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6/22/2008
Partners in Healthcare Education, LLC 1
Identification and Managementof Heartburn and GERD: 2008
Wendy L Wright MS RN ARNP FNP FAANP
1
Wendy L. Wright, MS, RN, ARNP, FNP, FAANPAdult/Family Nurse Practitioner
Owner – Wright & Associates Family HealthcarePartner – Partners in Healthcare Education, LLC
Facilitated by Partners In Healthcare Education, LLC and supported by aneducational grant from the National Heartburn Alliance
Objectives• Upon completion, the participant will be
able to:1. Discuss the impact of heartburn and GERD
on individuals in the United Stateson individuals in the United States2. Outline the nonpharmacologic treatment
options for the individual with heartburn and GERD
3. Differentiate the pharmacologic treatment options (OTC and prescription) available for the individual with heartburn and GERD
Case StudyElizabeth
3
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Partners in Healthcare Education, LLC 2
Elizabeth• 52 year-old female presents with a burning in her anterior
chest; non-radiating and not associated with exertion or shortness of breath. Occurs 4 days per week unless she avoids many foods. Has tried OTC antacids without much effect.A ti f t• Aggravating factors:– Foods – fatty meals, spicy meals, spearmint, caffeine
• Alleviating factors:– None
• Medications:– Escitalopram (LexaproTM) 5 mg one po daily– Amlodipine (NorvascTM) 5 mg one po daily– Cyclobenzaprine (FlexerilTM) 5 mg one po daily at bedtime prn
Elizabeth (Continued)• PMH
– Anxiety disorder– Hypertension– Postmenopausal– Overweightg– L5-S1 disc surgery
• No previous evaluation for this complaint• Physical Examination
– Unremarkable except for 1+ tenderness epigastric region
– 12-lead ECG: No abnormalities– Stool for guaiac: negative
Differentials to Consider…
• Episodic heartburn• Frequent heartburn• GERD• Chest pain of cardiac origin• Cholecystitis / Cholelithiasis• Gastric/duodenal ulcerations• H. pylori induced pathology• Gastroparesis / Gastric dysmotility
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Heartburn: What is it?• Heartburn has many names:
– Indigestion– Acid regurgitation– Sour stomach– Official name: pyrosis py
• Characterized by– Burning in the chest– Burning in the upper abdomen– Rises into the throat– Most common symptom of GERD
• Seems to be ubiquitous in the United Stateshttp://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
Prevalence: Heartburn Population
Approximately two-thirds of individuals in the United States experience heartburn1
Frequent heartburn occurs in up to 46% of consumers with heartburn or approximately 50 million people1,2,3with heartburn or approximately 50 million people , ,
Even worse, daily heartburn occurs in 7% to 10% of the adult population or approximately 25 million individuals4,5
1. National Omnibus Study 2003 #US035247, data in Sponsors file.2. P&G MRD#US972782, data in Sponsor’s file. Yankelovich3. Oliveria SA, Christos PJ, Talley NJ, Dannenberg AJ. Heartburn risk factors, knowledge, and prevention strategies: a population-based survey of individuals with heartburn. Arch Int Med. 1999;159:1592–1598.4. P&G MRD#US983190, data in Sponsor’s file.5. Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesophageal reflux: incidence and precipitating factors. Dig Dis. 1976; 21(11):953–956.
Frequency of Heartburn Prescriptions
• In 1999, 90 million prescriptions were written for antisecretive medications
• Cost of therapy - $8.5 billion annually
9
Corley DA, Katz P, Wo JM, et al. Improvement of gastroesophageal reflux symptomsAfter radiofrequency energy: a randomized, sham-controlled trial. Gastroenterology.2003;125:668-676.
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Population Based Study:Frequency of Heartburn
• Population based study of 25 -75 year-old patients (n = 1511):– 42% experienced heartburn
45% had heartburn in last year– 45% had heartburn in last year– 18% had heartburn at least weekly– 12% of those with symptoms weekly reported it
as severe or very severe
10
Rao, Goutham. Management of GERD: Current Primary Care Approaches.The Journal of Family Practice. 2005 ( Suppl):Dec 3-8.
Heartburn Frequency
11 8%
5.9%4 – 6 per week
62.8%< 1 per week
7.9%Daily
Frequency of Heartburn in the US Population (1997)1 (Days per Week)
11.8%1 per week
11.8%2 – 3 per week
What is Episodic Heartburn?
Heartburn that occurs 2 ti kl< 2 times weekly
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
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What Is Frequent Heartburn?
Frequent heartburn (FHB) is described as
“heartb rn occ rring 2 or“heartburn occurring 2 or more days per week.”
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
Demographics: Frequent Heartburn Population
Slightly more women (58%) than men report frequent heartburn1,2
The mean age for FHB sufferers is 45 to 50 years1,3
Many factors contribute to the development of heartburn and may be influenced by geographicheartburn and may be influenced by geographic location, marital status, family status (children), educational level, job type and level, and socioeconomic status4
1. Oliveria SM, Christos PJ, Talley NJ, Dannenberg AJ. Heartburn risk factors, knowledge, and prevention strategies: a population-based survey of individuals with heartburn.
Arch Int Med. 1999; 159: 1592-15982. Yankelovich Partners n= 507 FBH. Data in sponsor’s file3.. American Gastroenterological Association and the Gallup Organization, Inc. A Gallup survey on heartburn across America, Princeton, NJ: 1988, 20004. AC Nielson/SmithKline Beecham Survey. Prog Groc. 1995;74(9):98-99
What is GERD?
• Constellation of symptoms which affects about 5 – 7% of the population
• Most common symptom of GERD is heartburn• Frequently accompanied by
– EructationEructation– Recurrent sore throat– Dysphagia– Chest pain– Hoarseness of voice– Waterbrash (sudden production of excess saliva)– Halitosis– Erosion of tooth enamel
http://www.webmd.com/heartburn-gerd/guide/reflux-disease accessed 05-25-2008
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Etiology of Heartburn and GERD
• Heartburn and GERD occurs when:– The lower esophageal sphincter (LES) temporarily
relaxes– Allows reflux of stomach acid into the esophagusp g– Normally, gravity and peristalsis clear material from the
esophagus and the saliva that we swallow neutralizes the remaining esophageal acid
– Heartburn occurs when any one of these mechanisms are impaired
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
Lower Esophageal Sphincter
17
www.med-ars.it/main.htm accessed 05-10-2008
Causes of Lower Esophageal Sphincter Relaxation
• Relaxation or weakening of the LES can be caused by:– Eating certain foods– Pressure on the stomach because of an
individual’s weight– Frequent bending and lifting, particularly
after eating– Vigorous exercise
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
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Aggravating Conditions/Factors
• Large meals• Stress• Lying down after eating• Tight clothing
– Especially a tight waistband or belt
Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2007.
Foods That Worsen Heartburn
• Acidic citrus fruits and juices• Chocolate• Drinks with caffeine, carbonation, or alcohol
F d f i d f d• Fatty and fried foods• Garlic and onions• Mint flavoring• Black pepper and vinegar• Tomato-based foods
20Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2007.
Causes of Heartburn and GERD
www.heartburnalliance.com accessed 01-25-2005
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Causes of Lower Esophageal Sphincter Relaxation
• Pregnancy– Progesterone relaxes LES; slows peristalsis and
increases retention of partially digested food and acidacid
• Medications also can decrease LES pressure– CCB’s, hormone replacement therapy, muscle
relaxants, and beta blockers– Alpha-blockers and nitrates
Rao, Goutham. Management of GERD: Current Primary Care Approaches.The Journal of Family Practice. 2005 ( Suppl):Dec . 3-8.
Causes of Heartburn / GERD
• Pathophysiologic mechanisms– Hiatal hernia– Zollinger Ellison syndromeg y– Zenker’s diverticulum
Rao, Goutham. Management of GERD: Current Primary Care Approaches.The Journal of Family Practice. 2005 ( Suppl):Dec . 3-8.
Etiology
• Several other defects thought to contribute to heartburn and GERD– Abnormal esophageal epithelial resistance– Abnormalities of gastric emptying– Gastric distention– Abnormal acid production
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
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H. Pylori and GERD
• Forty percent of patients with GERD are infected with Helicobacter Pylori
• Cause and effect have not been clearly t bli h destablished
• Much of the discomfort associated with H. pylori is related to gastritis and/or ulcerations
25
O’Connor HJ. Helicobacter pylori and GERD: clinical implications and Treatment. Aliment Pharmacol Ther. 1999:Feb; 13(2):117-27.
Symptoms of Heartburn / GERD• Burning, substernal pain• Radiates up into the throat• Acid taste in mouth• Chest painp• Nausea• Hoarseness of voice• Wheezing• Cough• Dysphagia
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
Physical Examination Findings
• None• Asthma
– WheezingC h– Cough
• Hoarseness of voice• Epigastric/subxyphoid tenderness
Wright, WL. Strategies for GERD and Heartburn. Advance for Nurse Practitioners2007;15:(9) 49 -50.
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Diagnosis of Heartburn
• Diagnosis of heartburn is usually made with history and physical examination
• Usually, this is all that is neededM li i i ill t ti t t t• Many clinicians will try routine treatments first and assess for response prior to ordering a variety of tests
Response to PPI -Does It Help Diagnose GERD?
• Omeprazole 40 mg given daily for 14 days• Thought to be as specific and sensitive for
diagnosis of GERD as the results of 24 hour pH monitoringmonitoring
• Conclusion: Due to efficacy of omeprazole in relieving reflux symptoms, failure to respond to this intervention would warrant investigation for other causes of reflux
29
Schenk BE, Kuipers EJ, et al. Omeprazole as a diagnostic tool in gastroesophagealReflux disease. Am J Gastroenterol 1997;92:1997-2000.
Elizabeth
• Most likely diagnosis is:–Frequent heartburn / GERD–Consider cardiac etiology given ageConsider cardiac etiology given age
• Negative nuclear stress test
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What Might Be Contributing To Heartburn in Elizabeth?
• Calcium channel blocker (amlodipine)• Muscle relaxant (cyclobenzaprine)• Weight• Fatty foods• Caffeine• Spearmint
31http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
Diagnostic Testing
Upper GI
• UGI: easiest, least expensive test– Hiatal hernia: present in 40-60% of
populationMild reflux seen in 30% of general population– Mild reflux seen in 30% of general population
– Looking for esophageal irregularities, ulcers– Normal barium swallow may be seen in 40-
60% of all individuals with GERD– Not sensitive nor specific
Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2008
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Esophageal Stricture
34www.cdc.gov/nchs/ppt/icd9/att3_Furuta_Sep07.ppt accessed 05-25-2008
Endoscopy
• Best study for the evaluation of recalcitrant or recurrent GERD– Allows for biopsy if abnormalities seen
• Allows for direct visualization of the mucosa of the esophagus and the lining of the stomach
• Essential when suspecting Barrett’s esophagitis
Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2008
• Endoscopy should be considered for 2 groups for patients1 Those with alarm symptoms
ACG Guidelines - GERD
1. Those with alarm symptoms• Dysphagia, bleeding, weight loss,
anemia1
36
1. Rao, Goutham. Management of GERD: Current Primary Care Approaches.The Journal of Family Practice. 2005 ( Suppl):Dec . 3-8.
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Endoscopy
2. Those at risk for Barrett’s esophagitis– 6%-12% of patients who undergo endoscopy
for GERD are found to have Barrett’s1
– Odds ratio for Barrett’s GERD 1-5 years = 3 0Odds ratio for Barrett s GERD 1-5 years = 3.0– Odds ratio for Barrett’s – GERD for 5-10 years
= 52
37
1. Falk GW. Barrett’s esophagus. Gastroenterology. 2002;122:1569-1591.2. Sampliner RE, The Practice Parameters Committee of the American
College of Gastroenterology. Updated guidelines for the diagnosis surveillance, and therapy of Barrett’s esophagus. Am J Gastrol. 2002;97:1888-1895.
Intraesophageal Acid Perfusion
• Also called Bernstein test• This is a test where the patients symptoms are
reproduced or relieved temporarily with this procedure• NG tube placed 30-35 cm from the tip of the nares intoNG tube placed 30 35 cm from the tip of the nares into
the esophagus– Saline is infused followed by HCL– Looking for reproduction of symptoms with HCL and relief of
symptoms with saline infusion
Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. accessed May 5, 2008
24-hour pH Monitoring
• 2 mm flexible probe is placed transnasally to about 5 cm above the LES– Can be placed by endoscopy
• Attached to the appropriate place above LES
• Probe is connected to a box similar to a Holter monitor• Patient then returns home and eats a normal diet• Monitoring of pH is conducted in addition to
documentation of patients symptoms
Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2008
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Esophageal Motility Studies
• Conducted to measure the pressure of the LES• Thin, pressure sensitive tube is passed through
mouth or nose and into stomach• Once in place, the tube is pulled back slowly intoOnce in place, the tube is pulled back slowly into
the esophagus while the patient is asked to swallow
• The pressure of the muscle contractions is then measured along several sections of the tube
Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2008
H. Pylori • 2/3rds of world population is infected• In the U.S, it is more prevalent in the
following individualsOlder adults– Older adults
– African Americans– Hispanics– Lower socioeconomic groups
41
Helicobacter pylori and Peptic Ulcer Disease accessed 5-30-08www.cdc.gov/ulcer/keytocure.htm
Who Should Be Tested for H. Pylori?
• Active gastric ulcers• Active duodenal ulcers• Documented history of ulcers• FYI: To date there has been no
conclusive evidence that treatment of H. pylori infections in patients with non-ulcer dyspepsia is warranted
42
Helicobacter pylori and Peptic Ulcer Disease accessed 5-30-08www.cdc.gov/ulcer/keytocure.htm
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H. Pylori Breath Test
• Gold standard: – Stomach Biopsy (Steiner’s Stain)– Sensitivity 95%; Specificity 99-100%1
H l i b th t t t t t t• H. pylori breath test – most accurate test to be performed in primary care– Sensitivity: 96.5%– Specificity: 96%
Seth AK, Kakkar S, Manchanda GS. Role of Biopsy from Gastric Corpus in diagnosis of Helicobacter Pylori infection in patients on acid suppression
therapy. MJAFI 2003;59:216-217 .
H Pylori Testing
• Stool antigen Test (HpSA test)–Sensitivity >97.8%–Specificity >94.9%Specificity 94.9%
44
Altindis M, Delik ON, Usefulness of the Helicobacter pylori stool antigenTest for detection of Helicobacter pylori . Acta Gastroenterol Belg. 2002;65:74-76.
H Pylori Testing
• C-Urea blood test– Sensitivity of 89%– Specificity of 96%1
• Blood Antibody Test – Sensitivity 75% – Specificity of 67%2-5
45
1. Chey WE. Et al. The 13C-urea Blood test accurately detects the active HelicobacterPylori infection: a United States, multicenter trial. Am Gastroenterol June 1999;94:1522-4.2.Quartero AO, Numans ME et.al In practice evaluation of whole blood Helicobacter3.Pylori test: its usefulness in detecting peptic ulcer. British Journal of GeneralPractice, Jan 2000: 13-16.4.Mauro M, Radovic V, et.al. 13C Urea breath test for Helicobacter Pylori : evaluation of5.10 minute breath collection. Can J Gastroenterol.2006 Dec;20(12):755-8.
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Long term Impact of Heartburn/GERD
• Untreated heartburn / GERD can cause serious complications– Inflammation of the esophagus from refluxed
id d li i / bl di / iacid damage lining / cause bleeding /anemia– Scars from tissue damage lead to strictures
and narrowing of esophagus– Barrett’s esophagus, esophageal cancer
46
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#1 accessed 5-6-08
Consequences of Heartburn / GERD
• 10% - 15% of individuals with GERD will develop complications– Barrett’s esophagitis– Carcinoma of the esophagusg– Hemorrhage– Achalasia: absence of esophageal peristalsis and
failure of lower esophageal sphincter (dysphagia)– Esophageal strictures
Heartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2007.
Barrett’s Esophagitis
• Occurs in < 1% of heartburn sufferers• Occurs when the esophageal lining is
replaced by tissue normally found in the intestines (metaplasia)intestines (metaplasia)
• Increased risk of adenocarcinoma of the esophagus– 30 – 125 times higher in the patient with
Barrett’sBarrett’s Esophagus. National Institute of Diabetes and Digestive and KidneyDiseases. Available at www.digestive.niddk.nih.gov/ddiseases/pubs/barrettsIndex.htm. Accessed June 21, 2007 .
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Barrett’s Esophagitis
49www.med-ars.it/main.htm accessed 05-30-2008
Complications of Heartburn / GERD
• Exacerbation of several pulmonary conditions:– Asthma
Pneumonia– Pneumonia– Chronic cough– Pulmonary fibrosis
50
Gastroesophageal reflux disease. MedlinePlus Medical Encyclopedia. Available at:www.nlm.nih.gov/medlineplus/ency/article/000265.htm accessed May 6, 2008
Risk Factors for Adenocarcinoma
• Uncontrolled GERD– Esophagitis– Esophageal bleeding and ulcers– Barrett’s Esophagus– Strictures– Increased risk of esophageal cancer
• Barrett’s Esophagus– Premalignant condition– Up to 0.5% of people with Barrett’s esophagus will
develop esophageal cancer each year
Heartburn/GERD Guide accessed 5-30-08 atwww.webmd.con/heartburn-gerd/guide/complications-untreated-gerd
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Red Flags• Weight loss accompanied by heartburn• Failure to respond to traditional treatment regimens• Black or bloody stools• Anemia• Difficulty swallowing/choking after eating• Hoarse voice• Difficulty breathing• Chest pain with radiation or accompanying
shortness of breath and diaphoresisHeartburn, hiatal hernia and gastroesophageal reflux disease (GERD)National Institute of Diabetes and Digestive and Kidney Diseases. Available At www.digestive.niddk.nih.gov/ddiseases/pubs/gerd. Accessed May 5, 2007.
What Signals Increased Risk of Complications?
• Frequency and severity of heartburn does not necessarily correlate with the development of esophageal damage or erosions
• Individuals with severe and frequent heartburn may h h l d h i di id lhave no esophageal damage whereas individuals with little heartburn may have significant damage
• Therefore…response to standard OTC medications by the patient is likely to be a predictor of more serious or less serious pathology
Heartburn’s hidden effects. National Heartburn Alliance Web site. AvailableAt: www.heartburnalliance.org/section3/consequences.jsp accessed 5-5-08.
Management Stages for GERDStage Treatment
Stage 1 : Lifestyle Changes Head of bed elevationsDecreased fat intakeSmoking cessation, weight reduction
Stage 2 : As needed pharmacologic therapy
Antacid and or antacid product OTC histamine H2 receptor blocker
54
py p
Stage 3 : Scheduled Pharmacologic therapy
H2 blocker for 8-12 weeksFor persistent symptoms, high dose H2 blocker or PPI for another 8-12 weeksWith documented erosive esophagitis, may use a PPI first line
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
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Stages TreatmentStage 4: Maintenance Therapy Appropriate for patient with
symptomatic relapse or complicated diseaseLowest effective dosage of H2 blocker
Management Stages for GERD
Lowest effective dosage of H2 blocker or PPI
Stage 5: Surgical Intervention Severe symptoms or erosive esophagitis or disease complicationsLaparoscopic Nissen fundoplication procedure
55
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
Elizabeth• History and physical examination were
consistent with frequent heartburn• No cardiac pathology identified• No additional red flags• No additional testing conducted• Patient started on lifestyle modification and
a proton pump inhibitor given frequency and severity of symptoms
Treatment Options
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Goals for Treatment
• Because stomach acid is the main cause of heartburn and GERD, the goal is to mitigate its effects by:1 P ti th l ti f th LES th t ll1. Preventing the relaxation of the LES that allows
stomach acid to reflux and/or 2. Reducing production of stomach acid,
and/or3. Neutralizing the acid
AND…eliminating the patient’s symptoms
Nonpharmacologic Treatment Options
• Dietary Modification– Avoidance of beverages containing
alcohol caffeine and carbonationalcohol, caffeine, and carbonation– Decrease fats, spearmint, peppermint,
tomato based products, raw onions etc– Avoid large meals
Marks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
Lifestyle Modification for Heartburn / GERD
• Smoking cessation• Weight reduction• Small frequent meals • Loose fitting clothing• Avoid lying down for 2 - 3 hours after a
meal
60
Marks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
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• Elevate head of the bed 6 - 8 inches• Wedge pillow may be a good option
– Does not bother the sleep partnerC i ll il bl f b t $30
Lifestyle Modification for Heartburn / GERD
– Commercially available for about $30
61
ACG Treatment Guidelines• Lifestyle Modification
– May benefit many patients with GERD– Lifestyle changes alone are unlikely to control
symptoms in the majority of patientssymptoms in the majority of patients• Patient Directed Therapy
– OTC acid suppressants are options for patient directed therapy
62
DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and TreatmentOf Gastroesophageal Reflux Disease. Am J Gastroenterol 2005;100:190-200.
• Acid Suppression– Mainstay of therapy for GERD– PPI provide most rapid symptom relief and
healing
ACG Treatment Guidelines
healing– Although less effective – H2RA given in
divided doses may be effective in some patients
63
DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and TreatmentOf Gastroesophageal Reflux Disease. Am J Gastroenterol 2005;100:190-200.
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• Maintenance Therapy– Because GERD is a chronic condition, chronic
therapy to control symptoms is appropriate
ACG Treatment Guidelines
• Refractory GERD– Is rare– Diagnosis should be carefully confirmed
64
DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and TreatmentOf Gastroesophageal Reflux Disease. Am J Gastroenterol 2005;100:190-200.
• Surgery– Antireflux surgery is a maintenance option for
the patient with well documented GERD who is responsive to treatment yet not adequately
ACG Treatment Guidelines
responsive to treatment yet not adequately controlled
65
DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and TreatmentOf Gastroesophageal Reflux Disease. Am J Gastroenterol 2005;100:190-200.
Medications
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Classes of Medications
• Antacids• Histamine 2 Receptor Antagonists• Proton Pump Inhibitors• Combination Therapy
ACG GuidelinesHeartburn and GERD
• Empiric therapy is appropriate for uncomplicated heartburn and GERD– If a patient has symptoms of heartburn or
GERD and responds to an initial trial of acidGERD and responds to an initial trial of acid suppressive therapy, an assumed diagnosis of GERD is reasonable
68
DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatmentOf gastroesophageal reflux disease. Am J Gastroenterol. 2005; 100:190-200
Antacids
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Antacids• Maalox™
– Aluminum hydroxide, magnesium hydroxide• Mylanta™
– Aluminum hydroxide, magnesium hydroxide and simethicone
• Rolaids™– Calcium carbonate, magnesium hydroxide
• Surpass™– Calcium carbonate
• Tums™– Calcium carbonate
Marks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
Antacids
• Although antacids have long been thought to work in the gastric lumen to decrease gastric acidity, they actually work in the esophageal lumen
• Rapidly increase esophageal pH• Rapidly increase esophageal pH• Neutralize esophageal acid for 90 minutes after
dosing• Little change in gastric pH• Indication: intermittent or episodic heartburn
Marks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
Antacids
• Advantages– Multiple products available– Many different preparations:
• Liquids, tablets, chewable tablets, effervescent solutions and gum
– Gum and chewed tablet antacids seem to be more effective (per patient report) than liquid products
– Fast onset of action– Ease of dosing – take when patient has symptoms
Marks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
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Disadvantages of Antacids
• Frequent dosing required– Short duration of action
• Few studies done with antacids• No role with prevention
Marks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
H2RA’sH2RA’s
H2RA’s
• Nizatidine - Axid™– 75 mg nizatidine
• Famotidine - Pepcid AC™ – 10 mg famotidine, 40 mg
• Maximum Strength Pepcid AC™Maximum Strength Pepcid AC– 20 mg famotidine
• Cimetidine - Tagamet HB™ – 200 mg cimetidine
• Ranitidine - Zantac™75/150 – 75 mg and 150 mg ranitidine, by Rx 300 mg
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
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Mechanism of Action• Drugs bind to histamine-2 receptors on parietal
cells to decrease gastric acid secretion• Begin to work by decreasing gastric acid
secretion within 1 – 2 hours of dosingS t k b t t l id ti• Seem to work best on nocturnal acid secretion vs. daytime
• Antacids vs. H2RA– Antacids: Onset: 30 minutes, Last: 60 minutes– H2RA: Onset: 90 minutes, Last: 9 hours
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
H2RA’s
• Indication: episodic heartburn• All products can be taken daily• Not indicated for frequent heartburn
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
Combination of Antacid and H2RA
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Low Dose H2RA and Antacid
• Pepcid Complete™– 10 mg famotidine, 800 mg of CaCO3 (TumsTM) and
165 mg of MG (OH)2 H2RA and antacid combination
• Speed of an antacid + duration of H2RA• Indication: intermittent or episodic heartburn
– Not cost effective or indicated for individuals with frequent heartburn
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
Proton Pump InhibitorsProton Pump Inhibitors
Mechanism of Action• PPIs
– Suppress gastric acid production by blocking parietal cell hydrogen/potassium ion adenosine triphosphatase
– Known as the proton pump– This is the final pathway involved in acid secretion– Remember…PPI’s affect only those pumps which are
active• Not all pumps are active at the same time
– 25% of new proton pumps are synthesized dailyMarks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
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Draft 82
Mechanism of Action: Proton Pump Inhibitor
Proton Pump Inhibitors
• Omeprazole magnesium (Prilosec OTC™)• Omeprazole (Prilosec™)• Lansoprazole (Prevacid™)• Esomeprazole (Nexium™)• Rabeprazole (AcipHex™)• Pantoprazole (Protonix™)
Indications
• Omeprazole magnesium (Prilosec OTC™) and omeprazole (Prilosec™)– Frequent heartburn
P i ti PPI’• Prescription PPI’s– GERD– Reduce risk of NSAID induced gastric ulceration– Erosive esophagitis– Hypersecretory conditions
• Zollinger-Ellison Syndrome
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• Discontinuation of treatment with a PPI may be followed by return of symptoms
• Continuous therapy to control symptoms and prevent complications may be
ACG Guidelines - GERD
and prevent complications may be appropriate for some patients
85
DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatmentOf gastroesophageal reflux disease. Am J Gastroenterol. 2005; 100:190-200
Efficacy of PPI vs. H2RA
• 3 PPI’s (omeprazole, lansoprazole, pantoprazole) relieved heartburn and healed esophagitis at significantly faster rates than did H2RA’s (cimetidine, (nizatidine, ranitidine, famotidine)– 2 weeks of PPI treatment relieved symptoms
that took 8 weeks for H2RA’s– PPI healed esophagitis in same number of
patients as did 12 weeks of treatment with H2RA’s
Chiba N, De Gara CJ, et. al. Speed of healing and symptom relief in Grade IITo IV gastroesophageal reflux disease: a meta-analysis. Gastroenterology1997;112:1798-1810.
PPI’s vs. ranitidine
• Endoscopically confirmed GERD• Meta-analysis of 26 randomized, placebo
controlled trialsP l d d t h d• Pooled data showed:– Rate of heartburn resolution after 4 weeks of
treatment was 1.53 times higher with PPI’s– 4 week and 8 week healing rate rates for PPI’s
compared with ranitidine were also higher
87
Caro JJ, Salas M, Ward A. Healing and relapse rate in GERD treated with newerProton pump inhibitors lansoprazole, rabeprazole, pantoprazole compared withomeprazole, ranitidine, and placebo: evidence from randomized clinical trials.Clin Ther. 2001;23:998-1017.
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Proton Pump Inhibitors
• Recent studies have shown there may be an increased risk of:– Osteoporosis
• Should take calcium citrate NOT carbonate• Should take calcium citrate NOT carbonate• Carbonate – i.e. TumsTM needs an acidic
environment– Pneumonia
• Diminished acid protection
Marks, JW. Gastroesophageal Reflux Disease (GERD, Acid Reflux, Heartburn)http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htmAccessed 5-12-08 .
Combination Therapy
• Zegerid™ Capsules– Omeprazole– Sodium bicarbonate– Indications
• Gastric and duodenal ulcer• Erosive esophagitis• Symptomatic GERD
Source: Product Insert 2007
Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Family Physician. 1999; 59:87-94.
Surgical Options
• Nissen fundoplication– The upper curve of the stomach (the fundus) is wrapped
around the esophagus and sewn into place so that the lower portion of the esophagus passes through a small
l f h ltunnel of stomach muscle– This surgery strengthens the LES between the
esophagus and stomach– In one study, 62% of people who had surgery were still
taking medications to control GERD symptoms.Bammer T, Hinder RA, Klaus A, Klinger PJ. Five to eight year outcomeof the first laparoscopic Nissen fundoplications.. J Gastrointerst Surg.2001;5:42-48.
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Fundoplication has drawbacks
• Majority of patients continue to require PPI or other disabling symptoms– 20% abdominal bloating
6% had persistent heartburn– 6% had persistent heartburn– 7% developed dysphagia requiring esophageal
dilatation– Difficulty with burping or vomiting in some
patients (may be technique specific outcome)
91
Bammer T, Hinder RA, Klaus A, Klinger PJ. Five to eight year outcomeof the first laparoscopic Nissen fundoplications. J Gastrointerst Surg.2001;5:42-48.
EsophyX
• Transoral Incisionless Fundoplication– Treatment of GERD
• Reconstruction of the antireflux barrier• Restores GE junction back to normal anatomyRestores GE junction back to normal anatomy• Same concept as the Nissen without incisions• Now FDA approved and available
92
Cadiere GB, Rajan A, Rqibate M, et al. Endoluminal fundoplication ELFEvolution of EsophyX, a new surgical device for transoral surgery. Min InvasiveTher Allied Technol. 2006;15:348-355.
Elizabeth
• Patient returns 1 month later after completing a 2 week regimen with omeprazole magnesium (Prilosec OTCTM)
• Reports that all of her symptoms have• Reports that all of her symptoms have resolved
• Patient is encouraged to follow-up if symptoms return
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But…What if the Case Study WereWhat if the Case Study Were
Different?
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Thomas…
• Patient returns 1 month after initiating treatment with a prescription PPI; no improvement in symptoms
• Referred for endoscopy given lack of py gresponse to traditional methods– Endoscopy shows mild esophagitis– Negative H. pylori biopsy
• PPI – increased by GI to 2 daily– No improvement at 1 month
What Now??
• 24 hour pH probe• Esophageal motility studies• Bernstein test
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Thomas
• 24 hour probe showed NO significant correlation between pH and symptoms
• Esophageal motility studies showed decreased motilitydecreased motility– Started on metoclopramide (Reglan™) 5 mg 1
po tid – 30 minutes prior to meals with significant improvement in symptoms
– Follow up monthly due to potential for extrapyramidal effects
Purpose of Additional Case Study
• Investigate failure to respond to traditional therapy
• Not all that sounds like heartburn or GERD is actually heartburn or GERDis actually heartburn or GERD
• Evaluate for the presence of any red flags
Web-Based Resources for Providers and Patients
• www.heartburnalliance.org• www.myheartburn.org• National Digestive Diseases Information
Cl i h (NDDIC)Clearinghouse (NDDIC)– www.digestive.niddk.nih.diseases
• Medline Plus– http://www.nlm.nih.gov/medlineplus/tutorials/g
erd/htm/index.htm
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Stop and Select Guide
www.heartburnalliance.orgg
Available in English and Spanish
www.heartburnalliance.org
Resources • American College of Gastroenterology
P.O. Box 342260Bethesda, MD 20827–2260Phone: 301–263–9000Internet: www.acg.gi.orgInternet: www.acg.gi.org
• American Gastroenterological AssociationNational Office4930 Del Ray AvenueBethesda, MD 20814Phone: 301–654–2055Fax: 301–654–5920Email: [email protected]: www.gastro.org 102
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Resources
• International Foundation for Functional Gastrointestinal DisordersP.O. Box 170864Milwaukee WI 53217–8076Milwaukee, WI 53217 8076Phone: 1–888–964–2001 or 414–964–1799Fax: 414–964–7176Email: [email protected]: www.aboutgerd.org
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Resources
• North American Society for Pediatric Gastroenterology, Hepatology, and NutritionP O Box 6P.O. Box 6Flourtown, PA 19031Phone: 215–233–0808Fax: 215–233–3918Email: [email protected]: www.naspghan.org
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Resources
• Pediatric/Adolescent Gastroesophageal Reflux Association, Inc.P.O. Box 486Buckeystown MD 21717–0486Buckeystown, MD 21717 0486Phone: 301–601–9541Email: [email protected]: www.reflux.org
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Conclusions
• Millions of individuals are affected by heartburn and GERD
• For many individuals, these symptoms significantly affect quality of lifesignificantly affect quality of life
• Nurse practitioners and physician assistants are in a perfect position to identify individuals with these symptoms and initiate treatments
• Red flags and failure to respond to traditional therapy necessitates further evaluation
Thank You for YourThank You for Your Time and Attention!!!
Please visit us at:Partners in Healthcare Education, LLC
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www.4healtheducation.com
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