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:

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:

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 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

Myocardial ischemia

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)