Transcript Gastroenterology

Week 4 – Gastroenterology Clinical
Pharmacy
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Goal: Provide an understanding of
complications of chronic liver disease and their
management and the current therapeutic
strategies for GORD.
Objectives: To enable the pharmacist to:
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Be familiar with the clinical features and potential
complications of GORD, and the drug and other
treatments options available to manage this condition
Understand the underlying mechanisms for the
common complications of chronic liver disease, and
how these are managed and monitored.
Gastro-oesophageal
Reflux Disease
Dr Ian Coombes, University of Queensland +
Safe Medication Practice Unit
(Adopted from karen Bettanay with permission)
Gastro-Oesophageal Reflux Disease
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Retrograde flow of gastric contents into
oesophagus
Only present when reflux of gastric contents
causes frequent, severe symptoms or mucosal
damage
Common disorder causing a variety of
symptoms
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Associated with asthma and oesophageal
adenocarcinoma
GORD is rarely life threatening but is frequently
chronic and relapsing, reducing the quality of
life.
Epidemiology
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~25% of the adult population in Western
society experience symptoms at least
monthly
5% experience daily symptoms.
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Incidence increases with age
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Pathophysiology
de Caestecker, J. BMJ 2001;323:736-739
Pathophysiology
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Multi-factorial
Anti-reflux barrier
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Transient changes in lower oesophageal
sphincter (LOS) pressure are normal - GORD
have lower LOS pressures, on average.
The diaphragm acts as an “external sphincter”
and may play an important role.
Refluxed material
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Acid and pepsin damage the oesophageal
mucosa, damage proportional to acid exposure
Bile acids and pancreatic enzymes probably have
a limited role
Oesophageal Defence Mechanisms
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Oesophageal clearance – gravity and peristalsis;
peristaltic dysfunction sometimes occurs in GORD
Hiatus hernia can impair oesophageal clearance
Saliva contains bicarbonate to neutralize acid.
Oesophageal mucosa – mucous, bicarbonate and
prostaglandins are protective
Ability to repair/heal also important
Oesophageal sensitivity (to acid and mechanical
stimuli) varies
Investigations for GORD
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Ambulatory GOR (oesophageal pH) Study (24
hours) (Nov 2004):
On maximal antireflux therapy.
Proximal oesophagus results:
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No. of refluxes:
No. of long refluxes:
Duration of longest reflux:
Time pH < 4
% of time pH < 4:
DeMeester Score
47
5
8 mins
67 mins
4.7% (normal < 0.1%)
20.7 (normal <14.72)
Risk Factors
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Genetic factors
Smokers
Diet
 Obesity
 Larger meals, especially late at night
 High fat content
 ?Caffeine
 ?Excess alcohol
Pregnancy
Hiatus hernia
Drugs
 eg TCA’s anticholinergics, nitrates, ca 2+ blockers
Natural history
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Chronic and relapsing
~80% relapse
Highly variable, intermittent or frequent
relapses
Majority don’t get worse or develop
complications
Symptoms ≠ oesophageal damage
Small percentage develop serious
complications-blockage + malignancy
Symptoms
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Heartburn
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Retrosternal discomfort
Acid brash
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Regurgitation acid or bile
Water brash
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Related to meals, lying down, stooping & straining, relieved
by antacids
Excessive salivation
Odynophagia
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Pain on swallowing may be due to severe oesophagitis or
stricture
Atypical symptoms
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Non cardiac chest pain
Dental erosions
Respiratory symptoms
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Chronic hoarseness
Laryngitis
Chronic cough
Asthmatic symptoms: wheeze, SOB
Episodic or chronic aspiration can cause
pneumonia, lung abscess, and interstitial
pulmonary fibrosis.
“Alarm Symptoms” -refer
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Acute gastrointestinal bleeding-refer immediately.
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Urgent referral for endoscopy for patients of any age
with dyspepsia when presenting with any of:
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Chronic gastrointestinal bleeding
Progressive unintentional weight loss
Progressive difficulty swallowing
Persistent vomiting
Iron deficiency anaemia
Epigastric mass
Management of GORD
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Drug treatment first unless alarm symptoms
Step down not step up approach
PPI (omeprazole) > effect vs H2RA (ranitidine)
Long-term trt’ may be required at lowest dose
H Pylori test and treat (2/52) if no response
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PPI + amoxycillin 1 g BD + clarithromycin 500mg bd
No evidence of much effect on GORD
Increases risk of peptic ulcer or gastric cancer
Management of GORD
Dyspepsia not needing referral
Review drugs
Lifestyle advice
response
no response or relapse
Full dose PPI (omeprazole
20mg daily) for 2-4/52
no response or relapse
relapse
response
response
Test and treat for H Pylori
Low dose treatment
as required
response ADD H2 receptor antagonist or
prokinetic (metoclopramide)
no response
Review
Fox M, Forgacs I. Gastro-oesophageal reflux disease. BMJ
2006;332:88-93
Return to self care
Step down of PPI therapy
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Symptoms well controlled
Maintain if sev. GORD, strictures, Barrett’s oesophagus
Intermittent
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Evidence good for intermittent symptom driven use in non or mild
erosive GORD
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Low dose therapy
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Surveys show most patients only take as required
Take on days when symptoms occur, may need repeated doses t
Return for review if becomes continuous
Continuous low dose PPI maintenance controls symptoms in
most people who have completed a 4 week course
Discuss cessation
Chronic use – side effects, increase LFTs, NVD, increase
risk of pneumonia, blood dyscrasias
Case 1
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52 year old , 98kg obese man
PC – worsening of her asthma
HPC
 SOB, coughing nocturnal waking, fevers & sweats for 3/7
 Ongoing problem with regurgitation of stomach contents 2
hours after eating, as well as regular N&V
PMH includes
 Asthma
 GORD for 3 years
Social history
 Lives with wife and 2 children
 Non smoker
 Occ alcohol
Case 1 GORD continued
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Medications
 Seretide accuhaler 250/50 1 puff bd
 Ventolin inhaler 2 puffs prn (currently using this
qid)
 Omeprazole 20mg bd
 Gastrogel 20mL prn
Allergies
 Penicillin → Rash
Investigations for GORD
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Endoscopy (Jan 2004):
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Large sliding hiatus hernia with very lax gastrooesophageal junction. Moderate ulceration within
hernial sac. No reflux oesophagitis.
Suggest trial of vigorous anti-reflux therapy.
Oesophageal motility report (Nov 2004):
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Normal oesophageal peristaltic motility
Diagnosis and Plan
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Worsening of asthma
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?infective
Possible worsening of GORD
Treat with clarithromycin 250mg bd
For gastroenterology review
Questions?
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What drugs can affect gastric emptying and
motility?
What other drug options may be useful for
GORD?
What are the complications of poorly
controlled GORD?
What lifestyle measures may be useful in
GORD?