Upper GI Problems

Are these upper OR lower GI problems?

- GERD

- PUD

- Upper GI bleed

Upper GI problems

What does GERD stand for?

Gastroesophageal reflux disease

Is GERD a disease or syndrome?

Syndrome- a group of signs and symptoms that are known to go together but don't have a clear cause, course, or treatment path. A disease on the other hand has a known cause, identifiable symptoms, and potential treatments.

What causes GERD?

No single cause

What is the most COMMON UGI problem seen in adults?

GERD

This syndrome results when?

- Defenses of the lower esophagus are overwhelmed by reflux of gastric contents into the lower esophagus

GERD

GERD can result from an incompetent ______________?

Incompetent LES

GERD can result from an incompetent LES resulting in a increase OR decrease in pressure in the distal portion of the esophagus?

Decrease in pressure

A decrease in pressure in the distal portion of the esophagus causes gastric contents to move from the ___________ to the esophagus?

The stomach

What are 3 predisposing factors that can cause GERD?

1) Hiatal hernia

2) Impaired esophageal mobility

3) Delayed gastric emptying

The development of GERD is a result of imbalance of pressure at the _______________?

The gastroesophageal junction (GEJ)

The development of _____________ is a result of:

- Acidity of the reflux

- Esophageal mucosal sensitivity

GERD

Both the ___________ and the lower esophageal sphincter contribute to pressures at the GEJ?

The diaphragm

Relaxation of or decrease of ___________ pressure allows gastric contents to move from the stomach to esophagus?

Lower esophageal sphincter

Does a increase OR decrease in abdominal pressure allow gastric contents to move from the stomach to the esophagus?

Increase in abdominal pressure

What 2 types of food decrease LES pressure by promoting smooth muscle relaxation?

Caffeine and chocolate

What type of drug decreases LES pressure by promoting relaxation of the LES by blocking parasympathetic activity that normally keep it tight?

Anticholinergics

What 2 lifestyle factors contribute to decreasing LES pressure by promoting smooth muscle relaxation?

Smoking and alcohol

Anatomical disruption of the gastroesophageal junction can contribute to decreasing LES pressure such as a _________________?

Hiatal hernia- decreases LES pressure by displacing the LES above the diaphragm, where it loses the supportive pressure from the diaphragm that normally helps keep it closed

What are 3 factors that contribute to an increase in abdominal pressure?

1) Delayed gastric emptying

2) Obesity

3) Pregnancy

With GERD there is more significant damage to the mucosa when the reflux pH is < _______?

<2

With GERD damage is not typically related to an increase in gastric secretion but the ____________ reflux is in contact with mucosa

Amount of time

What 2 drugs can irritate the gastric mucosa?

NSAIDs and corticosteroids

NSAIDs and corticosteroids inhibit the synthesis of ________________ that are protective to the gastric mucosa

Prostaglandins

What's another term for heartburn?

Pyrosis

Heartburn is a burning tight sensation beneath the _____________ and spreads upward to throat or jaw

Beneath the lower sternum

With GERD why does heartburn occur after meals?

Heartburn occurs after meals because when your stomach is full is secretes acid to digest the food and as a result with a weak LES this acid back flows into the esophagus

With GERD why does heartburn worsen at night?

Heartburn worsens at night because when lying down it's easier for acid to back flow into the esophagus due to less gravity compared to sitting up

With GERD why does heartburn worsen when bending or stooping?

Heartburn worsens when bending or stooping because it increases abdominal pressure thus pushing acid in the stomach to the esophagus

One clinical manifestation of GERD is regurgitation. What is that?

Regurgitation is the back flow of stomach contents into the esophagus and mouth

Why is a clinical manifestation of GERD dysphagia?

Dysphagia occurs due to acid back flowing into the esophagus causing inflammation and swelling thus making it harder to swallow

What type of clinical manifestation of GERD is more common in older adults?

Chest pain (non-cardiac)

All of these are extra esophageal symptoms of __________?

- Sore throat

- Hoarseness

- Laryngitis

- Cough

- Wheezing

GERD

How many times a week of heartburn can be diagnosed as GERD?

2 or more times per week

A complication of GERD is inflammation of the esophagus, which is called?

Esophagitis

A complication of GERD is a condition where the lining of the esophagus changes to resemble the lining of the intestines, often due to chronic acid reflux?

Barrett's esophagus- considered precancerous

A complication of GERD is irritation of the upper airway causing?

Cough and laryngospasm

What condition increases the risk of these respiratory symptoms?

- Aspiration and pneumonia

- Asthma

- Bronchitis

GERD

A complication of GERD in the mouth is?

Dental erosion

Diagnostic studies for GERD include a medical procedure where a doctor uses a thin, flexible tube with a camera (an endoscope) to look inside the upper GI tract. They are assessing LES competence, degree of inflammation, scarring, and strictures. With this method they also can collect biopsy and cytologic specimens.

Upper GI endoscopy

Diagnostic studies for GERD include a test that measures the function of the esophagus and its muscles as well as measures the PRESSURE in the esophagus and LES.

Esophageal manometric (motility) studies

To diagnose GERD what high dose treatment may be tried?

High-dose of proton pump inhibitor treatment

If a hiatal hernia is suspected a diagnostic imaging test that uses X-rays to detect the protrusion of the gastric fundus will be done and involves drinking a liquid containing barium. What is this called?

Barium swallow/upper GI series

Treatment for this condition include diet/lifestyle/behavior modification to increase LES pressure or decrease abdominal pressure and to decrease acidity in the stomach?

GERD

__________ therapy for GERD focuses on:

- Decreasing volume of reflux

- Decreasing acidity of reflux

- Improving LES function

- Increasing esophageal clearance

- Protecting esophageal mucosa

Drug therapy

If diet/lifestyle/behavior modification or drug therapy doesn't work for GERD what's the next treatment option?

Surgery

If someone has a hiatal hernia how is it treated?

Through surgery

What type of foods should be avoided with GERD due to promoting muscle relaxation?

1) Caffeine

2) Chocolate

3) Peppermint/spearmint

What type of foods should be avoided with GERD due to being really acidic and decreasing LES pressure?

1) Tomato products

2) Orange juice

What type of drugs decrease LES pressure and promote muscle relaxation?

1) Anticholinergics

2) Nitrates

3) Beta blockers

4) Calcium channel blockers

5) Morphine

6) Nicotine

7) Antidepressants

Other drugs that should be avoided with this condition include those that increase acid secretion and gastric emptying?

GERD

Why should those with GERD eat small frequent meals?

Eating small frequent meals decreasing the amount of acid secretion compared to eating a large meal thus decreasing the risk of acid back flowing into the esophagus

Why should those with GERD drink fluids between rather than with meals?

Fluids should be drunk between rather than with meals because fluids on top of a meal can further distend the stomach causing pressure on the LES resulting in acid to back flow into the esophagus

With GERD why should late night snacking or meals be avoided?

Late night snacking or meals should be avoided because not only does lying down increase the risk of acid back flowing into the esophagus but food can distend the stomach and put more pressure on the LES thus increasing the risk more

Why should weight reduction be considered those that have GERD?

Excess weight puts pressure on the abdomen increasing the risk of acid reflux into the esophagus

Why should tight fitting clothing be avoided for those that have GERD?

Tight fitting clothing puts more pressure on the abdomen increasing the risk of acid reflux into the esophagus

These drug are used to treat GERD?

- Reduces stomach acid production by blocking the action of histamine on H2 receptors located on the parietal cells in the stomach lining

Histamine 2 receptor blockers

Are histamine 2 receptor blockers usually taken in the morning or at night?

At night

True or false side effects of H2 receptor blockers are uncommon?

True

What ending do H2 receptor blockers have?

Tidine

What drugs are these that help with GERD?

- Help reduce the amount of acid produced in the stomach

Proton pump inhibitors

Proton pump inhibitors should be taken before?

Take before first meal of the day

What is the most common side effect of PPI?

Headache

Why does long term use or high doses of PPI increase the risk of fractures of the hip, wrist, and spine?

PPI decrease the amount of acid secretion which is essential for the absorption of calcium

PPI are associated with an increased risk of _______________ infection in hospitalized patients because they educe stomach acid, which normally helps kill harmful bacteria and prevent their overgrowth and with lower acid levels, C. diff spores are more likely to survive?

Cdiff infection

What ending do PPI have?

Prazole

What is this medication?

- Neutralizes pH of acid

- Quick but short lived relief

Antacids

When should antacids be taken?

1 and 3 hours after meals and at bedtime

What are common side effects of antacids?

Constipation and diarrhea

Aluminum-based antacids can cause constipation or diarrhea?

Constipation

Magnesium-based antacids can cause constipation or diarrhea?

Diarrhea

What are these drugs?

- Acid protective

- Used for cytoprotective properties

- Creates a protective barrier

Cytoprotective drugs

Cytoprotective drugs are usually used for ____________?

Ulcers

Sucralfate (Carafate) a protective drug should be administered when?

Administer on empty stomach 4 times a day including 1 hr before meals and at bedtime

What drug is this that is used for GERD?

- Mimics the effects of acetylcholine, a neurotransmitter in the parasympathetic nervous system

- Keeps LES tight

- Improves esophageal emptying

- Increases gastric emptying

Cholinergic drugs

What is a NEGATIVE of cholinergic drugs?

Stimulates HCL acid secretion

What is a med name of a cholinergic drug?

Bethanechol (Urecholine)

What are these drugs?

- Increase gastric emptying meaning they enhance GI motility

- Reduce risk of gastric acid reflux

Prokinetic drugs

All of these are side effects of what drug?

- Restlessness

- Anxiety

- Increased acid production

Prokinetic drugs

High doses of prokinetic drugs can cause what 2 side effects?

Sedation and diarrhea

Chronic or high dose use of prokinetic drugs can cause?

Tardive dyskinesia

What type of diet should patients with GERD eat?

Low fat diet- helps keep LES tight while high fat foods relax the LES

What are some examples of high fat foods?

1) Avocado

2) Nuts

3) Fatty fish

4) Olive oil

5) Dark chocolate

6) Processed meats

7) Fried foods

8) Full-fat dairy products

What are some examples of low fat foods?

1) Lean meats

2) Low-fat dairy products

3) Fish

4) Whole grains

5) Fruits

6) Vegetables

7) Legumes

For GERD patients it should be advised that they do not lie down for _________ hours after eating?

Do not lie down 2-3 hours after eating

GERD patients should avoid eating how many hours before bedtime?

3 hours before bedtime

How should GERD patients be encouraged to sleep?

Sleep w/ HOB elevated on 4-6 in blocks (fosters esophageal emptying)

____________ may be needed if:

1) Conservative therapy fails such as lifestyle changes and meds

2) There's bleeding, chronic esophagitis, or narrowing of the esophagus

3) There's a hiatal hernia

Surgery

Surgical therapy enhances the integrity of the _______________ thus, reducing the reflux of gastric contents

The LES

What type of hernia is this?

- Both the stomach and junction move up and down

Sliding hernia

What type of hernia is this?

- Only part of the stomach rolls up, junction stays put

Rolling (paraesophageal) hernia

What is the most common type of hernia?

Sliding hernia

True or false clinical manifestations of a hiatal hernia include a feeling of fullness and discomfort after meals?

True

Hiatal hernias often symptoms of _____________ because they disrupt the normal function of the LES

Symptoms of GERD such as belching and heartburn

What are hiatal hernias caused by?

Weakening of the muscles in the diaphragm (aging)

All of these are other causes of ___________:

- Obesity

- Pregnancy

- Intense physical exertion

- Heavy lifting

Hiatal hernias

What are the 3 ways that a hiatal hernia can be diagnosed?

1) CT of abdomen/pelvis

2) Esophagram (barium swallow)- uses x-rays

3) Esophagogastroduodenoscopy- tube with camera

Patients with a hiatal hernia should avoid?

Avoid lifting and straining because it puts more pressure on the hernia possibly causing it to worsen

Why should patients with hiatal hernias be educated on weight management?

Increased weight on the abdomen puts more pressure on the hernia possibly causing it to worsen

If a hiatal hernia is severe how is it treated?

Treated with surgery