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GASTROESOPHAGEAL REFLUX DISEASE (GERD)

GASTROESOPHAGEAL REFLUX DISEASE (GERD). Ahmed A. Elberry, MD. Anatomy of the stomach:. Incidence:. GERD is the most common GIT disorder (over 1.0 million out patient visits to physicians every year!)

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)

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  1. GASTROESOPHAGEAL REFLUX DISEASE (GERD) Ahmed A. Elberry, MD Ahmed A. Elberry, MBBCH, MSc, MD

  2. Anatomy of the stomach: Ahmed A. Elberry, MBBCH, MSc, MD

  3. Incidence: • GERD is the most common GIT disorder (over 1.0 million out patient visits to physicians every year!) • The prevalence in U.S is about 45 % of the adult population on a monthly basis. 10% of patients require daily acid suppression medication for relief of symptoms. Ahmed A. Elberry, MBBCH, MSc, MD

  4. Pathophysiology: • GERD occurs when the LES does not close properly, and stomach content reflux into the esophagus. • The LES acts as a physical barrier between the esophagus & stomach. During swallowing the LES relaxes and allows passage of food & liquids into the stomach. • When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. • Occasional heartburn is common normally. Heartburn that occurs more than twice a week may be considered GERD. Ahmed A. Elberry, MBBCH, MSc, MD

  5. Causes GERD: • Hiatal hernias are sometimes contributing factors. Ahmed A. Elberry, MBBCH, MSc, MD

  6. Etiology of GERD: Ahmed A. Elberry, MBBCH, MSc, MD

  7. Medications causing GERD: • DECREASING LES PRESSURE: - α-adrenergic agonists - ß-adrenergic agonists - oral Contraceptives - Calcium channel blockers - Diazepam- Dopamine - Nitrates- Narcotics- Nicotine patch - Theophllyine • DIRECTLY INJURE ESOPHAGEAL LINING:- NSAIDS (i.e.: Aspirin - Ibuprofen)- Quinidine - Tetracycline- Potassium- Iron Ahmed A. Elberry, MBBCH, MSc, MD

  8. Symptoms of GERD: • Typical symptoms include: • Burning sensation in the chest (Heart burn), & regurgitation of food. • These symptoms are general & not specific (patients may experience chest pain or burning as a result of cardiac problem, or another esophageal disorder) • Atypical symptoms of GERD include: • asthma; • chronic hoarseness; • difficulty swallowing (dysphagia); • vomiting; • choking sensation at night time; • excessive salivation.; Ahmed A. Elberry, MBBCH, MSc, MD

  9. Complications of Untreated GERD: • Inflammation of the esophagus causes bleeding or ulcers. • Scarsfrom tissue damage can narrow the esophagus and make swallowing difficult. • Over time can lead to cancer. • Asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD. Ahmed A. Elberry, MBBCH, MSc, MD

  10. Treatment of GERD: The goals of therapy for GERD include: a) Symptomatic relief; b) Resolution of esophagitis c) Prevention of complications. Treatment include: A- Nonpharmacologic B- Pharmacologic Ahmed A. Elberry, MBBCH, MSc, MD

  11. A- Nonpharmacologic treatment: (Lifestyle & food modification): • Avoid lying down for several hours after eating & Elevate the head of your bed • Avoid Smoking, Foods & Medications that can exacerbate GERD (see above). Eat small meals. • Lose weight. Excess weight can increase intra-abdominal pressure overcome the resting pressure of the LES. • Avoid tight fitting clothes. Ahmed A. Elberry, MBBCH, MSc, MD

  12. Avoid heavy meals Ahmed A. Elberry, MBBCH, MSc, MD

  13. B- Pharmacologic treatment: • Antacids • Anti-secretory: • - H2 blockers • - Proton pump inhibitors • Mucosal protective: Bismuth subsalicylate • Prokinetic drugs Ahmed A. Elberry, MBBCH, MSc, MD

  14. Antacid • They include: • Na bicarbonate • Ca carbonate • Mg oxide & hydroxide • Mg trisilicate • Al hydroxide gel Ahmed A. Elberry, MBBCH, MSc, MD

  15. Advantages of antacids Ahmed A. Elberry, MBBCH, MSc, MD

  16. Disadvantages of antacids Ahmed A. Elberry, MBBCH, MSc, MD

  17. (Maalox, Mylanta): Mg hydroxide + Al hydroxide • Drug interactions of antacids: 1- Antacids  absorption of most drugs: - Al+++ - Ca++ - Mg++  Absorption of Tetracycline - Al+++ & Mg++  Absorption of: ranitidine – digoxin - theophylline – warfarin – quinolone – ketoconazol - Antacids  effect of sucralfate 2- Antacids may  absorption of enteric coated drugs Ahmed A. Elberry, MBBCH, MSc, MD

  18. Antacids are the 1st drugs recommended to relieve heartburn & other mild GERD symptoms. However for patients with more frequent symptoms & esophagitis, further therapy may be required. • Alginates (thick gel derived from Algae) May be used with antacid especially in reflux esophagitis as they may  adherence of mucous to the esophageal mucosa • Dimethicone is not antacid & may be also included in the antacid mixture as Anti-foaming agent to reduce flatulence. Ahmed A. Elberry, MBBCH, MSc, MD

  19. H2 blockers(Cimetidine – Ranitidine – Famotidine – Nizatidine) • 1. Cimetidine: no longer used now (400 – 800 mg/d) • 2- Ranitidine [Zantac] Like cimitidine but – Stronger [10 times] – Longer – Not pass B.B.B Ahmed A. Elberry, MBBCH, MSc, MD

  20. 2- Ranitidine [Zantac] • Uses: • Peptic ulcer: 300 mg at bed time or 150 mg twice orally • Gastroesophageal reflux disease [GERD] • Upper G.I.T bleeding & stress related gastritis • Zollinger Ellison syndrome • Side effects: • Recurrence if stopped suddenly • G.I.T disturbances & diarrhea • Hypersensitivity & skin rash •  Hepatic blood flow (non-specific enzymatic inhibition) • Hepatitis like ( serum transaminases) Ahmed A. Elberry, MBBCH, MSc, MD

  21. 3- Famotidine • Like Ranitidine but strong [10 times] • Dose: 40 mg at bed time or 20 mg twice orally 4- Nizatidine - Like Ranitidine but not metabolized [100% oral bioavailability] Ahmed A. Elberry, MBBCH, MSc, MD

  22. II- Proton pump inhibitors (PPIs)[H+ / K+ ATPase inhibitors] • Preparations: eg.:- Omeprazole 20 – 40 mg/d orally • Uses: as H2 blockers • Side effects: • Allergy & skin rash • G.I.T.  Nausea, colic & diarrhea. Long use  Gastric carcinoid tumor • C.N.S.  Headache – Dizziness – Drowsiness •  risk of enteric & respiratory infections • HME metabolism of [ Warfarine - Diazepam- Phenytoin] Ahmed A. Elberry, MBBCH, MSc, MD

  23. NB.: Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD. Ahmed A. Elberry, MBBCH, MSc, MD

  24. Prokinetics • Makes the stomach empty faster. • This group includes Bethanechol (Urecholine) and Metoclopramide (Reglan), but these drugs have frequent side effects that limit their usefulness. Erythromycin, an antibiotic, can also help your stomach empty faster. Ahmed A. Elberry, MBBCH, MSc, MD

  25. GOOD LUCK berry_ahmed@yahoo.com

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