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GERD Presentation.pptx

  1. Gastroesophageal Reflux Disease (GERD)
  2. :Definitions Gastroesophageal Reflux (GER): Escape of gastric contents into the esophagus. This process may or may not produce symptoms. Reflux esophagitis: Esophageal inflammation caused by the refluxed material. Gastroesophageal Reflux Disease (GERD): Any symptomatic condition or anatomic alteration caused by the reflux of noxious material from the stomach into the esophagus.
  3. Gastroesophageal reflux disease occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury i.e., esophagitis
  4. PATHOPHYSIOLOGY OF GERD A) Dysfunctional Lower Esophageal Sphincter B) Gastric Factors C) Impaired Esophageal Clearance
  5. A) Dysfunctional Lower Esophageal Sphincter (LES) • The LES is a 1-3.5 cm segment of specialized circular muscle in the wall of the distal esophagus. • It maintains a resting pressure of 10-45 mmHg higher than that of the stomach.
  6. Types of LES dysfunction • Intrinsic weakness of the LES muscle: Occurs when the resting pressure in the LES remains at or near 0. Responsible for > 25% of reflux episodes in patients with severe GERD. • Inadequate LES response to increased abdominal pressure: Increased abdominal pressure could be caused by inspiration or bending over.
  7. • Transient LES relaxation (TLESR): Normally, the LES relaxes for 3-10 seconds to allow the swallowed bolus to enter the stomach. TLESR lasts for up to 45 seconds and is responsible for 70% of reflux episodes in patients with severe GERD. Incompetent LES
  8. B) Gastric Factors: • Irritant potency of the refluxed material: Esophageal injury occurs when the refluxed material is caustic to the esophageal mucosa. Caustic agents that can be found in the stomach include acid, pepsin, bile & pancreatic enzymes.
  9. • Delayed gastric emptying: It causes gastric distention that can stimulate gastric acid secretion & trigger TLESR. • Causes: I. Pyloric channel or duodenal ulcers. II. Mechanical obstruction e.g. by tumor. III. Neuromuscular abnormalities e.g. DM, collagen vascular diseases, hypothyroidism, etc.
  10. C) Impaired Esophageal Clearance Impaired esophageal clearance can occur in: Sleep: due to I. Elimination of the effect of gravity. II. Salivation & swallowing cease during sleep “no peristalsis due to absent swallowing”. Scleroderma: due to impaired peristalsis. Cigarette smoking: due to decreased salivation. Hiatus hernia.
  11. ETIOLOGY A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of GERD. Transient relaxation of the LES can be caused by: • Food (coffee, alcohol, chocolate, fatty meals) • Medications (beta-agonists, nitrates, CCBs, BDZ, anticholinergics) • Hormones (e.g. progesterone)
  12. RISK FACTORS • Black pepper, garlic, raw onions, and other spicy foods • Chocolate and High fatty food • Citrus fruits and products, such as lemons, oranges, and orange juice • Coffee and caffeinated drinks, including tea and soda • Tobacco smoking • Pregnancy • Obesity and weight gain • Wearing tight clothing, lying flat after a meal
  13. CLINICAL PRESENTATION Esophageal symptoms • Heartburn • Nausea • Regurgitation: Reflux of bitter material into the mouth, usually at night or when bending down. • Dysphagia: Difficulty in swallowing. Usually indicates narrowing or stricture of the esophagus. It may occur due to inflammation & edema. • Waterbrash: Filling of the mouth suddenly with saliva. It’s due to reflex salivary secretion stimulated by acid in the esophagus.
  14. Esophageal symptoms cont’d • Belching • Odynophagia: Pain on swallowing. It suggests the presence of esophageal ulceration. • Epigastric pain • Hemorrhage
  15. Extraesophageal symptoms • Coughing and/or wheezing • Hoarseness, sore throat • Otitis media • Noncardiac chest pain • Enamel erosion or other dental manifestations
  16. Diagnostic tests I. Endoscopic examinations II. Barium swallow III. Ambulatory monitoring of esophageal pH
  17. COMPLICATIONS OF GERD • Inflammation of the esophagus (increased risk of cancer from chronic inflammation) • Narrowing of the esophagus: strictures • Lung problems: asthma, pneumonia, voice changes, wheezing, fluid in the lungs • Barrett’s esophagus: the lining of the esophagus is replaced with a similar lining that makes up the intestinal lining which increases the risk of cancer.
  18. MANAGEMENT OF GERD The goals are: • to control symptoms • to heal esophagitis • to prevent recurrent esophagitis or other complications. The treatment is based on lifestyle modifications and control of gastric acid secretion through medical therapy with antacids or proton pump inhibitors or surgical treatment with corrective antireflux surgery.
  19. LIFESTYLE MODIFICATIONS • Losing weight (if overweight) • Avoiding alcohol, chocolate, citrus juice, and tomato- based products • Avoiding peppermint, coffee, and possibly the onion family • Eating small, frequent meals rather than large meals • Waiting 3 hours after a meal to lie down • Refraining from ingesting food (except liquids) within 3 hours of bedtime • Elevating the head of the bed by 8 inches
  20. LIFESTYLE MODIFICATIONS CONT’D • Avoiding bending or stooping positions • Cessation of smoking. • Foods to eat: i. Whole grain e.g. cereals, oats ii. Dry fruits like dates, apricots, figs, raisins iii. Alkaline fruits like bananas iv. Non-peppery soups v. Smoothies
  21. PHARMACOLOGICAL MANAGEMENT 1. H2 receptor antagonists • These are the first-line agents for patients with mild to moderate symptoms and grades I-II esophagitis. • They block the action of histamine. When histamine is released it causes the parietal cells to release HCL but this response will be blocked so gastric acid secretion will be decreased. • Examples: Ranitidine ,Cimetidine, Famotidine, Nizatidine.
  22. Drug Duration Cimetidine Indication - Erosive esophagitis diagnosed by endoscopy. - 12 w Famotidine Dose - 800 mg BDS or 400 mg QDS - 20 mg BDS -6 w - 20-40 mg - 12 w BDS Nizatidine - Short term ttt of symptoms. -Esophagitis due to GERD including erosive or ulcerative disease diagnosed by endoscopy -Esophagitis due to GERD. including erosive or ulcerative disease & associated heartburn. - 150 mg BDS - 12 w Ranitidine - Treatment of symptoms. -Esophagitis due to GERD including erosive or ulcerative disease diagnosed by endoscopy -150 mg BDS - 150 mg QDS No limit specifi ed
  23. PHARMACOLOGICAL MANAGEMENT 2. Proton Pump Inhibitors (PPIs) • Attach to the “proton pump” on the parietal cells which is the hydrogen/potassium (H+, K+) ATPase enzyme and blocks the release of hydrogen ions. These ions would mixed with the chloride ions and form gastric acid but this is blocked so there is a decrease in gastric acid. • PPIs are effective in control of symptoms & signs of GERD, heal erosive esophagitis & diminish formation of esophageal strictures.
  24. • PPIs improves dysphagia & decrease the need for esophageal dilatation in patients who have esophageal strictures. • PPIs are effective if taken 15-30 minutes before breakfast or dinner. Drugs of this group include: Omeprazole 20 mg – 40 mg. Lansoprazole15 mg – 30 mg. Rabeprazole 20 mg. Pantoprazole 20 mg – 40 mg. Esomeprazole 20 mg – 40 mg. Omeprazole NaHCO3 20 mg – 40 mg.
  25. PHARMACOLOGICAL MANAGEMENT 3. Antacids • Antacids may be aluminum, magnesium, or calcium based. Antacids neutralize the acid in the stomach so that there is no acid to reflux. • They are emptied from the empty stomach quickly so they should be given an hour after meal to prolong their duration of action. • Effective in controlling mild symptoms of GERD.
  26. PHARMACOLOGICAL MANAGEMENT 4. Prokinetic Drugs These agents act by: a) Increasing LES pressure. b) Enhancing gastric & esophageal emptying. Examples: Metoclopramide HCl. Domperidone. Mosapride citrate.
  27. -Metoclopramide HCl: Dopamine antagonist, centrally acting antiemetic. Its effective in treatment of mild disease. It crosses BBB so, it has many central side effects. Side effects: Agitation, restlessness, somnolence, anxiety, insomnia, extrapyramidal manifestations & galactorrhea. -Domperidone: Dopamine antagonist & produce effects similar to metoclopramide. Unlike metoclopramide it doesn’t cross BBB so there is no central side effects.
  28. - Mosapride citrate: 5-HT4 receptor agonist & partial 5- HT3 antagonist. Unlike cisapride it doesn’t block K+ channels so no cardiac toxicity will occur, also doesn’t block D2 receptors, so there are no extrapyramidal manifestations.
  29. PHARMACOLOGICAL MANAGEMENT 5. Sucralfate An aluminum sucrose polysulfate. Effective in treatment of mild reflux esophagitis. It’s efficacy is comparable to that of H2 blockers.
  30. SURGICAL MANAGEMENT There are several different antireflux operations (e.g. Nissen, Belesy, Toupet fundoplication). The most popular is Nissen fundoplication (open or laparoscopic). Nissen fundoplication: The gastric fundus (upper part) of the stomach is wrapped around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter.
  31. SAMPLE CASE STUDIES 1. A 54 year old male patient walked into your pharmacy with a complaint of intermittent chest pain with substernal burning that radiates to his mid-back. He describes the pain as stabbing. He states that the symptoms occur after he has eaten a large meal and in the middle of the night, which often wakes him from his sleep. He awakes with shortness of breath, coughing, and a bitter taste in his mouth. He keeps antacids with him at all times to help with the symptoms.
  32. SAMPLE CASE STUDIES • Based on the information you have already received what other history is essential for you to gather from the patient? • How do you manage the patient?
  33. SAMPLE CASE STUDIES 2. MC, a 20-year-old Muslim man, came into your Pharmacy on day 20 of Ramadan fasting to complain of loss of appetite and occasional lower sternal chest pain 30-60 minutes after meals. He says that symptoms began about 8 weeks ago. MC is 5ft, 10 inches tall, and weighs 92kg. Besides chest pain after meals, MC complains of heartburn several times a week and occasionally brings up bitter liquid into his mouth. On further inquiries, he opens up on the fact that he was placed on a new medication 4 weeks ago but stopped taking his medications when Ramadan started.
  34. SAMPLE CASE STUDIES • What other information will you be requiring from MC? • How will you manage MC as a Pharmacist?