1. Background
1.1. Parietal cells secrete HCl through proton pump
1.1.1. Pump stimulated by histamine, acetylcholine, & gastrin (also stimulates stomach muscle contractions)
1.2. Lower esophogeal sphincter usually stops backflow
1.2.1. GERD pts have reduced muscle tone/pressure in LES
1.3. Drugs which can worsen GERD
1.3.1. ASA/NSAIDs
1.3.2. Bisphosphonates
1.3.3. Dabigatran
1.3.4. Estrogen products
1.3.5. Fish oil
1.3.6. Iron
1.3.7. Nicotine replacement therapy
1.3.8. Steroids
1.3.9. Tetracyclines
2. Treatment principles
2.1. Refer if...
2.1.1. No response to lifestyle mods (weight loss, elevate head of bed, avoid high-fat meals close to bedtime, avoid triggers)
2.1.2. No response to 2 weeks OTC
2.1.3. Alarm sx
2.1.3.1. Odynophagia
2.1.3.2. Dysphagia
2.1.3.3. Frequent N/V
2.1.3.4. Hematemesis, black/bloody stools
2.1.3.5. Unintentional weight loss
2.2. Initial tx
2.2.1. PPI once daily for 8 weeks
2.2.1.1. Can :arrow_up: to twice daily if partial response or nocturnal sx present
2.2.1.2. Stop tx at 8 weeks; if sx return, start maintenance therapy
2.3. Maintenance tx
2.3.1. PPI @ lowest effective dose
2.3.1.1. Warning: C.diff, hypomag, B12 deficiency, osteoporosis-related bone fractures
2.3.1.2. Omep & esomep can diminish effect of clopidogrel; use pantop instead
2.3.1.3. Pantop & esomep are only ones available IV
2.3.1.4. Dexlansop **(Dexilant)** can be opened & sprinkled on applesauce
2.3.2. Alternative: H2RA, if no erosive esophagitis & it relieves sx
2.4. **Metoclopramide (Reglan)**
2.4.1. Dopamine antagonist; usually used if coexisting gastroparesis
2.4.1.1. BBW: can cause tardive dyskinesia
2.4.1.2. Warnings: EPS, parkinsonian-like symptoms; avoid in parkinson's disease
2.4.2. At higher doses, it blocks serotonin receptors in chemoreceptor zone which helps N/V
2.4.3. Enhances response to acetylcholine in upper GI leading to increased motility, gastric emptying, & :arrow_up: LES tone
3. PUD
3.1. Background
3.1.1. Occurs when there is mucosal erosion within GI tract
3.1.2. 3 most common causes
3.1.2.1. H. pylori-positive ulcer
3.1.2.1.1. Gram-neg; spiral shaped
3.1.2.2. NSAID ulcer
3.1.2.3. Stress ulcers
3.1.2.3.1. Critically ill or mech-ventilated pts
3.1.3. Sx
3.1.3.1. Dyspepsia
3.1.3.2. If duodenal (usually H. pylori), pain usually worse 2-3 hours after eating, eating usually lessens pain
3.1.3.3. If gastric (usually NSAID), eating usually worsens pain
3.1.3.3.1. Risk factors: > 60 yrs, hx of PUD, 1+ NSAID, concomitant anticoag, steroids, SSRIs, SNRIs
3.1.3.3.2. Prevention
3.1.3.3.3. Cytoprotective drugs
3.1.4. Dx
3.1.4.1. Urea breath test, if positive = H pylori
3.1.4.1.1. D/c PPIs, bismuth, & abx 2 weeks prior to testing
3.2. Tx
3.2.1. If left untreated, can lead to gastric cancer
3.2.2. ACG recommends quad therapy as 1st line
3.2.2.1. Triple therapy only recommended 1st line when clarithromycin resistance rates are low (< 15%) & no previous macrolide use
3.2.2.1.1. Bismuth quad
3.2.2.1.2. Concomitant
3.2.2.1.3. Clarith triple