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Chapter 13 Heartburn and Dyspepsia

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  Heartburn and Dyspepsia PATHOPHYSIOLOGY Basic Upper GI Anatomy Food travels along the gastrointestinal (GI tract) in the following fashion: Mouth !  Esophagus !  Stomach !  Small Intestine Three sphincters discussed in class control the movement of food within these different compartments. (1)   The upper esophageal sphincter separates the mouth and the esophagus. It opens whenever we are swallowing. (2)   The lower esophageal sphincter (LES) separates the esophagus and the stomach. It opens to allow food into the stomach and remains closed otherwise. (3)   The pyloric sphincter separates the stomach and the small intestine. It opens to allow gastric juices and food digested by the stomach into the small intestine for further absorption. Food is brought into the stomach for three general purposes: (1)   Food storage (2)   Breakdown of food into liquid mixture by gastric juices (3)   Delivery of liquid mixture into the small intestine Parietal cells within the stomach produce acid to aid in food digestion. Sodium  bicarbonate produced by mucosal cells neutralizes this acidic juice for protection. Heartburn in the US 60% of the adult population experiences some type of GERD within 1 year. 20-30% will have weekly symptoms for as long as five years. 8-26% have symptoms 2-3% a week. 7-10% have daily symptoms. 30-50% of pregnant women experience heartburn during their pregnancies. 64.6 million prescriptions are written annually for GERD treatment. Defining Heartburn Heartburn is described as a warm discomfort, which begins in the lower chest and travels to the neck. Patients may feel a burning sensation or pain in the lower chest. This feeling is a result of stomach acid backing up into the esophagus. There are various classifications of heartburn. Depending on the situation, a patient’s heartburn can fit into more than one classification. Simple heartburn: Infrequent heartburn that is mild, episodic, and typically can be directly related to diet or lifestyle choices. Frequent heartburn: Chronic or regular heartburn, which occurs at least 2 days every  week.  It is important to note that frequent heartburn, which persists for more than 3 months , is referred to as gastroesophageal reflux disease  (GERD). If a patient presents with frequent heartburn lasting for at least 3 months, he or she must be referred to the M.D. GERD is usually not relieved by antacids or any other OTC treatment. A diagnosis cannot be made without an upper GI endoscopy and manometry. Postprandial heartburn: Heartburn that occurs within 2 hours of eating a large meal or other trigger food Non-erosive gastroesophageal reflux disease (NERD): frequent and severe heartburn  without esophageal damage Nocturnal heartburn: Heartburn that disturbs restful sleep. This occurs partly because  when a person lies flat, gravity no longer pulls down on the gastric juices, inviting the  juice towards the esophagus. Defining Dyspepsia Dyspepsia is a synonym for “bad digestion.” It is defined as consistent or recurring discomfort in the upper abdomen. It is not restricted to meal related symptoms. Dyspepsia often is associated with bloating,  belching, early satiety, and nausea. The causes of dyspepsia are: (1)   Structural: Peptic ulcer disease or GERD damaging the lining of the esophageal wall (2)   Functional/ idiopathic for 60% of patients Contributing factors to heartburn and dyspepsia -    Weakened LES tone o   Sphincter is more readily opened -   Delayed stomach emptying o   Increases the gastric pressure, opening the LES -   Increased acid secretion o   Lowers the pH of the gastric juices, further exacerbates painful symptoms heartburn/ dyspepsia -   Decreased salivation with increased age o   May cause stomach to work harder Risk Factors Diet Lifestyle Chocolates Fatty foods increase abdominal pressure Spicy foods directly irritate the upper GI tract Spearmint/ peppermint Garlic/ onions  Alcohol and caffeine lower the LES tone Smoking Stress Exercise Laying down within 3 hours after eating Large meals Tight fitting clothes Obesity Drugs (direct irritants) Drugs (lowers LES tone)  Bisphosphonates  Aspirin NSAIDs Iron Potassium Quinidine Tetracycline Estrogen Morphine Nitrates -   Prostaglandins protect the GI lining. NSAIDs inhibit prostaglandin production. -   Bisphosphonates are indicated for osteoporosis therapy. -   Iron and calcium interact. Signs and Symptoms Common Alarm [immediately refer to MD] Burning sensation behind breast bone Increased salivation Burping/ belching Regurgitation without nausea Pain around epigastric area Dysphagia (difficulty swallowing) GI bleed (evidenced by dark stools) Unexplained weight loss (at least 10% of  body weight) Continuous nausea/ vomiting/ diarrhea Heartburn Complications If left untreated, heartburn can lead to a wide variety of other medical problems. -   Esophageal ulcers may led to short term and long term bleeding -   Esophageal strictures -   Trouble swallowing -   Cancer -   Barrett’s esophagus -    A decreased quality of life Heartburn and Pregnancy   Heartburn occurs in 45-85% of women in the third trimester. For pregnancy-related heartburn, antacids are safe as long as they are taken PRN and high doses are avoided. Sodium bicarbonate containing antacids should be avoided, because the sodium  bicarbonate content can lead to fluid accumulation. Tagamet (H2RA) has been shown to cross the placenta, but adverse effects to the child have not been proven. Prilosec (PPI) crosses into breast milk, and its administration to lactating women should only be considered if the benefits outweigh the risk. In general, pregnant and lactating women should only take H2RAs and PPIs after M.D. consultation. Patients should seek medical attention if: - Heartburn symptoms persist after two weeks of treatment with antacids or H2RAs. - Symptoms such as difficulty swallowing or persistent abdominal pain occur. - Chest pain occurs, particularly: tight, viselike pain or discomfort that radiates the neck, shoulder, or left arm. TREATMENT Treatment of Heartburn The purpose of treating heartburn and dyspepsia OTC is to achieve the following goals:  1.   Relieve heartburn or prevent its recurrence 2.   Relieve stomach pain/ discomfort 3.   Prevent complications, such as ulcer formations 4.   Improve the patient’s quality of life Role of the Pharmacist The pharmacist is responsible for assessing whether the patient is a candidate for self- treatment, or whether the patient will need to be referred to an MD. The pharmacist should recommend lifestyle changes that will improve the condition or prevent its recurrence. If appropriate, the pharmacist should recommend OTC medications based on the specific patient, including: symptom presentation, lifestyle, cost issues, drug interactions, and co-morbidities. Primary Treatment Options Once it has been assessed that the patient is experiencing simple heartburn and does not need to be referred to a physician, there are three main drug classes which may help treat the patient:  Antacids Histamine-2 Receptor Antagonists (H2RAs) Proton Pump Inhibitors (PPIs) Remember, the pharmacist must always recommend lifestyle modifications. Lifestyle Modifications -   Elevate the head of bed at least 6 inches before sleeping -   Eat no later than 3 hours before going to bed to allow adequate time for gastric emptying -    Avoid foods that trigger heartburn -    Avoid lying down after meals -   Limit alcohol intake -   Smoking cessation -    Weight loss, if obese  Antacids  Antacids are used for temporary relief of mild and infrequent heartburn and dyspepsia. It is not used for prevention. Common antacid- containing products include Mylanta, Maalox, Milk of Magnesia, Tums, Rolaids, Pepto Bismol, and Simethicone Mechanism of action of antacids (1)   Increases LES tone to restore normal LES activity (2)   Neutralize stomach acid by acting as a pH buffer  All antacids contain at least one salt, which acts as a base, thereby neutralizing gastric juices: sodium bicarbonate, calcium carbonate, aluminum salts, and magnesium salts Pharmacokinetics of antacids  Antacids begin working in less than 5 minutes.
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