Diseases, Disorders information

Histamine antagonists

Histamine2 (H2) receptor antagonists are moderately effective for treating GERD. These drugs are safe, with rare side effects. However, cimetidine may cause mental status changes, antiandrogenic activity (gynecomastia), and inhibition of the cytochrome P-450 system, which may alter levels of drugs metabolized by this pathway (eg, theophylline, warfarin, phenytoin).

The indicated oral doses for the treatment of reflux esophagitis are cimetidine (Tagamet), 800 mg twice daily; ranitidine (Zantac), 150 mg two to four times daily; famotidine (Pepcid), 20 mg to 40 mg twice daily; and nizatidine (Axid), 150 mg twice daily. The efficacy of all the H2 receptor antagonists is equivalent.

Proton pump inhibitors

The proton pump inhibitors (PPIs), omeprazole (Prilosec) and lansoprazole (Prevacid), are the most effective acid-suppressing medications available. These drugs inhibit the proton pump.

The usual dosage for treatment of reflux esophagitis is 20 to 40 mg of omeprazole (Prilosec) daily or 30 mg of lansoprazole (Prevacid) daily. At these doses, reflux symptoms are abolished in most patients. PPIs are safe and well tolerated. Side effects of headache, abdominal pain and diarrhea are rare.

Patients with classic symptoms who are less than 40 years old and who have had symptoms for less than 10 years do not require diagnostic studies. Indications for upper gastrointestinal endoscopy include onset of new symptoms in older patients with long-standing GERD, the presence of alarm symptoms, atypical or equivocal symptoms, and failure of full-dose H2 receptor antagonist therapy.

Alarm symptoms in patients with suspected GERD: Hematemesis Melena Dysphagia Unexplained weight loss Frequent vomiting.
PROTONIX helps to control NIGHTTIME heartburn and other symptoms associated with erosive Gastroesophageal Reflux Disease (GERD).

GERD Diagnosis
Esophageal endoscopy is the most popular test for initial evaluation of GERD symptoms. Barium swallow modified by a barium-coated test meal is the most sensitive test for evaluation of dysphagia. The observation of reflux of free barium into the esophagus establishes the diagnosis of GERD.

Ambulatory esophageal pH monitoring is the best test to establish the presence of abnormal acid esophageal reflux, although it provides no information about the esophageal structure or mucosa.

Treatment

Lifestyle modifications recommended for all patients with GERD:
Stop smoking cigarettes. Lose excess weight. Eat small meals Reduce consumption of caffeine, chocolate, fatty foods, alcohol, onions, peppermint, and spearmint. Elevate head of bed 6 to 9 in. Avoid tight-fitting garments

Antacids. Antacids work by neutralizing gastric acid and are indicated for treatment of occasional heartburn. Antacids have a very short duration of action, necessitating frequent dosing.

Gastroesophageal Reflux Disease
About 18% of the adult population in the United States have heartburn at least once a week. Gastroesophageal reflux describes the movement of gastric acid into the esophagus. The major antireflux barrier is the lower esophageal sphincter (LES), located at the esophagogastric junction. Patients with disordered esophageal motility from connective-tissue diseases or primary motility disorders and those with hyposalivation from chronic xerostomia, cigarette smoking, or anticholinergic medications are predisposed to increased severity of GERD.

Clinical evaluation

Heartburn, defined as a retrosternal burning sensation radiating to the pharynx, and acid regurgitation are classic symptoms of GERD. They usually occur postprandially, especially after large meals.

Symptoms may be exacerbated by recumbency, straining, and bending over and are usually improved by antacids. These symptoms are specific enough that their presence establishes the diagnosis of GERD without confirmatory tests.

Complications

Esophagitis with ulceration may result in gastrointestinal hemorrhage, which is reported in about 2% of patients with reflux esophagitis.

Esophageal strictures form in about 10% of patients with GERD. These patients are managed with periodic dilations and acid suppression with proton pump inhibitors.

Barrett’s esophagus. Metaplastic changes in the esophageal mucosa that result from GERD are referred to as Barrett’s esophagus. The presence of columnar-appearing epithelium more than 3 cm above the proximal gastric folds is a criterion for diagnosis. The reported incidence of adenocarcinoma in Barrett’s esophagus, which is considered a premalignant condition, is 1 in 52 patient-years.

Extraesophageal manifestations of GERD may include noncardiac chest pain, chronic hoarseness and cough, and asthma