heartburn - cracksmodqu.edu.iq/ph/wp-content/uploads/2016/03/heartburn.pdf · 2016-03-12 ·...
TRANSCRIPT
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:
should pain severePatient who have
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, Ca-carbonate, 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 Ca-salts).
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:
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 acid-
neutralizing 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
answers
1-Age
children, who should be referred.
first-time indigestion in patients aged 45 years or over and refer.
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
Appendicitis
A-Ulcer
5-Details of pain/associated symptoms
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 ..
Dudenal ulcer
Gastric ulcer (GU)
The pain of a GU is in the
less wellsame area but
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)