described as feeling of fullness, but is generally not burning in nature
Significance of questions and 1-Age children, who should be referred. first-time indigestion in patients aged 45 years or over and refer. answers 2-Symptoms The symptoms of typical indigestion include upper abdominal discomfort,).
3-Duration/previous history Indigestion that is persistent or recurrent should be referred to the doctor. history of the symptom which has not responded to treatment, or which has worsened, should be referred.
Gallstones This causes severe pain below the right rib margin. may be precipitate d by a fatty meal
C-Gastro-Esophageal reflux
Irritable bowel syndrome
Myocardial ischemia
Appendicitis
5-Details of pain/associated symptoms A-Ulcer
Dudenal ulcer 1-Pain of a DU is localised to the upper abdomen, slightly to the right of the midline. The pain is most likely to occur when the stomach is empty, especially at night. It is relieved by food..
Gastric ulcer (GU) The pain of a GU is in the same area but less well localised. It is often aggravated by food.
G-More serious disorders Persisting upper abdominal pain, especially when associated with unexplained weight loss, may herald an underlying cancer. Ulcers sometimes start bleeding, which may present with blood in the vomit (haematemesis) or in the stool (melaena). In the latter the stool becomes tarry and black. Urgent referral is necessary
melaena
6-Medication A-Medicines already tried: B-Other medicines being taken:. Severe or prolonged indigestion in any patient taking an NSAID is an indication for referral
Summary of Symptoms and circumstances for referral : 1-Age over 45 years if symptoms develop for first time. 2-Symptoms are persistent or recurrent. 3-Pain is severe. 4-Blood in vomit or stool. 5-Pain worsens on effort. 6-Persistent vomiting. 7- Treatment has failed. 8-Adverse drug reaction is suspected. 9-Associated weight loss. 10-Children. 11- Indigestion between meals or at night.12-pain radiating from central or epigastric areas.
Treatment timescale If symptoms have not improved within 5 days, the patient should see the doctor. Management A-Antacids: as in GERD B-Famotidine and ranitidine: as in GERD.
dimethicone : sometimes added to antacid ( antigases)