GERD

Question 1

Gastroesophageal reflux

Answer 1

Retrograde movement of gastric contents from the stomach in to the esophagus

Question 2

Gastroesophageal reflux disease (GERD)

Answer 2

A condition which develops when reflux of stomach contents causes troublesome symptoms and/or complications

Question 3

Reflux esophagitis

Answer 3

Inflammation of the esophagus

Question 4

Erosive esophagitis

Answer 4

Visible damage as seen on endoscopy

Question 5

Epidemiology (4)

Answer 5

1. Difficult to detect in infants and children
2. Up to 35% of all children may have reflux within the first few months of life
3. Reflux usually outgrown by 1 year of age
4. Risk of reflux not subsiding increases with strong family history of GERD

Question 6

Defense Mechanisms (5)

Answer 6

1. Lower esophageal sphincter (LES)
2. Esophageal mucus
3. Esophageal clearance
4. Acid neutralization, Via saliva
5. Gastric emptying

Question 7

Contributing Factors (6)

Answer 7

1. Hiatal hernia
2. Obesity
3. Zollinger-Ellison Syndrome (Increased acidity due to gastrin production)
4. Hypercalcemia
5. Scleroderma
6. Medications (Prednisone, CCBs, NSAIDs)

Question 8

GERD Factors (5)

Answer 8

1. Gastric Acid
2. Pepsin
3. Bile salts
4. Pancreatic enzymes
5. NSAID use

Question 9

GERD risk factors (4)

Answer 9

1. Decreased/increased LES pressure
2. Delayed gastric emptying
3. Increased gastric acid secretion
4. Impaired gastro-esophageal pressure gradient

Question 10

Treatment - Diet
Infant (1)
Children (3)

Answer 10

• Infant
Formula composition

• Children
Avoid foods that irritate GERD symptoms
Eat small meals
Avoid eating immediately prior to sleeping

Avoid exacerbating Meds

Question 11

Treatment - Positioning Therapy
Infants (1)
Children (2)

Answer 11

Infants
Supine versus prone

Children
Elevate head of bed
Avoid reclining after meals

Question 12

Pharmacological Treatments of GERD (4)

Answer 12

1. Antacids
   • Calcium carbonate
   • Magnesium Hydroxide
2. Histamine 2 Receptor Antagonists
3. Proton Pump Inhibitors
4. Prokinetic Agents

Question 13

Antacids MOA (2)

Answer 13

1. Neutralize stomach acid

2. Deactivate pepsin and acidity of reflux

Question 14

Antacids Place in therapy (2)

Answer 14

1. Mild GERD

2. Immediate relief

Question 15

Antacids (2) Available Agents

Answer 15

1. Calcium Carbonate (Tums®, Maalox®)

2. Aluminum Hydroxide/Magnesium Hydroxide (Mylanta®)

Question 16

Antacids ADE (4)

Answer 16

1. Diarrhea (magnesium containing products)
2. Constipation (aluminum containing products)
3. Alteration in mineral metabolism
4. Caution with acid rebound*

Question 17

Antacids Drug Interactions (2)

Answer 17

1. Fluoroquinolones

2. Tetracyclines

Question 18

H2 Receptor Blockers MOA (2)

Answer 18

1. Block histamine-mediated gastric acid secretion

2. Decrease acidity of reflux

Question 19

H2 Receptor Blockers Available Agents (2)

Answer 19

1. Ranitidine (Zantac®)
   - TID dosing
   - Large dosing range recommendation
2. Famotidine (Pepcid®)
   - Twice daily dosing
   - Standard dosing 1 mg/kg twice daily

Question 20

H2 Receptor Blockers Place in Therapy (2)

Answer 20

1. Mild to severe GERD

2. Also use for prevention

Question 21

H2 Receptor Blockers ADE (6)

Answer 21

1. Headache
2. Mental confusion
3. Somnolence
4. Dizziness
5. Abdominal discomfort
6. Thrombocytopenia

Question 22

H2 Receptor Blockers Pearls (2)

Answer 22

1. Dose adjust with renal dysfunction

2. Tachyphylaxis – Increased risk with chronic use

Question 23

Proton Pump Inhibitors MOA (3)

Answer 23

1. Blocks acid secretion by inhibiting ATPase enzyme system in parietal cells
2. Causes prolonged decrease in gastric acid secretion
3. Decreases acidity of reflux

Question 24

Proton Pump Inhibitors Available Agents(4)

Answer 24

1. Esomeprazole (Nexium®)
2. Omeprazole (Prilosec®)
3. Lansoprazole (Prevacid®)
4. Pantoprazole (Protonix®)

Question 25

Proton Pump Inhibitors Place in Therapy (2)

Answer 25

1. Used for more severe GERD symptoms | 2. Erosive esophagitis

Question 26

Proton Pump Inhibitors ADE (6)

Answer 26

1. Diarrhea 2. Flatulence 3. Abdominal discomfort 4. Dizziness 5. Headache 6. Infections

Question 27

Omeprazole - Alternative Admin Technique/Pearls

Answer 27

Open capsules, mix with applesauce/Juice

Question 28

Esomeprazole - Alternative Admin Technique/Pearls

Answer 28

Open capsules, dissolve in 60mL water for NG tube

Question 29

Lansoprazole - Alternative Admin Technique/Pearls (2)

Answer 29

1. Open capsules mix with applesauce, cottage cheese, pudding yogurt, strained pears, or 60mL tomato/orange/apple juice 2. Liquid formulation is best option for enteral tube feeding * If a child can’t take a capsule or has a G-tube or NG-tube, then lansoprazole should be go to agent

Question 30

Pantoprazole - Alternative Admin Technique/Pearls (3)

Answer 30

1. DO NOT CRUSH capsules 2. delayed release packets (Do not use partial doses!) 3. CYP drug-drug interactions

Question 31

Prokinetic Agents MOA (2)

Answer 31

1. Increase gastric emptying | 2. Increase LES pressure

Question 32

Prokinetic Agents Place in Therapy (2)

Answer 32

1. Mild to moderate GERD | 2. Severe GERD

Question 33

Prokinetic Agents Available Agents (2)

Answer 33

1. Metoclopramide (Reglan®) | 2. Erythromycin

Question 34

Prokinetic Agents ADE (6)

Answer 34

1. Abdominal discomfort 2. Acute dystonic reactions (Metoclopramide) 3. Anxiety 4. Insomnia 5. Fatigue 6. QT prolongation

Question 35

Sucralfate (Carafate®) MOA

Answer 35

Forms a paste in the presence of gastric pH to coat the lining of the esophagus and stomach

Question 36

Sucralfate (Carafate®) Place in Therapy (2)

Answer 36

1. Used in combination with other therapies | 2. Mild to moderate GERD

Question 37

Sucralfate (Carafate®) ADE (4)

Answer 37

1. Constipation 2. Bezoar formation 3. Abdominal discomfort 4. Caution with administration with other medications